X12 278 Health Care Services Review Information - Notification (X216)

Beginning of Hierarchical Transaction

Functional Group Header

Transaction Set Header

Information Source Level Loop

detail

Information Source Name Loop

Information Source Supplemental Identification

Information Source Name

Information Source Address

Information Source City, State, ZIP Code

Information Source Contact Information

Information Source Provider Information

Information Receiver Level Loop

Information Receiver Name Loop

Information Receiver Name

Subscriber Supplemental Identification

Subscriber Level Loop

Subscriber City, State, ZIP Code

Subscriber Demographic Information

Subscriber Relationship

Dependent Supplemental Identification

Dependent City, State, ZIP Code

Dependent Demographic Information

Dependent Relationship

Patient Event Tracking Number

Patient Event Level Loop

Patient Event Request Validation

Last Menstrual Period Date

Estimated Date of Birth

Onset of Current Symptoms or Illness Date

Ambulance Transport Information

Institutional Claim Code

Spinal Manipulation Service Information

Home Oxygen Therapy Information

Home Health Care Information

Additional Patient Information

Patient Event Provider Name Loop

Patient Event Provider Name

Patient Event Provider Supplemental Identification

Max use 7

Patient Event Provider Address

Patient Event Provider City, State, ZIP Code

Patient Event Provider Contact Information

Patient Event Provider Request Validation

Patient Event Provider Information

Additional Patient Information Contact Name Loop

Additional Patient Information Contact Name

Additional Patient Information Contact Address

Additional Patient Information City, State, ZIP Code

Additional Patient Information Contact Information

Patient Event Transport Information Loop

Patient Event Transport Information

Patient Event Transport Location Address

Patient Event Transport Location City/State/ZIP Code

Patient Event Transport Information Request Validation

Patient Event Other UMO Name Loop

Patient Event Other UMO Name

Other UMO Denial Reason

Other UMO Denial Date

Service Request Validation

Institutional Service Line

Additional Service Information

Service Provider Name Loop

Service Provider Supplemental Identification

Service Provider Name

Max use 8

Service Provider Address

Service Provider City, State, ZIP Code

Service Provider Contact Information

Service Provider Request Validation

Service Provider Information

Patient Event Tracking Number

Patient Event Level Loop

Patient Event Request Validation

Last Menstrual Period Date

Estimated Date of Birth

Onset of Current Symptoms or Illness Date

Ambulance Transport Information

Institutional Claim Code

Spinal Manipulation Service Information

Home Oxygen Therapy Information

Home Health Care Information

Additional Patient Information

Patient Event Provider Name Loop

Patient Event Provider Name

Patient Event Provider Supplemental Identification

Max use 7

Patient Event Provider Address

Patient Event Provider City, State, ZIP Code

Patient Event Provider Contact Information

Patient Event Provider Request Validation

Patient Event Provider Information

Additional Patient Information Contact Name Loop

Additional Patient Information Contact Name

Additional Patient Information Contact Address

Additional Patient Information City, State, ZIP Code

Additional Patient Information Contact Information

Patient Event Transport Information Loop

Patient Event Transport Information

Patient Event Transport Location Address

Patient Event Transport Location City/State/ZIP Code

Patient Event Transport Information Request Validation

Patient Event Other UMO Name Loop

Patient Event Other UMO Name

Other UMO Denial Reason

Other UMO Denial Date

Service Request Validation

Institutional Service Line

Additional Service Information

Service Provider Name Loop

Service Provider Supplemental Identification

Service Provider Name

Max use 8

Service Provider Address

Service Provider City, State, ZIP Code

Service Provider Contact Information

Service Provider Request Validation

Service Provider Information

2800

Transaction Set Trailer

Functional Group Trailer

Interchange Control Trailer

IEA

ISA

Interchange Control Header

RequiredMax use 1

—

Example

ISA-01

I01

Authorization Information Qualifier

Required

Identifier (ID)

—

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

ISA-02

I02

Authorization Information

Required

String (AN)

Min 10Max 10

—

ISA-03

I03

Security Information Qualifier

Required

Identifier (ID)

—

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

ISA-04

I04

Security Information

Required

String (AN)

Min 10Max 10

—

ISA-05

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 2

—

Codes

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

ISA-06

I06

Interchange Sender ID

Required

String (AN)

Min 15Max 15

—

ISA-07

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 2

—

Codes

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

ISA-08

I07

Interchange Receiver ID

Required

String (AN)

Min 15Max 15

—

ISA-09

I08

Interchange Date

Required

Date (DT)

YYMMDD format

—

ISA-10

I09

Interchange Time

Required

Time (TM)

HHMM format

—

ISA-11

I65

Repetition Separator

Required

String (AN)

Min 1Max 1

—

^: Repetition Separator

ISA-12

I11

Interchange Control Version Number

Required

Identifier (ID)

—

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

ISA-13

I12

Interchange Control Number

Required

Numeric (N0)

Min 9Max 9

—

ISA-14

I13

Acknowledgment Requested

Required

Identifier (ID)

Min 1Max 1

—

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

ISA-15

I14

Interchange Usage Indicator

Required

Identifier (ID)

Min 1Max 1

—

I: Information
P: Production Data
T: Test Data

ISA-16

I15

Component Element Separator

Required

String (AN)

Min 1Max 1

—

>: Component Element Separator

Functional Group Header

RequiredMax use 1

—

Example

GS-01

479

Functional Identifier Code

Required

Identifier (ID)

—

HI: Health Care Services Review Information (278)

GS-02

142

Application Sender's Code

Required

String (AN)

Min 2Max 15

—

GS-03

124

Application Receiver's Code

Required

String (AN)

Min 2Max 15

—

GS-04

373

Date

Required

Date (DT)

CCYYMMDD format

—

GS-05

337

Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

GS-06

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

GS-07

455

Responsible Agency Code

Required

Identifier (ID)

Min 1Max 2

—

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

GS-08

480

Version / Release / Industry Identifier Code

Required

String (AN)

—

005010X216

Heading

0100

Heading > ST

Transaction Set Header

RequiredMax use 1

—

Usage notes

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

278: Health Care Services Review Information

ST-02

329

Transaction Set Control Number

Required

Numeric (N)

Min 4Max 9

—

Usage notes

—

ST-03

1705

Implementation Guide Version Name

Required

String (AN)

—

Usage notes

—

005010X216

BHT

0200

Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

—

Example

BHT-01

1005

Hierarchical Structure Code

Required

Identifier (ID)

—

0007: Information Source, Information Receiver, Subscriber, Dependent, Event, Services

BHT-02

353

Transaction Set Purpose Code

Required

Identifier (ID)

—

14: Advance Notification
—
22: Information Copy
—
CN: Completion Notification
—

BHT-03

127

Submitter Transaction Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

BHT-04

373

Transaction Set Creation Date

Required

Date (DT)

CCYYMMDD format

—

BHT-05

337

Transaction Set Creation Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

BHT-06

640

Transaction Type Code

Optional

Identifier (ID)

—

Usage notes

—

NO: Notice

Heading end

Detail

2000A Information Source Level Loop

RequiredMax 1

0100

Detail > Information Source Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

20: Information Source

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010A Information Source Name Loop

RequiredMax 2

NM1

1700

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

Information Source Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider
2B: Third-Party Administrator
FA: Facility
PR: Payer
X3: Utilization Management Organization

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Information Source Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Information Source First Name

Optional

String (AN)

Min 1Max 35

—

1037

Information Source Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Information Source Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
PI: Payor Identification
—
XV: Centers for Medicare and Medicaid Services PlanID
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Information Source Identifier

Required

String (AN)

Min 2Max 80

—

REF

1800

Detail > Information Source Level Loop > Information Source Name Loop > REF

Information Source Supplemental Identification

OptionalMax use 9

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
G5: Provider Site Number
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Information Source Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

2000

Detail > Information Source Level Loop > Information Source Name Loop > N3

Information Source Address

OptionalMax use 1

—

Usage notes

—

Example

166

Information Source Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Information Source Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Source Name Loop > N4

Information Source City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Information Source State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Information Source City Name

Required

String (AN)

Min 2Max 30

—

156

Information Source State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Information Source Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Information Source Level Loop > Information Source Name Loop > PER

Information Source Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Information Source Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Information Source Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Information Source Contact Communication Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Information Source Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Information Source Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Information Source Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Information Source Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PRV

2400

Detail > Information Source Level Loop > Information Source Name Loop > PRV

Information Source Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

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

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010A Information Source Name Loop end

2000B Information Receiver Level Loop

RequiredMax 1

0100

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

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

21: Information Receiver

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010B Information Receiver Name Loop

RequiredMax 1

NM1

1700

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

Information Receiver Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider
2B: Third-Party Administrator
FA: Facility
PR: Payer
X3: Utilization Management Organization

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Information Receiver Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Information Receiver First Name

Optional

String (AN)

Min 1Max 35

—

1037

Information Receiver Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Information Receiver Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
PI: Payor Identification
—
XV: Centers for Medicare and Medicaid Services PlanID
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Information Receiver Identifier

Required

String (AN)

Min 2Max 80

—

2010B Information Receiver Name Loop end

2000C Subscriber Level Loop

RequiredMax 1

0100

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

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

22: Subscriber

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010C Subscriber Name Loop

RequiredMax 1

NM1

1700

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

Subscriber Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

IL: Insured or Subscriber

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Subscriber Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Subscriber First Name

Optional

String (AN)

Min 1Max 35

—

1037

Subscriber Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

1039

Subscriber Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

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

Subscriber Primary Identifier

Required

String (AN)

Min 2Max 80

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

Subscriber Supplemental Identification

OptionalMax use 9

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1L: Group or Policy Number
—
6P: Group Number
EJ: Patient Account Number
—
F6: Health Insurance Claim (HIC) Number
—
HJ: Identity Card Number
—
IG: Insurance Policy Number
N6: Plan Network Identification Number
NQ: Medicaid Recipient Identification Number
SY: Social Security Number
—

127

Subscriber Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1

—

Usage notes

—

Example

166

Subscriber Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Subscriber Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Subscriber City Name

Required

String (AN)

Min 2Max 30

—

156

Subscriber State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Subscriber Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

DMG

2500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

—

Usage notes

—

Example

DMG-01

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

1251

Subscriber Birth Date

Required

String (AN)

Min 1Max 35

—

DMG-03

1068

Subscriber Gender Code

Optional

Identifier (ID)

—

F: Female
M: Male
U: Unknown

INS

2600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Subscriber Relationship

OptionalMax use 1

—

Usage notes

—

Example

INS-01

1073

Insured Indicator

Required

Identifier (ID)

—

Y: Yes

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

18: Self

INS-08

584

Employment Status Code

Required

Identifier (ID)

—

Usage notes

—

AO: Active Military - Overseas
AU: Active Military - USA
DI: Deceased
PV: Previous
RU: Retired Military - USA

2010C Subscriber Name Loop end

2000D Dependent Level Loop

OptionalMax 1

Variants (all may be used)

Patient Event Level Loop

0100

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

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

23: Dependent

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010D Dependent Name Loop

RequiredMax 1

NM1

1700

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

Dependent Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

QC: Patient

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Dependent Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Dependent First Name

Optional

String (AN)

Min 1Max 35

—

1037

Dependent Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Dependent Name Suffix

Optional

String (AN)

Min 1Max 10

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

Dependent Supplemental Identification

OptionalMax use 3

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

EJ: Patient Account Number
—
SY: Social Security Number
—

127

Dependent Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

Dependent Address

OptionalMax use 1

—

Usage notes

—

Example

166

Dependent Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Dependent Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

Dependent City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Dependent State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Dependent City Name

Required

String (AN)

Min 2Max 30

—

156

Dependent State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Dependent Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

DMG

2500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

Dependent Demographic Information

OptionalMax use 1

—

Usage notes

—

Example

DMG-01

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

1251

Dependent Birth Date

Required

String (AN)

Min 1Max 35

—

DMG-03

1068

Dependent Gender Code

Optional

Identifier (ID)

—

F: Female
M: Male
U: Unknown

INS

2600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

Dependent Relationship

OptionalMax use 1

—

Usage notes

—

Example

INS-01

1073

Insured Indicator

Required

Identifier (ID)

—

N: No

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

01: Spouse
19: Child
G8: Other Relationship

INS-17

1470

Birth Sequence Number

Optional

Numeric (N0)

Min 1Max 9

—

2010D Dependent Name Loop end

2000E Patient Event Level Loop

RequiredMax 1

0100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

EV: Event

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

TRN

0200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 3

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers
—

127

Patient Event Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

AAA

0300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > AAA

Patient Event Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
52: Service Dates Not Within Provider Plan Enrollment
—
56: Inappropriate Date
—
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
—
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
—

0400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

AR: Admission Review
—
HS: Health Services Review
—
SC: Specialty Care Review
—

1322

Certification Type Code

Required

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
5: Notification
I: Initial
N: Reconsideration
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

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
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

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

UM-06

1338

Level of Service Code

Optional

Identifier (ID)

—

03: Emergency
E: Elective
U: Urgent

HCR

0500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HCR

Health Care Services Review

OptionalMax use 1

—

Usage notes

—

Example

306

Action Code

Required

Identifier (ID)

—

A1: Certified in total
A2: Certified - partial
—
A3: Not Certified
A4: Pended
A6: Modified
C: Cancelled
CT: Contact Payer
NA: No Action Required
—

127

Review Identification Number

Optional

String (AN)

Min 1Max 50

—

1271

Review Decision Reason Code

Optional

String (AN)

Max use 5

Min 1Max 30

—

Usage notes

—

1073

Second Surgical Opinion Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

127

Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Accident Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

439: Accident

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Accident Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Last Menstrual Period Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

484: Last Menstrual Period

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Last Menstrual Period Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Estimated Date of Birth

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

ABC: Estimated Date of Birth

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPEvent Date DTPAdmission Date DTPDischarge Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Estimated Birth Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Onset of Current Symptoms or Illness Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

431: Onset of Current Symptoms or Illness

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPAdmission Date DTPDischarge Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Onset Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Event Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

AAH: Event

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPDischarge Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Proposed or Actual Event Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Admission Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

435: Admission

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Proposed or Actual Admission Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Discharge Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

096: Discharge

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Proposed or Actual Discharge Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Issue Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

102: Issue

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Certification Issue Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

036: Expiration

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Certification Expiration Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Effective Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

007: Effective

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Certification Effective Date

Required

String (AN)

Min 1Max 35

—

0800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HI

Patient Diagnosis

OptionalMax use 1

—

Usage notes

—

Example

HI-01

C022

Health Care Code Information

RequiredMax use 1

To send health care codes and their associated dates, amounts and quantities

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-02

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-03

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-04

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-05

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-06

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-07

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-08

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-09

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-10

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-11

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-12

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HSD

0900

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
WE: Weekend
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

CL1

1100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CL1

Institutional Claim Code

OptionalMax use 1

—

Usage notes

—

Example

CL1-01

1315

Admission Type Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-02

1314

Admission Source Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-03

1352

Patient Status Code

Optional

Identifier (ID)

Min 1Max 2

—

CR1

1200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR1

Ambulance Transport Information

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required

CR1-03

1316

Ambulance Transport Code

Required

Identifier (ID)

—

I: Initial Trip
R: Return Trip
T: Transfer Trip
X: Round Trip

CR1-05

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DH: Miles
DK: Kilometers

CR1-06

380

Transport Distance

Optional

Decimal number (R)

Min 1Max 15

—

CR2

1300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

—

Usage notes

—

Example

If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required

If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required

CR2-01

609

Treatment Series Number

Optional

Numeric (N0)

Min 1Max 9

—

CR2-02

380

Treatment Count

Optional

Decimal number (R)

Min 1Max 15

—

CR2-03

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR2-04

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR5

1400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR5

Home Oxygen Therapy Information

OptionalMax use 1

—

Usage notes

—

Example

CR5-03

1348

Oxygen Equipment Type Code

Required

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-04

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-06

380

Oxygen Flow Rate

Required

Decimal number (R)

Min 1Max 15

—

CR5-07

380

Daily Oxygen Use Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-08

380

Oxygen Use Period Hour Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-09

352

Respiratory Therapist Order Text

Optional

String (AN)

Min 1Max 80

—

CR5-16

380

Portable Oxygen System Flow Rate

Optional

Decimal number (R)

Min 1Max 15

—

CR5-17

1382

Oxygen Delivery System Code

Required

Identifier (ID)

—

A: Nasal Cannula
B: Oxygen Conserving Device
C: Oxygen Conserving Device with Oxygen Pulse System
D: Oxygen Conserving Device with Reservoir System
E: Transtracheal Catheter

CR5-18

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

Min 1Max 1

—

CR6

1500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR6

Home Health Care Information

OptionalMax use 1

—

Usage notes

—

Example

If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required

CR6-01

923

Prognosis Code

Required

Identifier (ID)

—

1: Poor
2: Guarded
3: Fair
4: Good
5: Very Good
6: Excellent
7: Less than 6 Months to Live
8: Terminal

CR6-02

373

Home Health Start Date

Required

Date (DT)

CCYYMMDD format

—

CR6-03

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

CR6-04

1251

Home Health Certification Period

Optional

String (AN)

Min 1Max 35

—

CR6-07

1073

Medicare Coverage Indicator

Required

Identifier (ID)

—

W: Not Applicable

CR6-08

1322

Certification Type Code

Required

Identifier (ID)

—

Usage notes

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
5: Notification
6: Verification
—
I: Initial
R: Renewal
S: Revised

PWK

1550

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > PWK

Additional Patient Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HP: History and Physical
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
NN: Nursing Notes
OB: Operative Note
OC: Oxygen Content Averaging Report
OD: Orders and Treatments Document
OE: Objective Physical Examination (including vital signs) Document
OX: Oxygen Therapy Certification
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
P7: Periodontal Reports
PE: Parenteral or Enteral Certification
PN: Physical Therapy Notes
PO: Prosthetics or Orthotic Certification
PQ: Paramedical Results
PY: Physician's Report
PZ: Physical Therapy Certification
QC: Cause and Corrective Action Report
QR: Quality Report
RB: Radiology Films
RR: Radiology Reports
RT: Report of Tests and Analysis Report
RX: Renewable Oxygen Content Averaging Report
SG: Symptoms Document
T7: Therapy Notes
V5: Death Notification
XP: Photographs

756

Report Transmission Code

Required

Identifier (ID)

—

BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

MSG

1600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

Additional Patient Information Contact Name Loop Patient Event Transport Information Loop Patient Event Other UMO Name Loop

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010EA Patient Event Provider Name Loop

OptionalMax 12

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

Patient Event Provider Name

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Patient Event Provider Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

71: Attending Physician
72: Operating Physician
73: Other Physician
77: Service Location
AAJ: Admitting Services
DD: Assistant Surgeon
DK: Ordering Physician
DN: Referring Provider
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Patient Event Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Patient Event Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Patient Event Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Patient Event Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Patient Event Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

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
—

Patient Event Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

Patient Event Provider Supplemental Identification

OptionalMax use 7

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Patient Event Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N3

Patient Event Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Patient Event Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N4

Patient Event Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Patient Event Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Patient Event Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Patient Event Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Patient Event Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PER

Patient Event Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Patient Event Provider Contact Communications Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Patient Event Provider Contact Communications Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Patient Event Provider Contact Communications Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Patient Event Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

AAA

2300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > AAA

Patient Event Provider Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Required

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
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
IP: Inappropriate Provider Role

PRV

2400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

Patient Event Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AD: Admitting
—
AS: Assistant Surgeon
—
AT: Attending
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—
RF: Referring
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

Patient Event Provider Name Loop Patient Event Transport Information Loop Patient Event Other UMO Name Loop

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010EA Patient Event Provider Name Loop end

2010EB Additional Patient Information Contact Name Loop

OptionalMax 1

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Additional Patient Information Contact Name Loop > NM1

Additional Patient Information Contact Name

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Response Contact Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

L5: Contact

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
—
2: Non-Person Entity

1035

Response Contact Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Response Contact First Name

Optional

String (AN)

Min 1Max 35

—

1037

Response Contact Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Response Contact Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
PI: Payor Identification
—
XV: Centers for Medicare and Medicaid Services PlanID
—
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Response Contact Identifier

Optional

String (AN)

Min 2Max 80

—

2000

Additional Patient Information Contact Address

OptionalMax use 1

—

Usage notes

—

Example

166

Response Contact Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Response Contact Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Additional Patient Information City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Additional Patient Information Contact State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Additional Patient Information Contact City Name

Required

String (AN)

Min 2Max 30

—

156

Additional Patient Information Contact State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Additional Patient Information Contact Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Additional Patient Information Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Response Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Response Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Response Contact Communication Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Response Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Response Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Response Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

Patient Event Provider Name Loop Additional Patient Information Contact Name Loop Patient Event Other UMO Name Loop

364

Response Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

2010EB Additional Patient Information Contact Name Loop end

2010EC Patient Event Transport Information Loop

OptionalMax 5

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > NM1

Patient Event Transport Information

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

45: Drop-off Location
FS: Final Scheduled Destination
ND: Next Destination
PW: Pickup Address
R3: Next Scheduled Destination

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Patient Event Provider Transport Location Name

Optional

String (AN)

Min 1Max 60

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N3

Patient Event Transport Location Address

RequiredMax use 1

—

Example

166

Patient Event Provider Transport Location Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Provider Transport Location Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N4

Patient Event Transport Location City/State/ZIP Code

RequiredMax use 1

—

Usage notes

—

Example

Patient Event Transport Location City Name

Optional

String (AN)

Min 2Max 30

—

156

Patient Event Transport Location State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Patient Event Transport Location Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

AAA

2300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > AAA

Patient Event Transport Information Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

Patient Event Provider Name Loop Additional Patient Information Contact Name Loop Patient Event Transport Information Loop

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
47: Invalid/Missing Provider State
—
97: Invalid or Missing Provider Address
—

AAA-04

889

Follow-up Action Code

Required

Identifier (ID)

—

C: Please Correct and Resubmit
N: Resubmission Not Allowed

2010EC Patient Event Transport Information Loop end

2010ED Patient Event Other UMO Name Loop

OptionalMax 3

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > NM1

Patient Event Other UMO Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

00: Alternate Insurer
—
CA: Carrier
—
GG: Intermediary
—

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Other UMO Name

Optional

String (AN)

Min 1Max 60

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > REF

Other UMO Denial Reason

RequiredMax use 1

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

REF-04

C040

Reference Identifier

OptionalMax use 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.

Usage notes

—

If either Reference Identification Qualifier (C040-03) or Other UMO Denial Reason (C040-04) is present, then the other is required

If either Reference Identification Qualifier (C040-05) or Reference Identification (C040-06) is present, then the other is required

C040-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-02

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

C040-03

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-04

127

Other UMO Denial Reason

Optional

String (AN)

Min 1Max 50

—

C040-05

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-06

127

Reference Identification

Optional

String (AN)

Min 1Max 50

—

DTP

2700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > DTP

Other UMO Denial Date

RequiredMax use 1

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

598: Rejected

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Other UMO Denial Date

Required

String (AN)

Min 1Max 35

—

2010ED Patient Event Other UMO Name Loop end

2000F Service Level Loop

OptionalMax >1

0100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

SS: Services

736

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

TRN

0200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TRN

Service Trace Number

OptionalMax use 3

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers
—
2: Referenced Transaction Trace Numbers
—

127

Service Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

AAA

0300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > AAA

Service Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
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
AG: Invalid/Missing Procedure Code(s)
T5: Certification Information Missing
—

0400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > UM

Health Care Services Review Information

OptionalMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

HS: Health Services Review
—
SC: Specialty Care Review
—

1322

Certification Type Code

Optional

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
5: Notification
I: Initial
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

Usage notes

—

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

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

HCR

0500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HCR

Health Care Services Review

OptionalMax use 1

—

Usage notes

—

Example

306

Action Code

Required

Identifier (ID)

—

A1: Certified in total
A3: Not Certified
A4: Pended
A6: Modified
C: Cancelled
CT: Contact Payer
NA: No Action Required
—

127

Review Identification Number

Optional

String (AN)

Min 1Max 50

—

1271

Review Decision Reason Code

Optional

String (AN)

Max use 5

Min 1Max 30

—

Usage notes

—

1073

Second Surgical Opinion Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

127

Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Service Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

472: Service

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPService Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Proposed or Actual Service Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Issue Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

102: Issue

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPService Date DTPCertification Issue Date DTPCertification Effective Date

1251

Certification Issue Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

036: Expiration

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPService Date DTPCertification Issue Date DTPCertification Expiration Date

1251

Certification Expiration Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Effective Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

007: Effective

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Certification Effective Date

Required

String (AN)

Min 1Max 35

—

SV1

0810

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV1

Professional Service

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (SV1-03) or Service Unit Count (SV1-04) is present, then the other is required

SV1-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Product or Service ID

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV1-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV1-03

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

F2: International Unit
—
MJ: Minutes
UN: Unit

SV1-04

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV1-07

C004

Composite Diagnosis Code Pointer

OptionalMax use 1

To identify one or more diagnosis code pointers

Usage notes

—

C004-01

1328

Diagnosis Code Pointer

Required

Numeric (N0)

Min 1Max 2

—

C004-02

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-03

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-04

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

SV1-11

1073

EPSDT Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

SV1-20

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

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

SV2

0820

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV2

Institutional Service Line

OptionalMax use 1

—

Usage notes

—

Example

At least one of Service Line Revenue Code (SV2-01) or Composite Medical Procedure Identifier (SV2-02) is required

If either Unit or Basis for Measurement Code (SV2-04) or Service Unit Count (SV2-05) is present, then the other is required

SV2-01

234

Service Line Revenue Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-02

C003

Composite Medical Procedure Identifier

OptionalMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

Usage notes

—

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format
WK: Advanced Billing Concepts (ABC) Codes
—
ZZ: Mutually Defined
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Product or Service ID

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-03

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV2-04

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
F2: International Unit
—
UN: Unit

SV2-05

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV2-06

1371

Service Line Rate

Optional

Decimal number (R)

Min 1Max 10

—

SV2-09

1345

Nursing Home Residential Status Code

Optional

Identifier (ID)

—

1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
2: Newly Admitted
3: Newly Eligible
4: No Longer Eligible
5: Still a Resident
6: Temporary Absence - Hospital
7: Temporary Absence - Other
8: Transferred to Intermediate Care Facility - Level II (ICF II)

SV2-10

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

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

SV3

0830

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV3

Dental Service

OptionalMax use 1

—

Usage notes

—

Example

SV3-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

AD: American Dental Association Codes

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Product or Service ID

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV3-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV3-04

C006

Oral Cavity Designation

OptionalMax use 1

To identify one or more areas of the oral cavity

Usage notes

—

C006-01

1361

Oral Cavity Designation Code

Required

Identifier (ID)

Min 1Max 3

—

C006-02

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-03

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-04

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-05

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

SV3-05

1358

Prosthesis, Crown, or Inlay Code

Optional

Identifier (ID)

—

I: Initial Placement
R: Replacement

SV3-06

380

Service Unit Count

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SV3-07

352

Description

Optional

String (AN)

Min 1Max 80

—

TOO

0840

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TOO

Tooth Information

OptionalMax use 32

—

Usage notes

—

Example

TOO-01

1270

Code List Qualifier Code

Required

Identifier (ID)

—

JP: Universal National Tooth Designation System

TOO-02

1271

Tooth Code

Required

String (AN)

Min 1Max 30

—

TOO-03

C005

Tooth Surface

OptionalMax use 1

To identify one or more tooth surface codes

Usage notes

—

C005-01

1369

Tooth Surface Code

Required

Identifier (ID)

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-02

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-03

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-04

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-05

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

HSD

0900

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

Usage notes

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

PWK

1550

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > PWK

Additional Service Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HP: History and Physical
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
NN: Nursing Notes
OB: Operative Note
OC: Oxygen Content Averaging Report
OD: Orders and Treatments Document
OE: Objective Physical Examination (including vital signs) Document
OX: Oxygen Therapy Certification
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
P7: Periodontal Reports
PE: Parenteral or Enteral Certification
PN: Physical Therapy Notes
PO: Prosthetics or Orthotic Certification
PQ: Paramedical Results
PY: Physician's Report
PZ: Physical Therapy Certification
QC: Cause and Corrective Action Report
QR: Quality Report
RB: Radiology Films
RR: Radiology Reports
RT: Report of Tests and Analysis Report
RX: Renewable Oxygen Content Averaging Report
SG: Symptoms Document
T7: Therapy Notes
V5: Death Notification
XP: Photographs

756

Report Transmission Code

Required

Identifier (ID)

—

AA: Available on Request at Provider Site
—
BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

MSG

1600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010F Service Provider Name Loop

OptionalMax 10

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

Service Provider Name

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Service Provider Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

1T: Physician, Clinic or Group Practice
72: Operating Physician
73: Other Physician
77: Service Location
DD: Assistant Surgeon
DK: Ordering Physician
DQ: Supervising Physician
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Service Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

1036

Service Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Service Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Service Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Service Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

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
—

Service Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Service Provider Supplemental Identification

OptionalMax use 8

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
G5: Provider Site Number
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Service Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

2000

Service Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Service Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Service Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Service Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Service Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Service Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Service Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Service Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Service Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Service Provider Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Service Provider Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Service Provider Contact Communication Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Service Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

AAA

2300

Service Provider Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
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

PRV

2400

Service Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AS: Assistant Surgeon
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010F Service Provider Name Loop end

2000F Service Level Loop end

2000E Patient Event Level Loop end

2000D Dependent Level Loop end

2000E Patient Event Level Loop

OptionalMax 1

Variants (all may be used)

Dependent Level Loop

0100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

EV: Event

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

TRN

0200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 3

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers
—

127

Patient Event Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

AAA

0300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > AAA

Patient Event Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
52: Service Dates Not Within Provider Plan Enrollment
—
56: Inappropriate Date
—
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
—
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
—

0400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

AR: Admission Review
—
HS: Health Services Review
—
SC: Specialty Care Review
—

1322

Certification Type Code

Required

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
5: Notification
I: Initial
N: Reconsideration
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

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
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

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

UM-06

1338

Level of Service Code

Optional

Identifier (ID)

—

03: Emergency
E: Elective
U: Urgent

HCR

0500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HCR

Health Care Services Review

OptionalMax use 1

—

Usage notes

—

Example

306

Action Code

Required

Identifier (ID)

—

A1: Certified in total
A2: Certified - partial
—
A3: Not Certified
A4: Pended
A6: Modified
C: Cancelled
CT: Contact Payer
NA: No Action Required
—

127

Review Identification Number

Optional

String (AN)

Min 1Max 50

—

1271

Review Decision Reason Code

Optional

String (AN)

Max use 5

Min 1Max 30

—

Usage notes

—

1073

Second Surgical Opinion Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > REF

Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

127

Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Accident Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

439: Accident

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Accident Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Last Menstrual Period Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

484: Last Menstrual Period

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Last Menstrual Period Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Estimated Date of Birth

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

ABC: Estimated Date of Birth

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Estimated Birth Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Onset of Current Symptoms or Illness Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

431: Onset of Current Symptoms or Illness

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Onset Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Event Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

AAH: Event

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Proposed or Actual Event Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Admission Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

435: Admission

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Proposed or Actual Admission Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Discharge Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

096: Discharge

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Proposed or Actual Discharge Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Certification Issue Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

102: Issue

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Certification Issue Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

036: Expiration

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Certification Expiration Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Certification Effective Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

007: Effective

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Certification Effective Date

Required

String (AN)

Min 1Max 35

—

0800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HI

Patient Diagnosis

OptionalMax use 1

—

Usage notes

—

Example

HI-01

C022

Health Care Code Information

RequiredMax use 1

To send health care codes and their associated dates, amounts and quantities

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-02

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-03

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-04

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-05

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-06

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-07

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-08

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-09

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-10

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-11

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-12

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

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

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

Min 2Max 3

—

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HSD

0900

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
WE: Weekend
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

CL1

1100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > CL1

Institutional Claim Code

OptionalMax use 1

—

Usage notes

—

Example

CL1-01

1315

Admission Type Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-02

1314

Admission Source Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-03

1352

Patient Status Code

Optional

Identifier (ID)

Min 1Max 2

—

CR1

1200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR1

Ambulance Transport Information

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required

CR1-03

1316

Ambulance Transport Code

Required

Identifier (ID)

—

I: Initial Trip
R: Return Trip
T: Transfer Trip
X: Round Trip

CR1-05

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DH: Miles
DK: Kilometers

CR1-06

380

Transport Distance

Optional

Decimal number (R)

Min 1Max 15

—

CR2

1300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

—

Usage notes

—

Example

If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required

If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required

CR2-01

609

Treatment Series Number

Optional

Numeric (N0)

Min 1Max 9

—

CR2-02

380

Treatment Count

Optional

Decimal number (R)

Min 1Max 15

—

CR2-03

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR2-04

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR5

1400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR5

Home Oxygen Therapy Information

OptionalMax use 1

—

Usage notes

—

Example

CR5-03

1348

Oxygen Equipment Type Code

Required

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-04

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-06

380

Oxygen Flow Rate

Required

Decimal number (R)

Min 1Max 15

—

CR5-07

380

Daily Oxygen Use Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-08

380

Oxygen Use Period Hour Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-09

352

Respiratory Therapist Order Text

Optional

String (AN)

Min 1Max 80

—

CR5-16

380

Portable Oxygen System Flow Rate

Optional

Decimal number (R)

Min 1Max 15

—

CR5-17

1382

Oxygen Delivery System Code

Required

Identifier (ID)

—

A: Nasal Cannula
B: Oxygen Conserving Device
C: Oxygen Conserving Device with Oxygen Pulse System
D: Oxygen Conserving Device with Reservoir System
E: Transtracheal Catheter

CR5-18

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

Min 1Max 1

—

CR6

1500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR6

Home Health Care Information

OptionalMax use 1

—

Usage notes

—

Example

If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required

CR6-01

923

Prognosis Code

Required

Identifier (ID)

—

1: Poor
2: Guarded
3: Fair
4: Good
5: Very Good
6: Excellent
7: Less than 6 Months to Live
8: Terminal

CR6-02

373

Home Health Start Date

Required

Date (DT)

CCYYMMDD format

—

CR6-03

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

CR6-04

1251

Home Health Certification Period

Optional

String (AN)

Min 1Max 35

—

CR6-07

1073

Medicare Coverage Indicator

Required

Identifier (ID)

—

W: Not Applicable

CR6-08

1322

Certification Type Code

Required

Identifier (ID)

—

Usage notes

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
5: Notification
6: Verification
—
I: Initial
R: Renewal
S: Revised

PWK

1550

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > PWK

Additional Patient Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HP: History and Physical
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
NN: Nursing Notes
OB: Operative Note
OC: Oxygen Content Averaging Report
OD: Orders and Treatments Document
OE: Objective Physical Examination (including vital signs) Document
OX: Oxygen Therapy Certification
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
P7: Periodontal Reports
PE: Parenteral or Enteral Certification
PN: Physical Therapy Notes
PO: Prosthetics or Orthotic Certification
PQ: Paramedical Results
PY: Physician's Report
PZ: Physical Therapy Certification
QC: Cause and Corrective Action Report
QR: Quality Report
RB: Radiology Films
RR: Radiology Reports
RT: Report of Tests and Analysis Report
RX: Renewable Oxygen Content Averaging Report
SG: Symptoms Document
T7: Therapy Notes
V5: Death Notification
XP: Photographs

756

Report Transmission Code

Required

Identifier (ID)

—

BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

MSG

1600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

Additional Patient Information Contact Name Loop Patient Event Transport Information Loop Patient Event Other UMO Name Loop

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010EA Patient Event Provider Name Loop

OptionalMax 12

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

Patient Event Provider Name

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Patient Event Provider Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

71: Attending Physician
72: Operating Physician
73: Other Physician
77: Service Location
AAJ: Admitting Services
DD: Assistant Surgeon
DK: Ordering Physician
DN: Referring Provider
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Patient Event Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Patient Event Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Patient Event Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Patient Event Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Patient Event Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

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
—

Patient Event Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

Patient Event Provider Supplemental Identification

OptionalMax use 7

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Patient Event Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N3

Patient Event Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Patient Event Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N4

Patient Event Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Patient Event Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Patient Event Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Patient Event Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Patient Event Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PER

Patient Event Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Patient Event Provider Contact Communications Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Patient Event Provider Contact Communications Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Patient Event Provider Contact Communications Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Patient Event Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

AAA

2300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > AAA

Patient Event Provider Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Required

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
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
IP: Inappropriate Provider Role

PRV

2400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

Patient Event Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AD: Admitting
—
AS: Assistant Surgeon
—
AT: Attending
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—
RF: Referring
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

Patient Event Provider Name Loop Patient Event Transport Information Loop Patient Event Other UMO Name Loop

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010EA Patient Event Provider Name Loop end

2010EB Additional Patient Information Contact Name Loop

OptionalMax 1

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Additional Patient Information Contact Name Loop > NM1

Additional Patient Information Contact Name

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Response Contact Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

L5: Contact

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
—
2: Non-Person Entity

1035

Response Contact Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Response Contact First Name

Optional

String (AN)

Min 1Max 35

—

1037

Response Contact Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Response Contact Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
PI: Payor Identification
—
XV: Centers for Medicare and Medicaid Services PlanID
—
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Response Contact Identifier

Optional

String (AN)

Min 2Max 80

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Additional Patient Information Contact Name Loop > N3

Additional Patient Information Contact Address

OptionalMax use 1

—

Usage notes

—

Example

166

Response Contact Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Response Contact Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Additional Patient Information Contact Name Loop > N4

Additional Patient Information City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Additional Patient Information Contact State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Additional Patient Information Contact City Name

Required

String (AN)

Min 2Max 30

—

156

Additional Patient Information Contact State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Additional Patient Information Contact Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Additional Patient Information Contact Name Loop > PER

Additional Patient Information Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Response Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Response Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Response Contact Communication Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Response Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Response Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Response Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

Patient Event Provider Name Loop Additional Patient Information Contact Name Loop Patient Event Other UMO Name Loop

364

Response Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

2010EB Additional Patient Information Contact Name Loop end

2010EC Patient Event Transport Information Loop

OptionalMax 5

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > NM1

Patient Event Transport Information

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

45: Drop-off Location
FS: Final Scheduled Destination
ND: Next Destination
PW: Pickup Address
R3: Next Scheduled Destination

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Patient Event Provider Transport Location Name

Optional

String (AN)

Min 1Max 60

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N3

Patient Event Transport Location Address

RequiredMax use 1

—

Example

166

Patient Event Provider Transport Location Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Provider Transport Location Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N4

Patient Event Transport Location City/State/ZIP Code

RequiredMax use 1

—

Usage notes

—

Example

Patient Event Transport Location City Name

Optional

String (AN)

Min 2Max 30

—

156

Patient Event Transport Location State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Patient Event Transport Location Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

AAA

2300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > AAA

Patient Event Transport Information Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

Patient Event Provider Name Loop Additional Patient Information Contact Name Loop Patient Event Transport Information Loop

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
47: Invalid/Missing Provider State
—
97: Invalid or Missing Provider Address
—

AAA-04

889

Follow-up Action Code

Required

Identifier (ID)

—

C: Please Correct and Resubmit
N: Resubmission Not Allowed

2010EC Patient Event Transport Information Loop end

2010ED Patient Event Other UMO Name Loop

OptionalMax 3

Variants (all may be used)

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > NM1

Patient Event Other UMO Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

00: Alternate Insurer
—
CA: Carrier
—
GG: Intermediary
—

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Other UMO Name

Optional

String (AN)

Min 1Max 60

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > REF

Other UMO Denial Reason

RequiredMax use 1

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

REF-04

C040

Reference Identifier

OptionalMax use 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.

Usage notes

—

If either Reference Identification Qualifier (C040-03) or Other UMO Denial Reason (C040-04) is present, then the other is required

If either Reference Identification Qualifier (C040-05) or Reference Identification (C040-06) is present, then the other is required

C040-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-02

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

C040-03

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-04

127

Other UMO Denial Reason

Optional

String (AN)

Min 1Max 50

—

C040-05

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-06

127

Reference Identification

Optional

String (AN)

Min 1Max 50

—

DTP

2700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > DTP

Other UMO Denial Date

RequiredMax use 1

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

598: Rejected

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Other UMO Denial Date

Required

String (AN)

Min 1Max 35

—

2010ED Patient Event Other UMO Name Loop end

2000F Service Level Loop

OptionalMax >1

0100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

SS: Services

736

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

TRN

0200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > TRN

Service Trace Number

OptionalMax use 3

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers
—
2: Referenced Transaction Trace Numbers
—

127

Service Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

AAA

0300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > AAA

Service Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
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
AG: Invalid/Missing Procedure Code(s)
T5: Certification Information Missing
—

0400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > UM

Health Care Services Review Information

OptionalMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

HS: Health Services Review
—
SC: Specialty Care Review
—

1322

Certification Type Code

Optional

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
5: Notification
I: Initial
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

Usage notes

—

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

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

HCR

0500

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HCR

Health Care Services Review

OptionalMax use 1

—

Usage notes

—

Example

306

Action Code

Required

Identifier (ID)

—

A1: Certified in total
A3: Not Certified
A4: Pended
A6: Modified
C: Cancelled
CT: Contact Payer
NA: No Action Required
—

127

Review Identification Number

Optional

String (AN)

Min 1Max 50

—

1271

Review Decision Reason Code

Optional

String (AN)

Max use 5

Min 1Max 30

—

Usage notes

—

1073

Second Surgical Opinion Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > REF

Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

DTPCertification Issue Date DTPCertification Expiration Date DTPCertification Effective Date

127

Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Service Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

472: Service

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPService Date DTPCertification Expiration Date DTPCertification Effective Date

1251

Proposed or Actual Service Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Issue Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

102: Issue

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPService Date DTPCertification Issue Date DTPCertification Effective Date

1251

Certification Issue Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

036: Expiration

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPService Date DTPCertification Issue Date DTPCertification Expiration Date

1251

Certification Expiration Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Effective Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

007: Effective

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Certification Effective Date

Required

String (AN)

Min 1Max 35

—

SV1

0810

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV1

Professional Service

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (SV1-03) or Service Unit Count (SV1-04) is present, then the other is required

SV1-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Product or Service ID

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV1-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV1-03

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

F2: International Unit
—
MJ: Minutes
UN: Unit

SV1-04

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV1-07

C004

Composite Diagnosis Code Pointer

OptionalMax use 1

To identify one or more diagnosis code pointers

Usage notes

—

C004-01

1328

Diagnosis Code Pointer

Required

Numeric (N0)

Min 1Max 2

—

C004-02

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-03

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-04

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

SV1-11

1073

EPSDT Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

SV1-20

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

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

SV2

0820

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV2

Institutional Service Line

OptionalMax use 1

—

Usage notes

—

Example

At least one of Service Line Revenue Code (SV2-01) or Composite Medical Procedure Identifier (SV2-02) is required

If either Unit or Basis for Measurement Code (SV2-04) or Service Unit Count (SV2-05) is present, then the other is required

SV2-01

234

Service Line Revenue Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-02

C003

Composite Medical Procedure Identifier

OptionalMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

Usage notes

—

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format
WK: Advanced Billing Concepts (ABC) Codes
—
ZZ: Mutually Defined
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Product or Service ID

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-03

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV2-04

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
F2: International Unit
—
UN: Unit

SV2-05

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV2-06

1371

Service Line Rate

Optional

Decimal number (R)

Min 1Max 10

—

SV2-09

1345

Nursing Home Residential Status Code

Optional

Identifier (ID)

—

1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
2: Newly Admitted
3: Newly Eligible
4: No Longer Eligible
5: Still a Resident
6: Temporary Absence - Hospital
7: Temporary Absence - Other
8: Transferred to Intermediate Care Facility - Level II (ICF II)

SV2-10

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

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

SV3

0830

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV3

Dental Service

OptionalMax use 1

—

Usage notes

—

Example

SV3-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

AD: American Dental Association Codes

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Product or Service ID

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV3-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV3-04

C006

Oral Cavity Designation

OptionalMax use 1

To identify one or more areas of the oral cavity

Usage notes

—

C006-01

1361

Oral Cavity Designation Code

Required

Identifier (ID)

Min 1Max 3

—

C006-02

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-03

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-04

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-05

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

SV3-05

1358

Prosthesis, Crown, or Inlay Code

Optional

Identifier (ID)

—

I: Initial Placement
R: Replacement

SV3-06

380

Service Unit Count

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SV3-07

352

Description

Optional

String (AN)

Min 1Max 80

—

TOO

0840

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > TOO

Tooth Information

OptionalMax use 32

—

Usage notes

—

Example

TOO-01

1270

Code List Qualifier Code

Required

Identifier (ID)

—

JP: Universal National Tooth Designation System

TOO-02

1271

Tooth Code

Required

String (AN)

Min 1Max 30

—

TOO-03

C005

Tooth Surface

OptionalMax use 1

To identify one or more tooth surface codes

Usage notes

—

C005-01

1369

Tooth Surface Code

Required

Identifier (ID)

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-02

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-03

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-04

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-05

1369

Tooth Surface Code

Optional

Identifier (ID)

—

Usage notes

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

HSD

0900

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

Usage notes

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

PWK

1550

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > PWK

Additional Service Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HP: History and Physical
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
NN: Nursing Notes
OB: Operative Note
OC: Oxygen Content Averaging Report
OD: Orders and Treatments Document
OE: Objective Physical Examination (including vital signs) Document
OX: Oxygen Therapy Certification
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
P7: Periodontal Reports
PE: Parenteral or Enteral Certification
PN: Physical Therapy Notes
PO: Prosthetics or Orthotic Certification
PQ: Paramedical Results
PY: Physician's Report
PZ: Physical Therapy Certification
QC: Cause and Corrective Action Report
QR: Quality Report
RB: Radiology Films
RR: Radiology Reports
RT: Report of Tests and Analysis Report
RX: Renewable Oxygen Content Averaging Report
SG: Symptoms Document
T7: Therapy Notes
V5: Death Notification
XP: Photographs

756

Report Transmission Code

Required

Identifier (ID)

—

AA: Available on Request at Provider Site
—
BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

MSG

1600

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010F Service Provider Name Loop

OptionalMax 10

NM1

1700

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

Service Provider Name

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Service Provider Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

1T: Physician, Clinic or Group Practice
72: Operating Physician
73: Other Physician
77: Service Location
DD: Assistant Surgeon
DK: Ordering Physician
DQ: Supervising Physician
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Service Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

1036

Service Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Service Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Service Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Service Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

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
—

Service Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > REF

Service Provider Supplemental Identification

OptionalMax use 8

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
G5: Provider Site Number
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Service Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

2000

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > N3

Service Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Service Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Service Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > N4

Service Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Service Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

Service Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Service Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Service Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PER

Service Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Service Provider Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Service Provider Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Service Provider Contact Communication Number (PER-08) is present, then the other is required

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Service Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

AAA

2300

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > AAA

Service Provider Request Validation

OptionalMax use 9

—

Usage notes

—

Example

1073

Valid Request Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

901

Reject Reason Code

Optional

Identifier (ID)

—

15: Required application data missing
—
33: Input Errors
—
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

PRV

2400

Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PRV

Service Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AS: Assistant Surgeon
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code