X12 277 Health Care Information Status Notification (X212)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Information Status Notification Transaction Set (277) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a health care claim or encounter or to request additional information from the provider regarding a health care claim or encounter, health care services review, or transactions related to the provisions of health care. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, will not be used for account payment posting. The notification may be at a summary or service line detail level. The notification may be solicited or unsolicited.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HN
- Health Care Information Status Notification (277)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X212
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 277
- Health Care Information Status Notification
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the implementation guide Version/Release/Industry Identifier Code named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X212
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0010
- Information Source, Information Receiver, Provider of Service, Subscriber, Dependent
Code identifying purpose of transaction set
- 08
- Status
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Code specifying the type of transaction
- DG
- Response
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Payer Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
- SECURITY HEALTH PLAN
- SHP
Code designating the system/method of code structure used for Identification Code (67)
- PI
- Payor Identification
Payer identification number established through trading partner agreement.
Payer Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when the payer's contact information is not otherwise specified in a Trading Partner Agreement and the Information Receiver does not know how to contact the payer. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. A telephone extension, when applicable is reported in the communication number immediately after the telephone number.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
- When an extension or additional contact number is required, use PER06.
Code identifying the type of communication number
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
To supply the full name of an individual or organizational entity
- This is the individual or organization requesting to receive the status information.;
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
- The ETIN is established through Trading Partner agreement.
Information Receiver Trace Identifier
To uniquely identify a transaction to an application
- Required when rejecting claim status requests for errors at Information Source or Information Receiver levels. If not required by this implementation guide, do not send.
- If reporting error status at this level, 2000C, 2000D and 2000E Loops are not used.
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This value must be the BHT03 data element value from the 276 Claim Status Request being rejected.
Information Receiver Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- Only the
D0' Category Code andE' Category Codes are allowable at this level.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 41
- Submitter
- AY
- Clearinghouse
- PR
- Payer
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
Required when a second status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required when a third status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 19
- Provider of Service
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Provider Name
To supply the full name of an individual or organizational entity
- During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
- After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop may be sent with the NPI reported in the NM109 and NM108=XX.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
- SV
- Service Provider Number
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required value when the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes must be used.
Provider of Service Trace Identifier
To uniquely identify a transaction to an application
- Required when rejecting the claim status request(s) for errors at the provider level. If not required by this implementation guide, do not send.
- If reporting error status at this level, the 2000D and 2000E Loops related to this provider are not used.
- The TRN Segment is syntactically required in order to use the Loop 2200C STC. TRN02 can be either a default value of zero (0) or any value the Information Source chooses to assign.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Provider Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- Only the
D0' Category Code andE' Category Codes are allowable at this level.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 1P
- Provider
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
Required when a second status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid value.
Required when a third status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid value.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Use the value "2" in an employer-subscriber situation, such as Worker's Compensation.
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
This code may be used in conjunction with a workers compensation claim.
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated for use. If not required, use one of the other values.
- MI
- Member Identification Number
Claim Status Tracking Number
To uniquely identify a transaction to an application
- This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.
- Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
- When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Claim Level Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 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
Used to identify the geographic location where a patient is transferred or diverted.
- 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
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
- This is the date the claim was placed in this status by the Information Source's adjudication process.
Monetary amount
- STC04 is the amount of original submitted charges.
- The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
Monetary amount
- STC05 is the amount paid.
- Zero is an acceptable amount when no payment is being made.
- Some payers are able to provide the adjudicated payment amount prior to the remittance being issued.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC06 is the paid date.
- This is the date of denial or approval for the claim. This date may or may not be the same as the issue date of the check, EFT or non-payment remittance (STC08).
- Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC08 is the check issue date.
- This is the check issue or EFT funds available date.
- This could include a non-payment remittance advice date if available from the Information Source's system.
Check identification number
- This is the check or EFT Trace Number.
- This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.
Required when a second claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Required when a third claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
To specify identifying information
- Required when received on the 276 status request. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Institutional Bill Type Identification
To specify identifying information
- Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code qualifying the Reference Identification
- BLT
- Billing Type
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code
Patient Control Number
To specify identifying information
- Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
- The maximum number of characters supported for the Patient Control Number is `20'.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Claim Control Number
To specify identifying information
- Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.
- This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
Code qualifying the Reference Identification
- 1K
- Payor's Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pharmacy Prescription Number
To specify identifying information
- Required when the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Voucher Identifier
To specify identifying information
- Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.
- Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.
Code qualifying the Reference Identification
- VV
- Voucher
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Service Date
To specify any or all of a date, a time, or a time period
- For professional claims, this date is derived from the service level dates.
- When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.
- Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Service Line Information
To supply payment and control information to a provider for a particular service
- Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
- For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - N4
- National Drug Code in 5-4-2 Format
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
This code is the NUBC Revenue Code.
- WK
- Advanced Billing Concepts (ABC) Codes
At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Monetary amount
- SVC02 is the submitted service charge.
- This is the line item total on the current claim service status.
Monetary amount
- SVC03 is the amount paid this service.
Identifying number for a product or service
- SVC04 is the National Uniform Billing Committee Revenue Code.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Service Line Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 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
Used to identify the geographic location where a patient is transferred or diverted.
- 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
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
- This is the date the service was placed in this status by the Information Source's adjudication process.
Required when a second claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Required when a third claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Service Line Item Identification
To specify identifying information
- Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- FJ
- Line Item Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Dependent Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Claim Status Tracking Number
To uniquely identify a transaction to an application
- This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Claim Level Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 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
Used to identify the geographic location where a patient is transferred or diverted.
- 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
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
- This is the date the claim was placed in this status by the Information Source's adjudication process.
Monetary amount
- STC04 is the amount of original submitted charges.
- The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
Monetary amount
- STC05 is the amount paid.
- Zero is an acceptable amount when no payment is being made.
- Some payers are able to provide the adjudicated payment amount prior to the remittance being issued.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC06 is the paid date.
- This is the date of denial or approval for the claim. This date may or may not be the same as the issue date of the check, EFT or non-payment remittance (STC08).
- Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC08 is the check issue date.
- This is the check issue or EFT funds available date.
- This could include a non-payment remittance advice date if available from the Information Source's system.
Check identification number
- This is the check or EFT Trace Number.
- This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.
Required when a second claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Required when a third claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
To specify identifying information
- Required when received on the 276 status request. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Institutional Bill Type Identification
To specify identifying information
- Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code qualifying the Reference Identification
- BLT
- Billing Type
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code
Patient Control Number
To specify identifying information
- Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
- The maximum number of characters supported for the Patient Control Number is `20'.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Claim Control Number
To specify identifying information
- Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.
- This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
Code qualifying the Reference Identification
- 1K
- Payor's Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pharmacy Prescription Number
To specify identifying information
- Required when the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Voucher Identifier
To specify identifying information
- Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.
- Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.
Code qualifying the Reference Identification
- VV
- Voucher
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Service Date
To specify any or all of a date, a time, or a time period
- For professional claims, this date is derived from the service level dates.
- When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.
- Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Service Line Information
To supply payment and control information to a provider for a particular service
- Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
- For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - N4
- National Drug Code in 5-4-2 Format
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
This code is the NUBC Revenue Code.
- WK
- Advanced Billing Concepts (ABC) Codes
At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Monetary amount
- SVC02 is the submitted service charge.
- This is the line item total on the current claim service status.
Monetary amount
- SVC03 is the amount paid this service.
Identifying number for a product or service
- SVC04 is the National Uniform Billing Committee Revenue Code.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Service Line Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 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
Used to identify the geographic location where a patient is transferred or diverted.
- 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
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
- This is the date the service was placed in this status by the Information Source's adjudication process.
Required when a second claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Required when a third claim status is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
- The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Code identifying a specific industry code list
- C043-04 is used to identify the Code Source referenced in C043-02.
- RX
- National Council for Prescription Drug Programs Reject/Payment Codes
Service Line Item Identification
To specify identifying information
- Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- FJ
- Line Item Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- Data value in SE02 must be identical to ST02.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Claim Level Status
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
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~
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