X12 HIPAA
/
Patient Information (X210)
  • Specification
  • EDI Inspector
Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us.
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X12 275 Patient Information (X210)

X12 Release 5010

j4

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • Example 1: Electronic Request
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0100
275 Transaction Header
Max use 1
Required
BGN
0200
Beginning Segment
Max use 1
Required
Payer Name Loop
detail
Assigned Number Loop
LX
0100
Assigned Number
Max use 1
Required
TRN
0150
Payer Claim Control Number/Provider Attachment Control Number
Max use 1
Required
STC
0175
Status Information
Max use 1
Optional
REF
0500
Service Line Item Identification
Max use 1
Optional
REF
0500
Procedure or Revenue Code
Max use 1
Optional
REF
0500
Procedure Code Modifier
Max use 1
Optional
Service Line Date of Service Loop
SE
1100
275 Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

To start and identify an interchange of zero or more functional groups and interchange-related control segments

Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Authorization Information

00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Security Information

00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format

Date of the interchange

ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format

Time of the interchange

ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1

Code indicating sender's request for an interchange acknowledgment

0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

To indicate the beginning of a functional group and to provide control information

Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)

Code identifying a group of application related transaction sets

PI
Patient Information (275)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

Code identifying party sending transmission; codes agreed to by trading partners

GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15

Code identifying party receiving transmission; codes agreed to by trading partners

GS-04
373
Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

005010X210

Heading

ST
0100
Heading > ST

275 Transaction Header

RequiredMax use 1

To indicate the start of a transaction set and to assign a control number

Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
Usage notes
  • Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set.
275
Patient Information
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.
ST-03
1705
Version, Release, or Industry Identifier
Required
String (AN)

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
Usage notes
  • This data element contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
  • This value is always 005010X210.
005010X210
BGN
0200
Heading > BGN

Beginning Segment

RequiredMax use 1

To indicate the beginning of a transaction set

Example
BGN-01
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

02
Add

Used when submitting an attachment to an unsolicited 837.

11
Response

Used when submitting Attachment information in response to a 277.

BGN-02
127
Transaction Set Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • BGN02 is the transaction set reference number.
Usage notes
  • The originator of the transaction set assigns the unique reference number in BGN02 and the date of creation in BGN03.
BGN-03
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

  • BGN03 is the transaction set date.
1000A Payer Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Information LoopProvider Name Information LoopPatient Name Loop
NM1
0500
Heading > Payer Name Loop > NM1

Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Payer Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Payer Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0900
Heading > Payer Name Loop > PER

Payer Contact Information

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • Required when the value in BGN01 is 11 and the Payer Response Contact Information (PER Segment) was reported in the 2210D loop of the 277 transaction. If not required by this implementation guide, do not send.
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The telephone extension, when applicable, should be included in the next sequential communication number data element.
Example
If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-02
93
Payer Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

ED
Electronic Data Interchange Access Number
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Payer Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Payer Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Payer Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

1000A Payer Name Loop end
1000B Submitter Information Loop
RequiredMax 1
NM1
0500
Heading > Submitter Information Loop > NM1

Submitter Information

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

41
Submitter
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Submitter Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Submitter First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Submitter Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

46
Electronic Transmitter Identification Number (ETIN)
NM1-09
67
Submitter Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

1000B Submitter Information Loop end
1000C Provider Name Information Loop
RequiredMax 1
NM1
0500
Heading > Provider Name Information Loop > NM1

Provider Name Information

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • In the solicited 275 model, the information from the 2100C NM1 segment of the 277 must be returned in this segment.
  • In the unsolicited 275 model, the billing provider information must be sent in this segment.
Example
If either Identification Code Qualifier (NM1-08) or Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

1P
Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Provider Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Provider Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Provider Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier

Required when the National Provider Identifier is mandated for use and the provider is a covered health care provider under the mandate.

NM1-09
67
Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PRV
0800
Heading > Provider Name Information Loop > PRV

Provider Taxonomy Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

BI
Billing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1000
Heading > Provider Name Information Loop > REF

Provider Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the provider is not covered under the NPI mandate. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name Loop associated with this claim. This may be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

1100C Provider Identification Loop
RequiredMax 1
NX1
1100
Heading > Provider Name Information Loop > Provider Identification Loop > NX1

Provider Identification

RequiredMax use 1

To define the attributes of a property or an entity

Usage notes
  • The provider address information in this loop applies to the provider information listed in the 1000C loop.
Example
NX1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

1P
Provider
N3
1200
Heading > Provider Name Information Loop > Provider Identification Loop > N3

Provider Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
1300
Heading > Provider Name Information Loop > Provider Identification Loop > N4

Provider City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of 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
N4-01
19
Provider City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Provider State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Postal Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 316.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
1100C Provider Identification Loop end
1000C Provider Name Information Loop end
1000D Patient Name Loop
RequiredMax 1
NM1
0500
Heading > Patient Name Loop > NM1

Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

QC
Patient
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Patient Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Patient First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Patient Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Patient Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

II
Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated for use. Otherwise, another listed code must be used.

MI
Member Identification Number

The code "MI" is intended to be the patient's identification number as assigned by the payer. Payers use different terminology to convey the same number. The Member Identification Number is used to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

NM1-09
67
Patient Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1000
Heading > Patient Name Loop > REF

Patient Control Number

RequiredMax use 1

To specify identifying information

Usage notes
  • When the value in BGN01 of the 275 is 02, the Patient Control Number must be the same number as reported in CLM01 of the 2300 loop in the 837. When the value in BGN01 is 11, the Patient Control Number must be the same number as reported in REF02 of the 2200D loop in the 277.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EJ
Patient Account Number
REF-02
127
Patient Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The maximum number of characters to be supported for this data element is "20". A provider may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any responding system is "20". Characters beyond "20" are not required to be stored nor returned by any 837 receiving system.
REF
1000
Heading > Patient Name Loop > REF

Institutional Type Of Bill

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Institutional Type of Bill from the submitted claim is available in the payer's system and is included in the 2200D REF segment of the 277. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BLT
Billing Type
REF-02
127
Bill Type Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The value in REF02 corresponds to a concatenation of Facility Type Code (CLM05-1) and Claim Frequency Type Code (CLM05-3) from the ASC X12N 837 claim transaction or this is the value from REF02 in the 2200D loop of the 277.
REF
1000
Heading > Patient Name Loop > REF

Medical Record Identification Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Medical Record Identification Number is submitted on the original claim. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EA
Medical Record Identification Number
REF-02
127
Medical Record Identification Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • This is the Medical Record Identification Number from the original claim.
REF
1000
Heading > Patient Name Loop > REF

Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this claim identification number is sent in the 2200D REF segment of the 277. If not required by this implementation guide, do not send.
  • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, trading partners are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

D9
Claim Number
REF-02
127
Clearinghouse Trace Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
DTP
1050
Heading > Patient Name Loop > DTP

Claim Service Date

OptionalMax use 1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the information submitted or requested applies to the entire claim. If not required by this implementation guide, may be provided at the sender's discretion but can not be required by the receiver.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

RD8 is required only when the To and From dates are different.

DTP-03
1251
Claim Service Period
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

1000D Patient Name Loop end
Heading end

Detail

2000A Assigned Number Loop
RequiredMax >1
LX
0100
Detail > Assigned Number Loop > LX

Assigned Number

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • Within the LX, LX01 is the sequence number of the segments that follow. The LX01 sequence number must start at 1 and increment by 1.
  • The LX segment can be repeated to respond to multiple questions on an individual claim. The 275 transaction structure only allows the submitter to send one claim in each 275. A separate Transaction Set Header/Trailer (ST/SE) must be sent for each claim.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

Usage notes
  • Within the LX, LX01 is the sequence number of the segments that follow. The LX01 sequence number must start at 1 and increment by 1.
TRN
0150
Detail > Assigned Number Loop > TRN

Payer Claim Control Number/Provider Attachment Control Number

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • Payer Claim Control Number is the value from the TRN segment loop 2200D of the 277 when in response to a solicited request.
  • The TRN02 value must be the same in each iteration of the 2000A loop when the value in TRN02 is the Payer claim control number.
  • For the unsolicited 275, the Attachment Control Number is the value from PWK06 loop 2300 of the 837. This is the main matching criteria and must be unique on a per attachment basis.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

Used when sending an unsolicited 275 to support an 837.

2
Referenced Transaction Trace Numbers

Used when responding to a 277.

TRN-02
127
Payer Claim Control Number or Provider Attachment Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN02 provides unique identification for the transaction.
Usage notes
  • When the value in BGN01 is 11, this number will be the payer claim control number that is in TRN02 of the 2200D loop, in the 277. This value must be the same in each LX loop.
  • When the value in BGN01 is 02, this number is the unique control number that the provider assigned for the attachment. It must match the number in PWK06 loop 2300 of the 837. This is the main matching criteria and must be unique on a per attachment basis. When using the Attachment Control Number the minimum length requirement is 2. For the unsolicited 275, payers and clearinghouses may ensure a match of the 275 attachment to the claim by concatenating other data in this transaction to the value in TRN02.
  • The payer does not set the format for the Attachment Control Number. However, the payer may have some system constraints, e.g. maximum readable length, that the provider needs to take into account when formatting this Control Number.
STC
0175
Detail > Assigned Number Loop > STC

Status Information

OptionalMax use 1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • Required when the value in BGN01 is 11 (Response). If not required by this implementation guide, do not send.
Example
STC-01
C043
Health Care Claim Status
RequiredMax use 1
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • This is the Category Code. For this implementation the value must be a category code beginning with `R'.
  • See Code Source 507: Health Care Claim Status Category Code
C043-02
1271
Additional Information Request Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • This will be the LOINC® Code that defines the additional information that was requested.
  • See Code Source 663: Logical Observation Identifier Names and Codes (LOINC®)
C043-04
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes
STC-10
C043
Health Care Claim Status
OptionalMax use 1
Used to convey status of the entire claim or a specific service line
Usage notes

Required when the 277 STC10 is used. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • This is the Category Code.
  • See Code Source 507: Health Care Claim Status Category Code
C043-02
1271
Additional Information Request Modifier
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • This will be the LOINC® modifier that clarifies the additional information that was requested.
  • See Code Source 663: Logical Observation Identifier Names and Codes (LOINC®)
C043-04
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes
STC-11
C043
Health Care Claim Status
OptionalMax use 1
Used to convey status of the entire claim or a specific service line
Usage notes

Required when the 277 STC11 is used. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • This is the Category Code.
  • See Code Source 507: Health Care Claim Status Category Code
C043-02
1271
Additional Information Request Modifier
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • This will be the LOINC® modifier that clarifies the additional information that was requested.
  • See Code Source 663: Logical Observation Identifier Names and Codes (LOINC®)
C043-04
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes
REF
0500
Detail > Assigned Number Loop > REF

Service Line Item Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the additional information is associated with the service line or revenue line information. If not required by this implementation guide, do not send.
  • If this segment is used, then there will be a REF segment that contains the Procedure Code or Revenue Code.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

6R
Provider Control Number

Used when the value in BGN01 is 02. This is the Provider Control Number for the line that is reported in the 837 in loop 2400 on the original claim.

FJ
Line Item Control Number

Used when the value in BGN01 is 11. This is the Line Item Control Number that is reported in the 277.

REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • This is the provider control number or the line item control number that is associated with the additional information.
REF
0500
Detail > Assigned Number Loop > REF

Procedure or Revenue Code

OptionalMax use 1

To specify identifying information

Usage notes
  • This segment will convey service line or revenue code information that is associated with the additional information. This matches the value in the 837 SV101-2, SV201-2, or SV301-2 or the 277 SVC01-2 or SVC04.
  • Required when the additional information is associated with the service line or revenue line information. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

CPT
Current Procedural Terminology Code

Used to convey the Procedure Code (HCPCS Level I (CPT) or Level II) reported in the 837 or the 277. Used to convey AMA CPT codes since they are considered Level I procedure codes.

See code source 130: Health Care Financing Administration Common Procedural Coding System

F8
Original Reference Number

Used to convey the Current Dental Terminology (CDT) code.

See code source 135: American Dental Association Codes.

FO
Drug Formulary Number

Used to convey the National Drug Code (NDC) in 5-4-2 format reported in the 837 or the 277.

See code source 240: National Drug Code by format.

PRT
Product Type

Used to convey HIEC codes.
The HIEC codes can only be used

  1. if a new rule names the HIEC codes as an allowable code set under HIPAA.
  2. the Secretary grants an exception to use the code set as a pilot project under the law.
  3. for claims which are not covered under HIPAA.
    See code source 513: Home Infusion EDI Coalition (HIEC)
RB
Rate code number

This code is used for Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code.

VP
Vendor Product Number

This code is used for the Universal Product Number or when the 277 SVC01-1 has the value of UX.

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:

  1. If a new rule names the Universal Product Code as an allowable code set under HIPAA.
  2. For Property & Casualty claims/encounters that are not covered under HIPAA.
YJ
Revenue Source

Used to convey the Revenue Code reported in the 837 or the 277.

See code source 132: National Uniform Billing Committee (NUBC) Codes

ZZ
Mutually Defined

Used to convey Alternative Link codes.

See code source 843: Complementary, Alternative or Holistic Procedure Codes

The ABC codes may only be used

  1. in transactions covered under HIPAA by parties registered in the pilot project and their trading partners.
  2. if a new rule names the ABC code as an allowable code set under HIPAA.
  3. for claims which are not covered under HIPAA.
REF-02
127
Procedure Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • When the service line item is identified with both a procedure code and a revenue code, the revenue code must be reported in REF04.
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

This element is required when the service line is identified with both a procedure code and a revenue code. If not required by this implementation guide, do not send.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

YJ
Revenue Source

Used to convey the Revenue Code reported in the 837 or the 277.

See code source 132: National Uniform Billing Committee (NUBC) Codes

C040-02
127
Revenue Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
0500
Detail > Assigned Number Loop > REF

Procedure Code Modifier

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the procedure code submitted on the original claim include modifiers. If not required by this implementation guide, do not send.
  • The procedure code modifiers should be reported in the same order as on the original claim.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SK
Service Change Number

Used to convey the procedure code modifier reported on the original claim.

REF-02
127
Procedure Code Modifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the original claim includes more than 1 modifier. If not required by this implementation guide, do not send.

If either Reference Identification Qualifier (C040-03) or Procedure Code Modifier (C040-04) is present, then the other is required
If either Reference Identification Qualifier (C040-05) or Procedure Code Modifier (C040-06) is present, then the other is required
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

XX4
Object Code

Used to convey the procedure code modifier reported on the original claim.

C040-02
127
Procedure Code Modifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

C040-03
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

06
System Number

Used to convey the procedure code modifier reported on the original claim.

C040-04
127
Procedure Code Modifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

C040-05
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

4N
Special Payment Reference Number

Used to convey the procedure code modifier reported on the original claim.

C040-06
127
Procedure Code Modifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2100A Service Line Date of Service Loop
OptionalMax 1
DTP
0600
Detail > Assigned Number Loop > Service Line Date of Service Loop > DTP

Service Line Date of Service

RequiredMax use 1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the date of service is not reported at the claim level. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

RD8 is required only when the To and From dates are different.

DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

2100A Service Line Date of Service Loop end
2100B Additional Information Submission Date Loop
RequiredMax 1
Variants (all may be used)
Service Line Date of Service Loop
DTP
0600
Detail > Assigned Number Loop > Additional Information Submission Date Loop > DTP

Additional Information Submission Date

RequiredMax use 1

To specify any or all of a date, a time, or a time period

Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

368
Submittal

Date information is submitted.

DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Additional Information Submitted Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

CAT
0700
Detail > Assigned Number Loop > Additional Information Submission Date Loop > CAT

Category of Patient Information Service

RequiredMax use 1

To specify categories of patient information service

Example
CAT-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

AE
Attachment
CAT-02
756
Attachment Information Format Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

Usage notes
  • Code specifying the format of the HL7 CDA attachment information sent in BIN02. It is up to mutual agreement among trading partners what CAT02 value is used for attachment information not yet adopted or for a business process not addressed under HIPAA.
HL
Health Industry Level 7 Interface Standards (HL/7) Format

Specifies that the content of BIN02 is an HL7 CDA computer decision variant formatted according to HL7 specifications.

IA
Electronic Image

Specifies that the content of BIN02 is an electronic image. "IA" is never used when sending attachment information adopted under HIPAA.

"HL", "MB", or "TX" may be used for attachment information not adopted under HIPAA, and must be used when the attachment information is adopted.

MB
Binary Image

Specifies that the content of BIN02 is an HL7 CDA human decision non-XML variant formatted according to HL7 specifications.

TX
Text

Specifies that the content of BIN02 is an HL7 CDA human decision XML markup variant formatted according to HL7 specifications.

CAT-03
799
Version Identification Code
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

2110B Electronic Format Identification Loop
RequiredMax 1
EFI
0900
Detail > Assigned Number Loop > Additional Information Submission Date Loop > Electronic Format Identification Loop > EFI

Electronic Format Identification

RequiredMax use 1

To provide basic information about the electronic format of the interchange data

Example
EFI-01
786
Security Level Code
Required
Identifier (ID)

Code indicating the level of confidentiality assigned by the sender to the information following

05
Personal

Per public law publication 104-191 August 21, 1996 Section 1177 [HIPAA] - This information is confidential and wrongful use is subject to penalties.

BIN
1000
Detail > Assigned Number Loop > Additional Information Submission Date Loop > Electronic Format Identification Loop > BIN

Binary Data Segment

RequiredMax use 1

To transfer binary data in a single data segment and allow identification of the end of the data segment through a count; there is no identification of the internal structure of the binary data in this segment

Usage notes
  • This segment is used to attach the data referenced in the CAT02 element.
Example
BIN-01
784
Binary Data Length Number
Required
Numeric (N0)
Min 1Max 15

The length in integral octets of the binary data

Usage notes
  • Senders must ensure that the count in BIN01 is equal to the byte count of the contents in BIN02.
BIN-02
785
Binary Data
Required
Binary (B)
Min 1Max 999999999999999

A string of octets which can assume any binary pattern from hexadecimal 00 to FF

Usage notes
  • This element contains the HL7 CDA formatted attachment information as specified in CAT02. It is recommended that BIN02 not exceed 64 megabytes.
  • The segment terminator used in the 275 transaction must not be used within the data content of BIN02.
  • It has been noted that line constraints, transfer protocols, zip programs or conversion processes may insert additional control characters such as, line feeds or carriage returns or other special characters into a transaction. If this occurs in BIN02, the sender's stated count in BIN01 may no longer be equal to the received contents of the data in BIN02.
2110B Electronic Format Identification Loop end
2100B Additional Information Submission Date Loop end
2000A Assigned Number Loop end
SE
1100
Detail > SE

275 Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10

Total number of segments included in a transaction set including ST and SE segments

Usage notes
  • Do not include the segments contained within the HL7 format. The entire BIN segment is considered one segment in the count.
SE-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

To indicate the end of a functional group and to provide control information

Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5

A count of the number of functional groups included in an interchange

IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

EDI Samples

Example 1: Electronic Request

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240222*0142*^*00501*000000001*0*T*>~
GS*PI*SENDERGS*RECEIVERGS*20240222*014254*000000001*X*005010X210~
ST*275*1001*005010X210~
BGN*11*0001*20060915~
NM1*PR*2*ABC INSURANCE COMPANY*****XV*12345~
NM1*41*2*XYZ SERVICES*****46*A222222221~
NM1*1P*2*ST HOLY HILLS HOSPITAL*****XX*3999000B01~
NX1*1P~
N3*2345 Winter Blvd~
N4*Miami*FL*33132~
NM1*QC*1*JACKSON*JACK*J***MI*987654320~
REF*EJ*JACKSON123~
REF*EA*STHHL12345~
DTP*472*D8*20060812~
LX*1~
TRN*2*1822634840~
STC*R4>18626-2>>LOI~
DTP*368*D8*20060915~
CAT*AE*TX~
EFI*05~
BIN*6*......~
LX*2~
TRN*2*1822634840~
STC*R4>18647-8>>LOI~
DTP*368*D8*20060915~
CAT*AE*TX~
EFI*05~
BIN*6*......~
SE*27*1001~
GE*1*000000001~
IEA*1*000000001~

Example 2: No 277 Request

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240222*0149*^*00501*000000001*0*T*>~
GS*PI*SENDERGS*RECEIVERGS*20240222*014957*000000001*X*005010X210~
ST*275*1001*005010X210~
BGN*02*0001*20060918~
NM1*PR*2*ABC INSURANCE COMPANY*****XV*12345~
NM1*41*2*XYZ SERVICES*****46*A222222221~
NM1*1P*2*ST HOLY HILLS HOSPITAL*****XX*3999000801~
NX1*1P~
N3*2345 Winter Blvd~
N4*Miami*FL*33132~
NM1*QC*1*JACKSON*JACK*J***MI*987654323~
REF*EJ*JACKSON123~
REF*EA*STHHL12345~
DTP*472*D8*20060915~
LX*1~
TRN*1*986543~
DTP*368*D8*20060918~
CAT*AE*HL~
EFI*05~
BIN*4*1101~
SE*19*1001~
GE*1*000000001~
IEA*1*000000001~

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