X12 277 Health Care Information Status Notification (X212)

X12 Release 5010

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA Interchange Control Header

Required · Max use 1

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

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

ISA-02 · I02 · Authorization Information · Required · String (AN) · Min 10 Max 10

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

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

ISA-04 · I04 · Security Information · Required · String (AN) · Min 10 Max 10

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

Codes

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

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

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

Codes

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

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

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

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

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

• ^: Repetition Separator

ISA-12 · I11 · Interchange Control Version Number · Required · Identifier (ID)

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

ISA-13 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

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

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

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

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

• HN: Health Care Information Status Notification (277)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

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

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

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

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

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

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

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

005010X212

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

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

• 277: Health Care Information Status Notification

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

ST-03 · 1705 · Version, Release, or Industry Identifier · Required · String (AN)

005010X212

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

BHT-01 · 1005 · Hierarchical Structure Code · Required · Identifier (ID)

• 0010: Information Source, Information Receiver, Provider of Service, Subscriber, Dependent

BHT-02 · 353 · Transaction Set Purpose Code · Required · Identifier (ID)

• 08: Status

BHT-03 · 127 · Originator Application Transaction Identifier · Required · String (AN) · Min 1 Max 50

BHT-04 · 373 · Transaction Set Creation Date · Required · Date (DT) · CCYYMMDD format

BHT-05 · 337 · Transaction Set Creation Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

BHT-06 · 640 · Transaction Type Code · Required · Identifier (ID)

• DG: Response

Detail

2000A Information Source Level Loop Required Max >1

0100 Detail > Information Source Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 20: Information Source

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

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

2100A Payer Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Payer Name Loop > NM1

NM1 Payer Name

Required · Max use 1

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

• PR: Payer

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

• 2: Non-Person Entity

NM1-03 · 1035 · Payer Name · Required · String (AN)

SECURITY HEALTH PLAN

SHP

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

• PI: Payor Identification

NM1-09 · 67 · Payer Identifier · Required · String (AN)

SHP

0800 Detail > Information Source Level Loop > Payer Name Loop > PER

PER Payer Contact Information

Optional · Max use 1

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

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

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

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

PER-03 · 365 · Communication Number Qualifier · Required · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone

PER-04 · 364 · Payer Contact Communication Number · Required · String (AN) · Min 1 Max 256

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

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-06 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

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

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-08 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

2000B Information Receiver Level Loop Required Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 21: Information Receiver

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

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

2100B Information Receiver Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

NM1 Information Receiver Name

Required · Max use 1

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

• 41: Submitter

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

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Information Receiver Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Information Receiver First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Information Receiver Middle Name · Optional · String (AN) · Min 1 Max 25

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

• 46: Electronic Transmitter Identification Number (ETIN)

NM1-09 · 67 · Information Receiver Identification Number · Required · String (AN) · Min 2 Max 80

2200B Information Receiver Trace Identifier Loop Optional Max 1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Trace Identifier Loop > TRN

TRN Information Receiver Trace Identifier

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 2: Referenced Transaction Trace Numbers

TRN-02 · 127 · Claim Transaction Batch Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Trace Identifier Loop > STC

STC Information Receiver Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max use 1 · Used to convey status of the entire claim or a specific service line

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 41: Submitter
• AY: Clearinghouse
• PR: Payer

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-10 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-11 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

2000C Service Provider Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 19: Provider of Service

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

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

2100C Provider Name Loop Required Max 2

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider Name Loop > NM1

NM1 Provider Name

Required · Max use 1

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

• 1P: Provider

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

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Provider Last or Organization Name · Optional · String (AN) · Min 1 Max 60

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

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

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

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

• FI: Federal Taxpayer's Identification Number
• SV: Service Provider Number
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

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

2200C Provider of Service Trace Identifier Loop Optional Max 1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider of Service Trace Identifier Loop > TRN

TRN Provider of Service Trace Identifier

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Provider of Service Information Trace Identifier · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider of Service Trace Identifier Loop > STC

STC Provider Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max use 1 · Used to convey status of the entire claim or a specific service line

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 1P: Provider

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-10 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-11 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

2000D Subscriber Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 22: Subscriber

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

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

2100D Subscriber Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

NM1 Subscriber Name

Required · Max use 1

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

• IL: Insured or Subscriber

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

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Subscriber Last Name · Required · String (AN) · Min 1 Max 60

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

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

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

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

• 24: Employer's Identification Number
• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number

NM1-09 · 67 · Subscriber Identifier · Required · String (AN) · Min 2 Max 80

2200D Claim Status Tracking Number Loop Optional Max >1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > TRN

TRN Claim Status Tracking Number

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 2: Referenced Transaction Trace Numbers

TRN-02 · 127 · Referenced Transaction Trace Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > STC

STC Claim Level Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max use 1 · Used to convey status of the entire claim or a specific service line

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 1E: Health Maintenance Organization (HMO)
• 1G: Oncology Center
• 1H: Kidney Dialysis Unit
• 1I: Preferred Provider Organization (PPO)
• 1O: Acute Care Hospital
• 1P: Provider
• 1Q: Military Facility
• 1R: University, College or School
• 1S: Outpatient Surgicenter
• 1T: Physician, Clinic or Group Practice
• 1U: Long Term Care Facility
• 1V: Extended Care Facility
• 1W: Psychiatric Health Facility
• 1X: Laboratory
• 1Y: Retail Pharmacy
• 1Z: Home Health Care
• 2A: Federal, State, County or City Facility
• 2B: Third-Party Administrator
• 2D: Miscellaneous Health Care Facility
• 2E: Non-Health Care Miscellaneous Facility
• 2I: Church Operated Facility
• 2K: Partnership
• 2P: Public Health Service Facility
• 2Q: Veterans Administration Facility
• 2S: Public Health Service Indian Service Facility
• 2Z: Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
• 03: Dependent
• 3A: Hospital Unit Within an Institution for the Mentally Retarded
• 3C: Tuberculosis and Other Respiratory Diseases Facility
• 3D: Obstetrics and Gynecology Facility
• 3E: Eye, Ear, Nose and Throat Facility
• 3F: Rehabilitation Facility
• 3G: Orthopedic Facility
• 3H: Chronic Disease Facility
• 3I: Other Specialty Facility
• 3J: Children's General Facility
• 3K: Children's Hospital Unit of an Institution
• 3L: Children's Psychiatric Facility
• 3M: Children's Tuberculosis and Other Respiratory Diseases Facility
• 3N: Children's Eye, Ear, Nose and Throat Facility
• 3O: Children's Rehabilitation Facility
• 3P: Children's Orthopedic Facility
• 3Q: Children's Chronic Disease Facility
• 3R: Children's Other Specialty Facility
• 3S: Institution for Mental Retardation
• 3T: Alcoholism and Other Chemical Dependency Facility
• 3U: General Inpatient Care for AIDS/ARC Facility
• 3V: AIDS/ARC Unit
• 3W: Specialized Outpatient Program for AIDS/ARC
• 3X: Alcohol/Drug Abuse or Dependency Inpatient Unit
• 3Y: Alcohol/Drug Abuse or Dependency Outpatient Services
• 3Z: Arthritis Treatment Center
• 4A: Birthing Room/LDRP Room
• 4B: Burn Care Unit
• 4C: Cardiac Catherization Laboratory
• 4D: Open-Heart Surgery Facility
• 4E: Cardiac Intensive Care Unit
• 4F: Angioplasty Facility
• 4G: Chronic Obstructive Pulmonary Disease Service Facility
• 4H: Emergency Department
• 4I: Trauma Center (Certified)
• 4J: Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
• 4L: Genetic Counseling/Screening Services
• 4M: Adult Day Care Program Facility
• 4N: Alzheimer's Diagnostic/Assessment Services
• 4O: Comprehensive Geriatric Assessment Facility
• 4P: Emergency Response (Geriatric) Unit
• 4Q: Geriatric Acute Care Unit
• 4R: Geriatric Clinics
• 4S: Respite Care Facility
• 4U: Patient Education Unit
• 4V: Community Health Promotion Facility
• 4W: Worksite Health Promotion Facility
• 4X: Hemodialysis Facility
• 4Y: Home Health Services
• 4Z: Hospice
• 5A: Medical Surgical or Other Intensive Care Unit
• 5B: Hisopathology Laboratory
• 5C: Blood Bank
• 5D: Neonatal Intensive Care Unit
• 5E: Obstetrics Unit
• 5F: Occupational Health Services
• 5G: Organized Outpatient Services
• 5H: Pediatric Acute Inpatient Unit
• 5I: Psychiatric Child/Adolescent Services
• 5J: Psychiatric Consultation-Liaison Services
• 5K: Psychiatric Education Services
• 5L: Psychiatric Emergency Services
• 5M: Psychiatric Geriatric Services
• 5N: Psychiatric Inpatient Unit
• 5O: Psychiatric Outpatient Services
• 5P: Psychiatric Partial Hospitalization Program
• 5Q: Megavoltage Radiation Therapy Unit
• 5R: Radioactive Implants Unit
• 5S: Therapeutic Radioisotope Facility
• 5T: X-Ray Radiation Therapy Unit
• 5U: CT Scanner Unit
• 5V: Diagnostic Radioisotope Facility
• 5W: Magnetic Resonance Imaging (MRI) Facility
• 5X: Ultrasound Unit
• 5Y: Rehabilitation Inpatient Unit
• 5Z: Rehabilitation Outpatient Services
• 6A: Reproductive Health Services
• 6B: Skilled Nursing or Other Long-Term Care Unit
• 6C: Single Photon Emission Computerized Tomography (SPECT) Unit
• 6D: Organized Social Work Service Facility
• 6E: Outpatient Social Work Services
• 6F: Emergency Department Social Work Services
• 6G: Sports Medicine Clinic/Services
• 6H: Hospital Auxiliary Unit
• 6I: Patient Representative Services
• 6J: Volunteer Services Department
• 6K: Outpatient Surgery Services
• 6L: Organ/Tissue Transplant Unit
• 6M: Orthopedic Surgery Facility
• 6N: Occupational Therapy Services
• 6O: Physical Therapy Services
• 6P: Recreational Therapy Services
• 6Q: Respiratory Therapy Services
• 6R: Speech Therapy Services
• 6S: Women's Health Center/Services
• 6U: Cardiac Rehabilitation Program Facility
• 6V: Non-Invasive Cardiac Assessment Services
• 6W: Emergency Medical Technician
• 6X: Disciplinary Contact
• 6Y: Case Manager
• 7C: Place of Occurrence
• 13: Contracted Service Provider
• 17: Consultant's Office
• 28: Subcontractor
• 30: Service Supplier
• 36: Employer
• 40: Receiver
• 43: Claimant Authorized Representative
• 44: Data Processing Service Bureau
• 61: Performed At
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• 74: Corrected Insured
• 77: Service Location
• 80: Hospital
• 82: Rendering Provider
• 84: Subscriber's Employer
• 85: Billing Provider
• 87: Pay-to Provider
• 95: Research Institute
• CK: Pharmacist
• CZ: Admitting Surgeon
• D2: Commercial Insurer
• DD: Assistant Surgeon
• DJ: Consulting Physician
• DK: Ordering Physician
• DN: Referring Provider
• DO: Dependent Name
• DQ: Supervising Physician
• E1: Person or Other Entity Legally Responsible for a Child
• E2: Person or Other Entity With Whom a Child Resides
• E7: Previous Employer
• E9: Participating Laboratory
• FA: Facility
• FD: Physical Address
• FE: Mail Address
• G0: Dependent Insured
• G3: Clinic
• GB: Other Insured
• GD: Guardian
• GI: Paramedic
• GJ: Paramedical Company
• GK: Previous Insured
• GM: Spouse Insured
• GY: Treatment Facility
• HF: Healthcare Professional Shortage Area (HPSA) Facility
• HH: Home Health Agency
• I3: Independent Physicians Association (IPA)
• IJ: Injection Point
• IL: Insured or Subscriber
• IN: Insurer
• LI: Independent Lab
• LR: Legal Representative
• MR: Medical Insurance Carrier
• MSC: Mammography Screening Center
• OB: Ordered By
• OD: Doctor of Optometry
• OX: Oxygen Therapy Facility
• P0: Patient Facility
• P2: Primary Insured or Subscriber
• P3: Primary Care Provider
• P4: Prior Insurance Carrier
• P6: Third Party Reviewing Preferred Provider Organization (PPO)
• P7: Third Party Repricing Preferred Provider Organization (PPO)
• PRP: Primary Payer
• PT: Party to Receive Test Report
• PV: Party performing certification
• PW: Pickup Address
• QA: Pharmacy
• QB: Purchase Service Provider
• QC: Patient
• QD: Responsible Party
• QE: Policyholder
• QH: Physician
• QK: Managed Care
• QL: Chiropractor
• QN: Dentist
• QO: Doctor of Osteopathy
• QS: Podiatrist
• QV: Group Practice
• QY: Medical Doctor
• RC: Receiving Location
• RW: Rural Health Clinic
• S4: Skilled Nursing Facility
• SEP: Secondary Payer
• SJ: Service Provider
• SU: Supplier/Manufacturer
• T4: Transfer Point
• TL: Testing Laboratory
• TQ: Third Party Reviewing Organization (TPO)
• TT: Transfer To
• TTP: Tertiary Payer
• TU: Third Party Repricing Organization (TPO)
• UH: Nursing Home
• X3: Utilization Management Organization
• X4: Spouse
• X5: Durable Medical Equipment Supplier
• ZZ: Mutually Defined

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-04 · 782 · Total Claim Charge Amount · Optional · Decimal number (R) · Min 1 Max 15

STC-05 · 782 · Claim Payment Amount · Optional · Decimal number (R) · Min 1 Max 15

STC-06 · 373 · Adjudication Finalized Date · Optional · Date (DT) · CCYYMMDD format

STC-08 · 373 · Remittance Date · Optional · Date (DT) · CCYYMMDD format

STC-09 · 429 · Remittance Trace Number · Optional · String (AN) · Min 1 Max 16

STC-10 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-11 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

Optional · Max use 1

Variants (all may be used)

REFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• D9: Claim Number

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Institutional Bill Type Identification

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• BLT: Billing Type

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Patient Control Number

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• EJ: Patient Account Number

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Payer Claim Control Number

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1K: Payor's Claim Number

REF-02 · 127 · Payer Claim Control Number · Required · String (AN) · Min 1 Max 50

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Pharmacy Prescription Number

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• XZ: Pharmacy Prescription Number

REF-02 · 127 · Pharmacy Prescription Number · Required · String (AN) · Min 1 Max 50

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Voucher Identifier

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• VV: Voucher

REF-02 · 127 · Voucher Identifier · Required · String (AN) · Min 1 Max 50

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > DTP

DTP Claim Service Date

Optional · Max use 1

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

• 472: Service

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

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

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

2220D Service Line Information Loop Optional Max >1

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

SVC Service Line Information

Required · Max use 1

SVC-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• ER: Jurisdiction Specific Procedure and Supply Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• NU: National Uniform Billing Committee (NUBC) UB92 Codes
• WK: Advanced Billing Concepts (ABC) Codes

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

SVC-02 · 782 · Line Item Charge Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-03 · 782 · Line Item Payment Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-04 · 234 · Revenue Code · Optional · String (AN) · Min 1 Max 48

SVC-07 · 380 · Units of Service Count · Required · Decimal number (R) · Min 1 Max 15

1900 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > STC

STC Service Line Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max use 1 · Used to convey status of the entire claim or a specific service line

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 1E: Health Maintenance Organization (HMO)
• 1G: Oncology Center
• 1H: Kidney Dialysis Unit
• 1I: Preferred Provider Organization (PPO)
• 1O: Acute Care Hospital
• 1P: Provider
• 1Q: Military Facility
• 1R: University, College or School
• 1S: Outpatient Surgicenter
• 1T: Physician, Clinic or Group Practice
• 1U: Long Term Care Facility
• 1V: Extended Care Facility
• 1W: Psychiatric Health Facility
• 1X: Laboratory
• 1Y: Retail Pharmacy
• 1Z: Home Health Care
• 2A: Federal, State, County or City Facility
• 2B: Third-Party Administrator
• 2D: Miscellaneous Health Care Facility
• 2E: Non-Health Care Miscellaneous Facility
• 2I: Church Operated Facility
• 2K: Partnership
• 2P: Public Health Service Facility
• 2Q: Veterans Administration Facility
• 2S: Public Health Service Indian Service Facility
• 2Z: Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
• 03: Dependent
• 3A: Hospital Unit Within an Institution for the Mentally Retarded
• 3C: Tuberculosis and Other Respiratory Diseases Facility
• 3D: Obstetrics and Gynecology Facility
• 3E: Eye, Ear, Nose and Throat Facility
• 3F: Rehabilitation Facility
• 3G: Orthopedic Facility
• 3H: Chronic Disease Facility
• 3I: Other Specialty Facility
• 3J: Children's General Facility
• 3K: Children's Hospital Unit of an Institution
• 3L: Children's Psychiatric Facility
• 3M: Children's Tuberculosis and Other Respiratory Diseases Facility
• 3N: Children's Eye, Ear, Nose and Throat Facility
• 3O: Children's Rehabilitation Facility
• 3P: Children's Orthopedic Facility
• 3Q: Children's Chronic Disease Facility
• 3R: Children's Other Specialty Facility
• 3S: Institution for Mental Retardation
• 3T: Alcoholism and Other Chemical Dependency Facility
• 3U: General Inpatient Care for AIDS/ARC Facility
• 3V: AIDS/ARC Unit
• 3W: Specialized Outpatient Program for AIDS/ARC
• 3X: Alcohol/Drug Abuse or Dependency Inpatient Unit
• 3Y: Alcohol/Drug Abuse or Dependency Outpatient Services
• 3Z: Arthritis Treatment Center
• 4A: Birthing Room/LDRP Room
• 4B: Burn Care Unit
• 4C: Cardiac Catherization Laboratory
• 4D: Open-Heart Surgery Facility
• 4E: Cardiac Intensive Care Unit
• 4F: Angioplasty Facility
• 4G: Chronic Obstructive Pulmonary Disease Service Facility
• 4H: Emergency Department
• 4I: Trauma Center (Certified)
• 4J: Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
• 4L: Genetic Counseling/Screening Services
• 4M: Adult Day Care Program Facility
• 4N: Alzheimer's Diagnostic/Assessment Services
• 4O: Comprehensive Geriatric Assessment Facility
• 4P: Emergency Response (Geriatric) Unit
• 4Q: Geriatric Acute Care Unit
• 4R: Geriatric Clinics
• 4S: Respite Care Facility
• 4U: Patient Education Unit
• 4V: Community Health Promotion Facility
• 4W: Worksite Health Promotion Facility
• 4X: Hemodialysis Facility
• 4Y: Home Health Services
• 4Z: Hospice
• 5A: Medical Surgical or Other Intensive Care Unit
• 5B: Hisopathology Laboratory
• 5C: Blood Bank
• 5D: Neonatal Intensive Care Unit
• 5E: Obstetrics Unit
• 5F: Occupational Health Services
• 5G: Organized Outpatient Services
• 5H: Pediatric Acute Inpatient Unit
• 5I: Psychiatric Child/Adolescent Services
• 5J: Psychiatric Consultation-Liaison Services
• 5K: Psychiatric Education Services
• 5L: Psychiatric Emergency Services
• 5M: Psychiatric Geriatric Services
• 5N: Psychiatric Inpatient Unit
• 5O: Psychiatric Outpatient Services
• 5P: Psychiatric Partial Hospitalization Program
• 5Q: Megavoltage Radiation Therapy Unit
• 5R: Radioactive Implants Unit
• 5S: Therapeutic Radioisotope Facility
• 5T: X-Ray Radiation Therapy Unit
• 5U: CT Scanner Unit
• 5V: Diagnostic Radioisotope Facility
• 5W: Magnetic Resonance Imaging (MRI) Facility
• 5X: Ultrasound Unit
• 5Y: Rehabilitation Inpatient Unit
• 5Z: Rehabilitation Outpatient Services
• 6A: Reproductive Health Services
• 6B: Skilled Nursing or Other Long-Term Care Unit
• 6C: Single Photon Emission Computerized Tomography (SPECT) Unit
• 6D: Organized Social Work Service Facility
• 6E: Outpatient Social Work Services
• 6F: Emergency Department Social Work Services
• 6G: Sports Medicine Clinic/Services
• 6H: Hospital Auxiliary Unit
• 6I: Patient Representative Services
• 6J: Volunteer Services Department
• 6K: Outpatient Surgery Services
• 6L: Organ/Tissue Transplant Unit
• 6M: Orthopedic Surgery Facility
• 6N: Occupational Therapy Services
• 6O: Physical Therapy Services
• 6P: Recreational Therapy Services
• 6Q: Respiratory Therapy Services
• 6R: Speech Therapy Services
• 6S: Women's Health Center/Services
• 6U: Cardiac Rehabilitation Program Facility
• 6V: Non-Invasive Cardiac Assessment Services
• 6W: Emergency Medical Technician
• 6X: Disciplinary Contact
• 6Y: Case Manager
• 7C: Place of Occurrence
• 13: Contracted Service Provider
• 17: Consultant's Office
• 28: Subcontractor
• 30: Service Supplier
• 36: Employer
• 40: Receiver
• 43: Claimant Authorized Representative
• 44: Data Processing Service Bureau
• 61: Performed At
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• 74: Corrected Insured
• 77: Service Location
• 80: Hospital
• 82: Rendering Provider
• 84: Subscriber's Employer
• 85: Billing Provider
• 87: Pay-to Provider
• 95: Research Institute
• CK: Pharmacist
• CZ: Admitting Surgeon
• D2: Commercial Insurer
• DD: Assistant Surgeon
• DJ: Consulting Physician
• DK: Ordering Physician
• DN: Referring Provider
• DO: Dependent Name
• DQ: Supervising Physician
• E1: Person or Other Entity Legally Responsible for a Child
• E2: Person or Other Entity With Whom a Child Resides
• E7: Previous Employer
• E9: Participating Laboratory
• FA: Facility
• FD: Physical Address
• FE: Mail Address
• G0: Dependent Insured
• G3: Clinic
• GB: Other Insured
• GD: Guardian
• GI: Paramedic
• GJ: Paramedical Company
• GK: Previous Insured
• GM: Spouse Insured
• GY: Treatment Facility
• HF: Healthcare Professional Shortage Area (HPSA) Facility
• HH: Home Health Agency
• I3: Independent Physicians Association (IPA)
• IJ: Injection Point
• IL: Insured or Subscriber
• IN: Insurer
• LI: Independent Lab
• LR: Legal Representative
• MR: Medical Insurance Carrier
• MSC: Mammography Screening Center
• OB: Ordered By
• OD: Doctor of Optometry
• OX: Oxygen Therapy Facility
• P0: Patient Facility
• P2: Primary Insured or Subscriber
• P3: Primary Care Provider
• P4: Prior Insurance Carrier
• P6: Third Party Reviewing Preferred Provider Organization (PPO)
• P7: Third Party Repricing Preferred Provider Organization (PPO)
• PRP: Primary Payer
• PT: Party to Receive Test Report
• PV: Party performing certification
• PW: Pickup Address
• QA: Pharmacy
• QB: Purchase Service Provider
• QC: Patient
• QD: Responsible Party
• QE: Policyholder
• QH: Physician
• QK: Managed Care
• QL: Chiropractor
• QN: Dentist
• QO: Doctor of Osteopathy
• QS: Podiatrist
• QV: Group Practice
• QY: Medical Doctor
• RC: Receiving Location
• RW: Rural Health Clinic
• S4: Skilled Nursing Facility
• SEP: Secondary Payer
• SJ: Service Provider
• SU: Supplier/Manufacturer
• T4: Transfer Point
• TL: Testing Laboratory
• TQ: Third Party Reviewing Organization (TPO)
• TT: Transfer To
• TTP: Tertiary Payer
• TU: Third Party Repricing Organization (TPO)
• UH: Nursing Home
• X3: Utilization Management Organization
• X4: Spouse
• X5: Durable Medical Equipment Supplier
• ZZ: Mutually Defined

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-10 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-11 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

2000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

REF Service Line Item Identification

Optional · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• FJ: Line Item Control Number

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

2100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

DTP Service Line Date

Required · Max use 1

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

• 472: Service

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

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

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

2000E Dependent Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 23: Dependent

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.

2100E Dependent Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

NM1 Dependent Name

Required · Max use 1

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

• QC: Patient

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

• 1: Person

NM1-03 · 1035 · Patient Last Name · Required · String (AN) · Min 1 Max 60

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

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

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

2200E Claim Status Tracking Number Loop Required Max >1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > TRN

TRN Claim Status Tracking Number

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 2: Referenced Transaction Trace Numbers

TRN-02 · 127 · Referenced Transaction Trace Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > STC

STC Claim Level Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max use 1 · Used to convey status of the entire claim or a specific service line

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 1E: Health Maintenance Organization (HMO)
• 1G: Oncology Center
• 1H: Kidney Dialysis Unit
• 1I: Preferred Provider Organization (PPO)
• 1O: Acute Care Hospital
• 1P: Provider
• 1Q: Military Facility
• 1R: University, College or School
• 1S: Outpatient Surgicenter
• 1T: Physician, Clinic or Group Practice
• 1U: Long Term Care Facility
• 1V: Extended Care Facility
• 1W: Psychiatric Health Facility
• 1X: Laboratory
• 1Y: Retail Pharmacy
• 1Z: Home Health Care
• 2A: Federal, State, County or City Facility
• 2B: Third-Party Administrator
• 2D: Miscellaneous Health Care Facility
• 2E: Non-Health Care Miscellaneous Facility
• 2I: Church Operated Facility
• 2K: Partnership
• 2P: Public Health Service Facility
• 2Q: Veterans Administration Facility
• 2S: Public Health Service Indian Service Facility
• 2Z: Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
• 03: Dependent
• 3A: Hospital Unit Within an Institution for the Mentally Retarded
• 3C: Tuberculosis and Other Respiratory Diseases Facility
• 3D: Obstetrics and Gynecology Facility
• 3E: Eye, Ear, Nose and Throat Facility
• 3F: Rehabilitation Facility
• 3G: Orthopedic Facility
• 3H: Chronic Disease Facility
• 3I: Other Specialty Facility
• 3J: Children's General Facility
• 3K: Children's Hospital Unit of an Institution
• 3L: Children's Psychiatric Facility
• 3M: Children's Tuberculosis and Other Respiratory Diseases Facility
• 3N: Children's Eye, Ear, Nose and Throat Facility
• 3O: Children's Rehabilitation Facility
• 3P: Children's Orthopedic Facility
• 3Q: Children's Chronic Disease Facility
• 3R: Children's Other Specialty Facility
• 3S: Institution for Mental Retardation
• 3T: Alcoholism and Other Chemical Dependency Facility
• 3U: General Inpatient Care for AIDS/ARC Facility
• 3V: AIDS/ARC Unit
• 3W: Specialized Outpatient Program for AIDS/ARC
• 3X: Alcohol/Drug Abuse or Dependency Inpatient Unit
• 3Y: Alcohol/Drug Abuse or Dependency Outpatient Services
• 3Z: Arthritis Treatment Center
• 4A: Birthing Room/LDRP Room
• 4B: Burn Care Unit
• 4C: Cardiac Catherization Laboratory
• 4D: Open-Heart Surgery Facility
• 4E: Cardiac Intensive Care Unit
• 4F: Angioplasty Facility
• 4G: Chronic Obstructive Pulmonary Disease Service Facility
• 4H: Emergency Department
• 4I: Trauma Center (Certified)
• 4J: Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
• 4L: Genetic Counseling/Screening Services
• 4M: Adult Day Care Program Facility
• 4N: Alzheimer's Diagnostic/Assessment Services
• 4O: Comprehensive Geriatric Assessment Facility
• 4P: Emergency Response (Geriatric) Unit
• 4Q: Geriatric Acute Care Unit
• 4R: Geriatric Clinics
• 4S: Respite Care Facility
• 4U: Patient Education Unit
• 4V: Community Health Promotion Facility
• 4W: Worksite Health Promotion Facility
• 4X: Hemodialysis Facility
• 4Y: Home Health Services
• 4Z: Hospice
• 5A: Medical Surgical or Other Intensive Care Unit
• 5B: Hisopathology Laboratory
• 5C: Blood Bank
• 5D: Neonatal Intensive Care Unit
• 5E: Obstetrics Unit
• 5F: Occupational Health Services
• 5G: Organized Outpatient Services
• 5H: Pediatric Acute Inpatient Unit
• 5I: Psychiatric Child/Adolescent Services
• 5J: Psychiatric Consultation-Liaison Services
• 5K: Psychiatric Education Services
• 5L: Psychiatric Emergency Services
• 5M: Psychiatric Geriatric Services
• 5N: Psychiatric Inpatient Unit
• 5O: Psychiatric Outpatient Services
• 5P: Psychiatric Partial Hospitalization Program
• 5Q: Megavoltage Radiation Therapy Unit
• 5R: Radioactive Implants Unit
• 5S: Therapeutic Radioisotope Facility
• 5T: X-Ray Radiation Therapy Unit
• 5U: CT Scanner Unit
• 5V: Diagnostic Radioisotope Facility
• 5W: Magnetic Resonance Imaging (MRI) Facility
• 5X: Ultrasound Unit
• 5Y: Rehabilitation Inpatient Unit
• 5Z: Rehabilitation Outpatient Services
• 6A: Reproductive Health Services
• 6B: Skilled Nursing or Other Long-Term Care Unit
• 6C: Single Photon Emission Computerized Tomography (SPECT) Unit
• 6D: Organized Social Work Service Facility
• 6E: Outpatient Social Work Services
• 6F: Emergency Department Social Work Services
• 6G: Sports Medicine Clinic/Services
• 6H: Hospital Auxiliary Unit
• 6I: Patient Representative Services
• 6J: Volunteer Services Department
• 6K: Outpatient Surgery Services
• 6L: Organ/Tissue Transplant Unit
• 6M: Orthopedic Surgery Facility
• 6N: Occupational Therapy Services
• 6O: Physical Therapy Services
• 6P: Recreational Therapy Services
• 6Q: Respiratory Therapy Services
• 6R: Speech Therapy Services
• 6S: Women's Health Center/Services
• 6U: Cardiac Rehabilitation Program Facility
• 6V: Non-Invasive Cardiac Assessment Services
• 6W: Emergency Medical Technician
• 6X: Disciplinary Contact
• 6Y: Case Manager
• 7C: Place of Occurrence
• 13: Contracted Service Provider
• 17: Consultant's Office
• 28: Subcontractor
• 30: Service Supplier
• 36: Employer
• 40: Receiver
• 43: Claimant Authorized Representative
• 44: Data Processing Service Bureau
• 61: Performed At
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• 74: Corrected Insured
• 77: Service Location
• 80: Hospital
• 82: Rendering Provider
• 84: Subscriber's Employer
• 85: Billing Provider
• 87: Pay-to Provider
• 95: Research Institute
• CK: Pharmacist
• CZ: Admitting Surgeon
• D2: Commercial Insurer
• DD: Assistant Surgeon
• DJ: Consulting Physician
• DK: Ordering Physician
• DN: Referring Provider
• DO: Dependent Name
• DQ: Supervising Physician
• E1: Person or Other Entity Legally Responsible for a Child
• E2: Person or Other Entity With Whom a Child Resides
• E7: Previous Employer
• E9: Participating Laboratory
• FA: Facility
• FD: Physical Address
• FE: Mail Address
• G0: Dependent Insured
• G3: Clinic
• GB: Other Insured
• GD: Guardian
• GI: Paramedic
• GJ: Paramedical Company
• GK: Previous Insured
• GM: Spouse Insured
• GY: Treatment Facility
• HF: Healthcare Professional Shortage Area (HPSA) Facility
• HH: Home Health Agency
• I3: Independent Physicians Association (IPA)
• IJ: Injection Point
• IL: Insured or Subscriber
• IN: Insurer
• LI: Independent Lab
• LR: Legal Representative
• MR: Medical Insurance Carrier
• MSC: Mammography Screening Center
• OB: Ordered By
• OD: Doctor of Optometry
• OX: Oxygen Therapy Facility
• P0: Patient Facility
• P2: Primary Insured or Subscriber
• P3: Primary Care Provider
• P4: Prior Insurance Carrier
• P6: Third Party Reviewing Preferred Provider Organization (PPO)
• P7: Third Party Repricing Preferred Provider Organization (PPO)
• PRP: Primary Payer
• PT: Party to Receive Test Report
• PV: Party performing certification
• PW: Pickup Address
• QA: Pharmacy
• QB: Purchase Service Provider
• QC: Patient
• QD: Responsible Party
• QE: Policyholder
• QH: Physician
• QK: Managed Care
• QL: Chiropractor
• QN: Dentist
• QO: Doctor of Osteopathy
• QS: Podiatrist
• QV: Group Practice
• QY: Medical Doctor
• RC: Receiving Location
• RW: Rural Health Clinic
• S4: Skilled Nursing Facility
• SEP: Secondary Payer
• SJ: Service Provider
• SU: Supplier/Manufacturer
• T4: Transfer Point
• TL: Testing Laboratory
• TQ: Third Party Reviewing Organization (TPO)
• TT: Transfer To
• TTP: Tertiary Payer
• TU: Third Party Repricing Organization (TPO)
• UH: Nursing Home
• X3: Utilization Management Organization
• X4: Spouse
• X5: Durable Medical Equipment Supplier
• ZZ: Mutually Defined

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-04 · 782 · Total Claim Charge Amount · Optional · Decimal number (R) · Min 1 Max 15

STC-05 · 782 · Claim Payment Amount · Optional · Decimal number (R) · Min 1 Max 15

STC-06 · 373 · Adjudication Finalized Date · Optional · Date (DT) · CCYYMMDD format

STC-08 · 373 · Remittance Date · Optional · Date (DT) · CCYYMMDD format

STC-09 · 429 · Remittance Trace Number · Optional · String (AN) · Min 1 Max 16

STC-10 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-11 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

Optional · Max use 1

Variants (all may be used)

REFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• D9: Claim Number

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

REF Institutional Bill Type Identification

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• BLT: Billing Type

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

REF Patient Control Number

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• EJ: Patient Account Number

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

REF Payer Claim Control Number

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPharmacy Prescription NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1K: Payor's Claim Number

REF-02 · 127 · Payer Claim Control Number · Required · String (AN) · Min 1 Max 50

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

REF Pharmacy Prescription Number

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFVoucher Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• XZ: Pharmacy Prescription Number

REF-02 · 127 · Pharmacy Prescription Number · Required · String (AN) · Min 1 Max 50

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

REF Voucher Identifier

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• VV: Voucher

REF-02 · 127 · Voucher Identifier · Required · String (AN) · Min 1 Max 50

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > DTP

DTP Claim Service Date

Optional · Max use 1

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

• 472: Service

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

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

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

2220E Service Line Information Loop Optional Max >1

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

SVC Service Line Information

Required · Max use 1

SVC-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• ER: Jurisdiction Specific Procedure and Supply Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• NU: National Uniform Billing Committee (NUBC) UB92 Codes
• WK: Advanced Billing Concepts (ABC) Codes

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

SVC-02 · 782 · Line Item Charge Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-03 · 782 · Line Item Payment Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-04 · 234 · Revenue Code · Optional · String (AN) · Min 1 Max 48

SVC-07 · 380 · Units of Service Count · Required · Decimal number (R) · Min 1 Max 15

1900 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > STC

STC Service Line Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max use 1 · Used to convey status of the entire claim or a specific service line

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 1E: Health Maintenance Organization (HMO)
• 1G: Oncology Center
• 1H: Kidney Dialysis Unit
• 1I: Preferred Provider Organization (PPO)
• 1O: Acute Care Hospital
• 1P: Provider
• 1Q: Military Facility
• 1R: University, College or School
• 1S: Outpatient Surgicenter
• 1T: Physician, Clinic or Group Practice
• 1U: Long Term Care Facility
• 1V: Extended Care Facility
• 1W: Psychiatric Health Facility
• 1X: Laboratory
• 1Y: Retail Pharmacy
• 1Z: Home Health Care
• 2A: Federal, State, County or City Facility
• 2B: Third-Party Administrator
• 2D: Miscellaneous Health Care Facility
• 2E: Non-Health Care Miscellaneous Facility
• 2I: Church Operated Facility
• 2K: Partnership
• 2P: Public Health Service Facility
• 2Q: Veterans Administration Facility
• 2S: Public Health Service Indian Service Facility
• 2Z: Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
• 03: Dependent
• 3A: Hospital Unit Within an Institution for the Mentally Retarded
• 3C: Tuberculosis and Other Respiratory Diseases Facility
• 3D: Obstetrics and Gynecology Facility
• 3E: Eye, Ear, Nose and Throat Facility
• 3F: Rehabilitation Facility
• 3G: Orthopedic Facility
• 3H: Chronic Disease Facility
• 3I: Other Specialty Facility
• 3J: Children's General Facility
• 3K: Children's Hospital Unit of an Institution
• 3L: Children's Psychiatric Facility
• 3M: Children's Tuberculosis and Other Respiratory Diseases Facility
• 3N: Children's Eye, Ear, Nose and Throat Facility
• 3O: Children's Rehabilitation Facility
• 3P: Children's Orthopedic Facility
• 3Q: Children's Chronic Disease Facility
• 3R: Children's Other Specialty Facility
• 3S: Institution for Mental Retardation
• 3T: Alcoholism and Other Chemical Dependency Facility
• 3U: General Inpatient Care for AIDS/ARC Facility
• 3V: AIDS/ARC Unit
• 3W: Specialized Outpatient Program for AIDS/ARC
• 3X: Alcohol/Drug Abuse or Dependency Inpatient Unit
• 3Y: Alcohol/Drug Abuse or Dependency Outpatient Services
• 3Z: Arthritis Treatment Center
• 4A: Birthing Room/LDRP Room
• 4B: Burn Care Unit
• 4C: Cardiac Catherization Laboratory
• 4D: Open-Heart Surgery Facility
• 4E: Cardiac Intensive Care Unit
• 4F: Angioplasty Facility
• 4G: Chronic Obstructive Pulmonary Disease Service Facility
• 4H: Emergency Department
• 4I: Trauma Center (Certified)
• 4J: Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
• 4L: Genetic Counseling/Screening Services
• 4M: Adult Day Care Program Facility
• 4N: Alzheimer's Diagnostic/Assessment Services
• 4O: Comprehensive Geriatric Assessment Facility
• 4P: Emergency Response (Geriatric) Unit
• 4Q: Geriatric Acute Care Unit
• 4R: Geriatric Clinics
• 4S: Respite Care Facility
• 4U: Patient Education Unit
• 4V: Community Health Promotion Facility
• 4W: Worksite Health Promotion Facility
• 4X: Hemodialysis Facility
• 4Y: Home Health Services
• 4Z: Hospice
• 5A: Medical Surgical or Other Intensive Care Unit
• 5B: Hisopathology Laboratory
• 5C: Blood Bank
• 5D: Neonatal Intensive Care Unit
• 5E: Obstetrics Unit
• 5F: Occupational Health Services
• 5G: Organized Outpatient Services
• 5H: Pediatric Acute Inpatient Unit
• 5I: Psychiatric Child/Adolescent Services
• 5J: Psychiatric Consultation-Liaison Services
• 5K: Psychiatric Education Services
• 5L: Psychiatric Emergency Services
• 5M: Psychiatric Geriatric Services
• 5N: Psychiatric Inpatient Unit
• 5O: Psychiatric Outpatient Services
• 5P: Psychiatric Partial Hospitalization Program
• 5Q: Megavoltage Radiation Therapy Unit
• 5R: Radioactive Implants Unit
• 5S: Therapeutic Radioisotope Facility
• 5T: X-Ray Radiation Therapy Unit
• 5U: CT Scanner Unit
• 5V: Diagnostic Radioisotope Facility
• 5W: Magnetic Resonance Imaging (MRI) Facility
• 5X: Ultrasound Unit
• 5Y: Rehabilitation Inpatient Unit
• 5Z: Rehabilitation Outpatient Services
• 6A: Reproductive Health Services
• 6B: Skilled Nursing or Other Long-Term Care Unit
• 6C: Single Photon Emission Computerized Tomography (SPECT) Unit
• 6D: Organized Social Work Service Facility
• 6E: Outpatient Social Work Services
• 6F: Emergency Department Social Work Services
• 6G: Sports Medicine Clinic/Services
• 6H: Hospital Auxiliary Unit
• 6I: Patient Representative Services
• 6J: Volunteer Services Department
• 6K: Outpatient Surgery Services
• 6L: Organ/Tissue Transplant Unit
• 6M: Orthopedic Surgery Facility
• 6N: Occupational Therapy Services
• 6O: Physical Therapy Services
• 6P: Recreational Therapy Services
• 6Q: Respiratory Therapy Services
• 6R: Speech Therapy Services
• 6S: Women's Health Center/Services
• 6U: Cardiac Rehabilitation Program Facility
• 6V: Non-Invasive Cardiac Assessment Services
• 6W: Emergency Medical Technician
• 6X: Disciplinary Contact
• 6Y: Case Manager
• 7C: Place of Occurrence
• 13: Contracted Service Provider
• 17: Consultant's Office
• 28: Subcontractor
• 30: Service Supplier
• 36: Employer
• 40: Receiver
• 43: Claimant Authorized Representative
• 44: Data Processing Service Bureau
• 61: Performed At
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• 74: Corrected Insured
• 77: Service Location
• 80: Hospital
• 82: Rendering Provider
• 84: Subscriber's Employer
• 85: Billing Provider
• 87: Pay-to Provider
• 95: Research Institute
• CK: Pharmacist
• CZ: Admitting Surgeon
• D2: Commercial Insurer
• DD: Assistant Surgeon
• DJ: Consulting Physician
• DK: Ordering Physician
• DN: Referring Provider
• DO: Dependent Name
• DQ: Supervising Physician
• E1: Person or Other Entity Legally Responsible for a Child
• E2: Person or Other Entity With Whom a Child Resides
• E7: Previous Employer
• E9: Participating Laboratory
• FA: Facility
• FD: Physical Address
• FE: Mail Address
• G0: Dependent Insured
• G3: Clinic
• GB: Other Insured
• GD: Guardian
• GI: Paramedic
• GJ: Paramedical Company
• GK: Previous Insured
• GM: Spouse Insured
• GY: Treatment Facility
• HF: Healthcare Professional Shortage Area (HPSA) Facility
• HH: Home Health Agency
• I3: Independent Physicians Association (IPA)
• IJ: Injection Point
• IL: Insured or Subscriber
• IN: Insurer
• LI: Independent Lab
• LR: Legal Representative
• MR: Medical Insurance Carrier
• MSC: Mammography Screening Center
• OB: Ordered By
• OD: Doctor of Optometry
• OX: Oxygen Therapy Facility
• P0: Patient Facility
• P2: Primary Insured or Subscriber
• P3: Primary Care Provider
• P4: Prior Insurance Carrier
• P6: Third Party Reviewing Preferred Provider Organization (PPO)
• P7: Third Party Repricing Preferred Provider Organization (PPO)
• PRP: Primary Payer
• PT: Party to Receive Test Report
• PV: Party performing certification
• PW: Pickup Address
• QA: Pharmacy
• QB: Purchase Service Provider
• QC: Patient
• QD: Responsible Party
• QE: Policyholder
• QH: Physician
• QK: Managed Care
• QL: Chiropractor
• QN: Dentist
• QO: Doctor of Osteopathy
• QS: Podiatrist
• QV: Group Practice
• QY: Medical Doctor
• RC: Receiving Location
• RW: Rural Health Clinic
• S4: Skilled Nursing Facility
• SEP: Secondary Payer
• SJ: Service Provider
• SU: Supplier/Manufacturer
• T4: Transfer Point
• TL: Testing Laboratory
• TQ: Third Party Reviewing Organization (TPO)
• TT: Transfer To
• TTP: Tertiary Payer
• TU: Third Party Repricing Organization (TPO)
• UH: Nursing Home
• X3: Utilization Management Organization
• X4: Spouse
• X5: Durable Medical Equipment Supplier
• ZZ: Mutually Defined

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-10 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

STC-11 · C043 · Health Care Claim Status · Optional Max use 1 · Used to convey status of the entire claim or a specific service line · Usage notes

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

C043-02 · 1271 · Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

C043-04 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RX: National Council for Prescription Drug Programs Reject/Payment Codes

2000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

REF Service Line Item Identification

Optional · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• FJ: Line Item Control Number

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

2100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

DTP Service Line Date

Required · Max use 1

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

• 472: Service

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

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

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

2700 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

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

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

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

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

IEA Interchange Control Trailer

Required · Max use 1

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

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

EDI Samples

Example 1: Claim Level Status

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231103*0216*^*00501*000000001*0*T*>~
GS*HN*SENDERGS*RECEIVERGS*20231103*021627*000000001*X*005010X212~
ST*277*0001*005010X212~
BHT*0010*08*277X212*20050916*0810*DG~
HL*1**20*1~
NM1*PR*2*SECURITY HEALTH PLAN*****PI*SHP~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*2*ABCXYZ1~
STC*P3>317*20050913**8513.88~
REF*1K*05347006051~
REF*BLT*111~
REF*EJ*SM123456~
DTP*472*RD8*20050831-20050906~
HL*5*3*22*0~
NM1*IL*1*JONES*MARY****MI*234567890A~
TRN*2*ABCXYZ2~
STC*F0>3*20050915**7599*7599~
REF*1K*0529675341~
REF*BLT*111~
REF*EJ*JO234567~
DTP*472*RD8*20050731-20050809~
HL*6*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~
HL*7*6*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
HL*8*7*23~
NM1*QC*1*MANN*JOSEPH~
TRN*2*ABCXYC3~
STC*F2>88>QC*20050612**150*0~
REF*1K*051681010827~
REF*EJ*MA345678~
SVC*HC>99203*150*0****1~
STC*F2>88>QC*20050612~
DTP*472*D8*20050501~
SE*38*0001~
GE*1*000000001~
IEA*1*000000001~

Example 2: Provider Level Status

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231103*0216*^*00501*000000001*0*T*>~
GS*HN*SENDERGS*RECEIVERGS*20231103*021638*000000001*X*005010X212~
ST*277*0001*005010X212~
BHT*0010*08*277X212*20050916*0810*DG~
HL*1**20*1~
NM1*PR*2*SECURITY HEALTH PLAN*****PI*SHP~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*2*ABCXYZ1~
STC*P3>317*20050913**8513.88~
REF*1K*05347006051~
REF*BLT*111~
REF*EJ*SM123456~
DTP*472*RD8*20050831-20050906~
HL*5*2*19*0~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~
TRN*1*0~
STC*E0>24>1P*20050916~
SE*21*0001~
GE*1*000000001~
IEA*1*000000001~