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X12 837 Post-adjudicated Claims Data Reporting: Professional (X298A1)
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Delimiters
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- * Element
- > Component
- ^ Repetition
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Billing Provider Name Loop
NM1
0150
Billing Provider Name
Max use 1
Required
N3
0250
Billing Provider Address
Max use 1
Required
N4
0300
Billing Provider City, State, ZIP Code
Max use 1
Required
REF
0350
Billing Provider Tax Identification
Max use 1
Required
REF
0350
Billing Provider License Information
Max use 2
Optional
REF
0350
Billing Provider Secondary Identification
Max use 2
Optional
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Required
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Required
DMG
0320
Subscriber Demographic Information
Max use 1
Required
REF
0350
Subscriber Social Security Number
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Required
AMT
3000
Remaining Patient Liability
Max use 1
Optional
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
DTP
3450
Claim Check or Remittance Date
Max use 1
Required
REF
3550
Other Payer Secondary Identifier
Max use 4
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Adjusted Claim Control Number
Max use 1
Optional
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV1
3700
Professional Service
Max use 1
Required
PWK
4200
Line Supplemental Information
Max use 10
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
Date - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Referral Number
Max use 1
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 1
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service Information
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
SE
5550
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
—
Example
Required
Identifier (ID)
—
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Required
Identifier (ID)
—
- 00
- No Security Information Present (No Meaningful Information in I04)
Required
Identifier (ID)
—
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
Required
Identifier (ID)
Min 1Max 1
—
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Required
Identifier (ID)
Min 1Max 1
—
- I
- Information
- P
- Production Data
- T
- Test Data
GS
Functional Group Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
Min 1Max 2
—
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Heading
ST
0050
Heading > ST
Transaction Set Header
RequiredMax use 1
—
Example
BHT
0100
Heading > BHT
Beginning of Hierarchical Transaction
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 0019
- Information Source, Subscriber, Dependent
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name LoopNM1
0200
Heading > Submitter Name Loop > NM1
Submitter Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)—
PER
0450
Heading > Submitter Name Loop > PER
Submitter EDI Contact Information
RequiredMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
Required
Identifier (ID)
—
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name LoopNM1
0200
Heading > Receiver Name Loop > NM1
Receiver Name
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)—
1000B Receiver Name Loop end
Heading end
Detail
2000A Billing Provider Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV
Billing Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR
Foreign Currency Information
OptionalMax use 1
—
Usage notes
—
Example
2010AA Billing Provider Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1
Billing Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
Usage notes
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3
Billing Provider Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4
Billing Provider City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Billing 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
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider Tax Identification
RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider License InformationREFBilling Provider Secondary IdentificationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider License Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax IdentificationREFBilling Provider Secondary IdentificationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax IdentificationREFBilling Provider License Information2010AA Billing Provider Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR
Subscriber Information
RequiredMax use 1
—
Example
2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Data Receiver LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1
Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3
Subscriber Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4
Subscriber City, State, ZIP Code
RequiredMax 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
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG
Subscriber Demographic Information
RequiredMax use 1
—
Usage notes
—
Example
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Subscriber Social Security Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim NumberREF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Property and Casualty Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFSubscriber Social Security Number2010BA Subscriber Name Loop end
2010BB Data Receiver Loop
RequiredMax 1
Variants (all may be used)
Subscriber Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Data Receiver Loop > NM1
Data Receiver
RequiredMax use 1
—
Example
2010BB Data Receiver Loop end
2000C Patient Hierarchical Level Loop
OptionalMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT
Patient Information
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 01
- Spouse
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
2010CA Patient Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1
Patient Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Patient Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3
Patient Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4
Patient City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Patient 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
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG
Patient Demographic Information
RequiredMax use 1
—
Usage notes
—
Example
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF
Patient Social Security Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim NumberREF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF
Property and Casualty Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFPatient Social Security Number2010CA Patient Name Loop end
2300 Claim Information Loop
RequiredMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM
Claim Information
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax 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
Optional
Identifier (ID)
—
Usage notes
—
- A
- Assigned
- B
- Assignment Accepted on Clinical Lab Services Only
- C
- Not Assigned
Optional
Identifier (ID)
—
Usage notes
—
- N
- No
- W
- Not Applicable—
- Y
- Yes
Optional
Identifier (ID)
—
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Optional
Identifier (ID)
—
- P
- Signature generated by provider because the patient was not physically present for services—
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
Optional
Identifier (ID)
—
- 02
- Physically Handicapped Children's Program
- 03
- Special Federal Funding
- 05
- Disability
- 09
- Second Opinion or Surgery
Optional
Identifier (ID)
—
- 1
- Proof of Eligibility Unknown or Unavailable
- 2
- Litigation
- 3
- Authorization Delays
- 4
- Delay in Certifying Provider
- 5
- Delay in Supplying Billing Forms
- 6
- Delay in Delivery of Custom-made Appliances
- 7
- Third Party Processing Delay
- 8
- Delay in Eligibility Determination
- 9
- Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
- 10
- Administration Delay in the Prior Approval Process
- 11
- Other
- 15
- Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Accident
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Acute Manifestation
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Admission
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Assumed and Relinquished Care Dates
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Authorized Return to Work
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Disability Dates
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateRequired
Identifier (ID)
—
- 314
- Disability—
- 360
- Initial Disability Period Start—
- 361
- Initial Disability Period End—
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Discharge
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Hearing and Vision Prescription Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Menstrual Period
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Onset of Current Illness or Symptom
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Initial Treatment Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Seen Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Worked
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last X-ray Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Property and Casualty Date of First Contact
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Repricer Received Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactPWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > PWK
Claim Supplemental 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
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
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- 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
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- 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
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Required
Identifier (ID)
—
- AA
- Available on Request at Provider Site—
- BM
- By Mail
- EL
- Electronically Only—
- EM
- FT
- File Transfer—
- FX
- By Fax
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1
Contract Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 01
- Diagnosis Related Group (DRG)
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT
Patient Amount Paid
OptionalMax use 1
—
Usage notes
—
Example
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Adjusted Repriced Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Investigational Device Exemption Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Claim Identifier For Transmission Intermediaries
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Mammography Certification Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Prior Authorization
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Payer Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Clinical Laboratory Improvement Amendment (CLIA) Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Medical Record Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Referral Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Repriced Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Service Authorization Exception Code
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberK3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3
File Information
OptionalMax use 10
—
Usage notes
—
Example
NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE
Claim Note
OptionalMax use 1
—
Usage notes
—
Example
CR1
1950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR1
Ambulance Transport Information
OptionalMax use 1
—
Usage notes
—
Example
If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
Required
Identifier (ID)
—
- A
- Patient was transported to nearest facility for care of symptoms, complaints, or both—
- B
- Patient was transported for the benefit of a preferred physician
- C
- Patient was transported for the nearness of family members
- D
- Patient was transported for the care of a specialist or for availability of specialized equipment
- E
- Patient Transferred to Rehabilitation Facility
CR2
2000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR2
Spinal Manipulation Service Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- A
- Acute Condition
- C
- Chronic Condition
- D
- Non-acute
- E
- Non-Life Threatening
- F
- Routine
- G
- Symptomatic
- M
- Acute Manifestation of a Chronic Condition
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC
Ambulance Certification
OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
CRCPatient Condition Information: VisionCRCHomebound IndicatorCRCEPSDT ReferralRequired
Identifier (ID)
—
- 01
- Patient was admitted to a hospital
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 06
- Patient was transported in an emergency situation
- 07
- Patient had to be physically restrained
- 08
- Patient had visible hemorrhaging
- 09
- Ambulance service was medically necessary
- 12
- Patient is confined to a bed or chair—
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC
Patient Condition Information: Vision
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- L1
- General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
- L2
- Replacement Due to Loss or Theft
- L3
- Replacement Due to Breakage or Damage
- L4
- Replacement Due to Patient Preference
- L5
- Replacement Due to Medical Reason
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC
Homebound Indicator
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
CRCAmbulance CertificationCRCPatient Condition Information: VisionCRCEPSDT ReferralCRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC
EPSDT Referral
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
CRCAmbulance CertificationCRCPatient Condition Information: VisionCRCHomebound IndicatorRequired
Identifier (ID)
—
Usage notes
—
- N
- No—
- Y
- Yes
Required
Identifier (ID)
—
Usage notes
—
- AV
- Available - Not Used—
- NU
- Not Used—
- S2
- Under Treatment—
- ST
- New Services Requested—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI
Health Care Diagnosis Code
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI
Anesthesia Related Procedure
OptionalMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI
Condition Information
OptionalMax use 2
—
Usage notes
—
Example
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP
Claim Pricing/Repricing Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Optional
Decimal number (R)
Min 1Max 15
—
Optional
Identifier (ID)
—
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Optional
Identifier (ID)
—
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Optional
Identifier (ID)
—
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
2310A Referring Provider Name Loop
OptionalMax 2
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1
Referring Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF
Referring Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
2310A Referring Provider Name Loop end
2310B Rendering Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1
Rendering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV
Rendering Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF
Rendering Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
RequiredMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1
Service Facility Location Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3
Service Facility Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4
Service Facility Location City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Laboratory or Facility 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
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF
Service Facility Location Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310C Service Facility Location Name Loop end
2310D Supervising Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1
Supervising Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF
Supervising Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310D Supervising Provider Name Loop end
2310E Ambulance Pick-up Location Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1
Ambulance Pick-up Location
RequiredMax use 1
—
Usage notes
—
Example
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N3
Ambulance Pick-up Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N4
Ambulance Pick-up Location City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Ambulance Pick-up 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
2310E Ambulance Pick-up Location Loop end
2310F Ambulance Drop-Off Location Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-Off Location Loop > NM1
Ambulance Drop-Off Location
RequiredMax use 1
—
Usage notes
—
Example
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-Off Location Loop > N3
Ambulance Drop-Off Location Address
RequiredMax use 1
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-Off Location Loop > N4
Ambulance Drop-Off Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Drop-off State or Province Code (N4-02) or Ambulance Drop-off Country Subdivision Code (N4-07) may be present
If Ambulance Drop-off Country Subdivision Code (N4-07) is present, then Ambulance Drop-off Country Code (N4-04) is required
2310F Ambulance Drop-Off Location Loop end
2320 Other Subscriber Information Loop
RequiredMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR
Other Subscriber Information
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- A
- Payer Responsibility Four
- B
- Payer Responsibility Five
- C
- Payer Responsibility Six
- D
- Payer Responsibility Seven
- E
- Payer Responsibility Eight
- F
- Payer Responsibility Nine
- G
- Payer Responsibility Ten
- H
- Payer Responsibility Eleven
- P
- Primary
- S
- Secondary
- T
- Tertiary
- U
- Unknown
Required
Identifier (ID)
—
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Required
Identifier (ID)
—
- 1
- Coordination of Benefits—
- 6
- No Coordination of Benefits—
Required
Identifier (ID)
—
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- OF
- Other Federal Program—
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined—
CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS
Claim Level Adjustments
OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
Required
Identifier (ID)
—
- CO
- Contractual Obligations
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Coordination of Benefits (COB) Payer Paid Amount
RequiredMax use 1
—
Example
Variants (all may be used)
AMTRemaining Patient LiabilityAMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Remaining Patient Liability
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountMOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA
Outpatient Adjudication Information
OptionalMax use 1
—
Usage notes
—
Example
2330A Other Subscriber Name Loop
RequiredMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1
Other Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3
Other Subscriber Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4
Other Subscriber City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Subscriber 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
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF
Other Subscriber Social Security Number
OptionalMax use 1
—
Usage notes
—
Example
2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1
Other Payer Name
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
Usage notes
—
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
DTP
3450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP
Claim Check or Remittance Date
RequiredMax use 1
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Secondary Identifier
OptionalMax use 4
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Claim Adjustment Indicator
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Adjusted Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
2330B Other Payer Name Loop end
2330C Other Patient Name Loop
OptionalMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > NM1
Other Patient Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Other Insured Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > N3
Other Patient Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > N4
Other Patient City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Patient 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
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > REF
Other Patient Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2330C Other Patient Name Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 50
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX
Service Line Number
RequiredMax use 1
—
Usage notes
—
Example
SV1
3700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV1
Professional Service
RequiredMax use 1
—
Example
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Required
Identifier (ID)
—
Usage notes
—
- ER
- Jurisdiction Specific Procedure and Supply Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
- WK
- Advanced Billing Concepts (ABC) Codes
RequiredMax use 1
To identify one or more diagnosis code pointers
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK
Line Supplemental Information
OptionalMax use 10
—
Usage notes
—
Example
Variants (all may be used)
PWKDurable Medical Equipment Certificate of Medical Necessity IndicatorIf either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
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
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- 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
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- 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
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Required
Identifier (ID)
—
- AA
- Available on Request at Provider Site—
- BM
- By Mail
- EL
- Electronically Only—
- EM
- FT
- File Transfer—
- FX
- By Fax
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK
Durable Medical Equipment Certificate of Medical Necessity Indicator
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
PWKLine Supplemental InformationCR1
4250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR1
Ambulance Transport Information
OptionalMax use 1
—
Usage notes
—
Example
If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
Required
Identifier (ID)
—
- A
- Patient was transported to nearest facility for care of symptoms, complaints, or both
- B
- Patient was transported for the benefit of a preferred physician
- C
- Patient was transported for the nearness of family members
- D
- Patient was transported for the care of a specialist or for availability of specialized equipment
- E
- Patient Transferred to Rehabilitation Facility
CR3
4350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR3
Durable Medical Equipment Certification
OptionalMax use 1
—
Usage notes
—
Example
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC
Ambulance Certification
OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
CRCHospice Employee IndicatorCRCCondition Indicator/Durable Medical EquipmentRequired
Identifier (ID)
—
Usage notes
—
- 01
- Patient was admitted to a hospital
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 06
- Patient was transported in an emergency situation
- 07
- Patient had to be physically restrained
- 08
- Patient had visible hemorrhaging
- 09
- Ambulance service was medically necessary
- 12
- Patient is confined to a bed or chair—
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC
Hospice Employee Indicator
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
CRCAmbulance CertificationCRCCondition Indicator/Durable Medical EquipmentCRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC
Condition Indicator/Durable Medical Equipment
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 38
- Certification signed by the physician is on file at the supplier's office
- ZV
- Replacement Item
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Initial Treatment Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Service Date
RequiredMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Prescription Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Certification Revision/Recertification Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Begin Therapy Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Last Certification Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Last Seen Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Last X-ray Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Shipped Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Test Date
OptionalMax use 2
—
Usage notes
—
Example
QTY
4600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY
Ambulance Patient Count
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
QTYObstetric Anesthesia Additional UnitsQTY
4600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY
Obstetric Anesthesia Additional Units
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
QTYAmbulance Patient CountMEA
4620
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > MEA
Test Result
OptionalMax use 5
—
Usage notes
—
Example
CN1
4650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1
Contract Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 01
- Diagnosis Related Group (DRG)
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Clinical Laboratory Improvement Amendment (CLIA) Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFAdjusted Repriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Immunization Batch Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFAdjusted Repriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Line Item Control Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFAdjusted Repriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Mammography Certification Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFAdjusted Repriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Referral Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFAdjusted Repriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
OptionalMax use 1
—
Usage notes
—
Example
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Repriced Line Item Reference Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFAdjusted Repriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Adjusted Repriced Line Item Reference Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFPrior AuthorizationREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Prior Authorization
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREFAdjusted Repriced Line Item Reference NumberAMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT
Sales Tax Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTPostage Claimed AmountAMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT
Postage Claimed Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTSales Tax AmountK3
4800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3
File Information
OptionalMax use 10
—
Usage notes
—
Example
NTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE
Line Note
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
NTEThird Party Organization NotesNTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE
Third Party Organization Notes
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
NTELine NotePS1
4880
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1
Purchased Service Information
OptionalMax use 1
—
Usage notes
—
Example
HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP
Line Pricing/Repricing Information
OptionalMax use 1
—
Usage notes
—
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
Required
Identifier (ID)
—
Usage notes
—
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Optional
Decimal number (R)
Min 1Max 15
—
Optional
Identifier (ID)
—
- ER
- Jurisdiction Specific Procedure and Supply Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
- WK
- Advanced Billing Concepts (ABC) Codes
Optional
Identifier (ID)
—
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Optional
Identifier (ID)
—
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Optional
Identifier (ID)
—
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
2410 Drug Identification Loop
OptionalMax 1
LIN
4930
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN
Drug Identification
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- EN
- EAN/UCC - 13
- EO
- EAN/UCC - 8
- HI
- HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message
- N4
- National Drug Code in 5-4-2 Format—
- ON
- Customer Order Number
- UK
- GTIN 14-digit Data Structure
- UP
- UCC - 12
LIN-03
234
National Drug Code, Universal Product Number or Device Identifier of the Unique Device Identifier
Required
String (AN)
Min 1Max 48
—
CTP
4940
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP
Drug Quantity
RequiredMax use 1
—
Usage notes
—
Example
REF
4950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF
Prescription or Compound Drug Association Number
OptionalMax use 1
—
Usage notes
—
Example
2410 Drug Identification Loop end
2420A Rendering Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1
Rendering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV
Rendering Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF
Rendering Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2420A Rendering Provider Name Loop end
2420B Purchased Service Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1
Purchased Service Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
Usage notes
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > REF
Purchased Service Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
2420B Purchased Service Provider Name Loop end
2420C Service Facility Location Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1
Service Facility Location Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3
Service Facility Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4
Service Facility Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Laboratory or Facility 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
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF
Service Facility Location Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2420C Service Facility Location Name Loop end
2420D Supervising Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1
Supervising Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF
Supervising Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2420D Supervising Provider Name Loop end
2420E Ordering Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1
Ordering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3
Ordering Provider Address
OptionalMax use 1
—
Usage notes
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4
Ordering Provider City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Ordering 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
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > REF
Ordering Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
PER
5300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > PER
Ordering Provider Contact Information
OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
Required
Identifier (ID)
—
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
2420E Ordering Provider Name Loop end
2420F Referring Provider Name Loop
OptionalMax 2
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1
Referring Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF
Referring Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
2420F Referring Provider Name Loop end
2420G Ambulance Pick-up Location Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > NM1
Ambulance Pick-up Location
RequiredMax use 1
—
Usage notes
—
Example
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N3
Ambulance Pick-up Location Address
RequiredMax use 1
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N4
Ambulance Pick-up Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Pick-up State or Province Code (N4-02) or Ambulance Pick-up Country Subdivision Code (N4-07) may be present
If Ambulance Pick-up Country Subdivision Code (N4-07) is present, then Ambulance Pick-up Country Code (N4-04) is required
2420G Ambulance Pick-up Location Loop end
2420H Ambulance Drop-Off Location Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-Off Location Loop > NM1
Ambulance Drop-Off Location
RequiredMax use 1
—
Usage notes
—
Example
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-Off Location Loop > N3
Ambulance Drop-Off Location Address
RequiredMax use 1
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-Off Location Loop > N4
Ambulance Drop-Off Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Drop-off State or Province Code (N4-02) or Ambulance Drop-off Country Subdivision Code (N4-07) may be present
If Ambulance Drop-off Country Subdivision Code (N4-07) is present, then Ambulance Drop-off Country Code (N4-04) is required
2420H Ambulance Drop-Off Location Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD
Line Adjudication Information
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
- SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
Required
Identifier (ID)
—
- ER
- Jurisdiction Specific Procedure and Supply Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
- WK
- Advanced Billing Concepts (ABC) Codes
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS
Line Adjustment
OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
Required
Identifier (ID)
—
- CO
- Contractual Obligations
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP
Line Check or Remittance Date
RequiredMax use 1
—
Example
AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT
Remaining Patient Liability
OptionalMax use 1
—
Usage notes
—
Example
2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop end
2000B Subscriber Hierarchical Level Loop end
2000A Billing Provider Hierarchical Level Loop end
SE
5550
Detail > SE
Transaction Set Trailer
RequiredMax use 1
—
Example
Detail end
GE
Functional Group Trailer
RequiredMax use 1
—
Example
IEA
Interchange Control Trailer
RequiredMax use 1
—
Example
EDI Samples
Adjudicated Claim submitted to All Payer Claim Data Base (APCD)
ST*837*0021*005010X298A1~
BHT*0019*00*244579*20120315*1023*RP~
NM1*41*2*ABC PLAN*****46*TGJ23~
PER*IC*IT GROUP*TE*3055552222*EX*231~
NM1*40*2*REPORTING ENTITY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*207Q00000X~
NM1*85*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*N~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*ZD*2*DATA RECEIVER~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
CLM*26463774*100***11>B>1~
REF*F8*20121092600001~
HI*ABK>M25375*ABF>M19072~
NM1*82*1*JONES*BARNABY****XX*1234567890~
NM1*77*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
SBR*P*19*2222-SJ***6***CI~
AMT*D*75~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*ABC PLAN*****PI*59999~
DTP*573*D8*20120314~
REF*F8*20121092600001~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
LX*1~
SV1*HC>99213*100*UN*1*11**1**Y**Y*Y~
DTP*472*D8*20120204~
SVD*59999*75*HC>99213**1~
CAS*CO*45*25~
DTP*573*D8*20120314~
SE*49*0021~
BHT*0019*00*244579*20120315*1023*RP~
NM1*41*2*ABC PLAN*****46*TGJ23~
PER*IC*IT GROUP*TE*3055552222*EX*231~
NM1*40*2*REPORTING ENTITY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*207Q00000X~
NM1*85*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*N~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*ZD*2*DATA RECEIVER~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
CLM*26463774*100***11>B>1~
REF*F8*20121092600001~
HI*ABK>M25375*ABF>M19072~
NM1*82*1*JONES*BARNABY****XX*1234567890~
NM1*77*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
SBR*P*19*2222-SJ***6***CI~
AMT*D*75~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*ABC PLAN*****PI*59999~
DTP*573*D8*20120314~
REF*F8*20121092600001~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
LX*1~
SV1*HC>99213*100*UN*1*11**1**Y**Y*Y~
DTP*472*D8*20120204~
SVD*59999*75*HC>99213**1~
CAS*CO*45*25~
DTP*573*D8*20120314~
SE*49*0021~
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