Security Health
/
Health Care Claim: Dental (X224A3)
  • Specification
  • EDI Inspector
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X12 837 Health Care Claim: Dental (X224A3)

X12 Release 5010
—
Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
—
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0050
Transaction Set Header
Max use 1
Required
BHT
0100
Beginning of Hierarchical Transaction
Max use 1
Required
Submitter Name Loop
NM1
0200
Submitter Name
Max use 1
Required
PER
0450
Submitter EDI Contact Information
Max use 2
Required
Receiver Name Loop
NM1
0200
Receiver Name
Max use 1
Required
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Billing Provider Name Loop
NM1
0150
Billing Provider Name
Max use 1
Required
N3
0250
Billing Provider Address
Max use 1
Required
N4
0300
Billing Provider City, State, ZIP Code
Max use 1
Required
REF
0350
Billing Provider Tax Identification
Max use 1
Required
REF
0350
Billing Provider UPIN/License Information
Max use 2
Optional
PER
0400
Billing Provider Contact Information
Max use 2
Optional
Pay-to Address Name Loop
NM1
0150
Pay-to Address Name
Max use 1
Required
N3
0250
Pay-to Address - ADDRESS
Max use 1
Required
N4
0300
Pay-To Address City, State, ZIP Code
Max use 1
Required
Pay-To Plan Name Loop
NM1
0150
Pay-To Plan Name
Max use 1
Required
N3
0250
Pay-to Plan Address
Max use 1
Required
N4
0300
Pay-To Plan City, State, ZIP Code
Max use 1
Required
REF
0350
Pay-to Plan Secondary Identification
Max use 1
Optional
REF
0350
Pay-To Plan Tax Identification Number
Max use 1
Required
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Optional
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Optional
DMG
0320
Subscriber Demographic Information
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
REF
0350
Subscriber Secondary Identification
Max use 1
Optional
Payer Name Loop
NM1
0150
Payer Name
Max use 1
Required
N3
0250
Payer Address
Max use 1
Optional
N4
0300
Payer City, State, ZIP Code
Max use 1
Optional
REF
0350
Billing Provider Secondary Identification
Max use 1
Optional
REF
0350
Payer Secondary Identification
Max use 3
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Appliance Placement
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
DTP
1350
Date - Service Date
Max use 1
Optional
DN1
1450
Orthodontic Total Months of Treatment
Max use 1
Optional
DN2
1500
Tooth Status
Max use 35
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Predetermination Identification
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 5
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
PRV
2550
Referring Provider Specialty Information
Max use 1
Optional
REF
2710
Referring Provider Secondary Identification
Max use 3
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
PRV
2550
Rendering Provider Specialty Information
Max use 1
Required
REF
2710
Rendering Provider Secondary Identification
Max use 4
Optional
Service Facility Location Name Loop
NM1
2500
Service Facility Location Name
Max use 1
Required
N3
2650
Service Facility Location Address
Max use 1
Required
N4
2700
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
2710
Service Facility Location Secondary Identification
Max use 3
Optional
Assistant Surgeon Name Loop
NM1
2500
Assistant Surgeon Name
Max use 1
Required
PRV
2550
Assistant Surgeon Specialty Information
Max use 1
Required
REF
2710
Assistant Surgeon Secondary Identification
Max use 4
Optional
Supervising Provider Name Loop
NM1
2500
Supervising Provider Name
Max use 1
Required
REF
2710
Supervising Provider Secondary Identification
Max use 4
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Subscriber Name Loop
NM1
3250
Other Subscriber Name
Max use 1
Required
N3
3320
Other Subscriber Address
Max use 1
Optional
N4
3400
Other Subscriber City, State, ZIP Code
Max use 1
Optional
REF
3550
Other Subscriber Secondary Identification
Max use 2
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3500
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Predetermination Identification
Max use 1
Optional
REF
3550
Other Payer Prior Authorization Number
Max use 1
Optional
REF
3550
Other Payer Referral Number
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 3
Optional
Other Payer Referring Provider Loop
NM1
3250
Other Payer Referring Provider
Max use 1
Required
REF
3550
Other Payer Referring Provider Secondary Identification
Max use 3
Required
Other Payer Rendering Provider Loop
NM1
3250
Other Payer Rendering Provider
Max use 1
Required
REF
3550
Other Payer Rendering Provider Secondary Identification
Max use 3
Required
Other Payer Supervising Provider Loop
NM1
3250
Other Payer Supervising Provider
Max use 1
Required
REF
3550
Other Payer Supervising Provider Secondary Identification
Max use 3
Required
Other Payer Billing Provider Loop
NM1
3250
Other Payer Billing Provider
Max use 1
Required
REF
3550
Other Payer Billing Provider Secondary Identification
Max use 2
Required
Other Payer Service Facility Location Loop
NM1
3250
Other Payer Service Facility Location
Max use 1
Required
REF
3550
Other Payer Service Facility Location Secondary Identification
Max use 3
Required
Other Payer Assistant Surgeon Loop
NM1
3250
Other Payer Assistant Surgeon
Max use 1
Required
REF
3550
Other Payer Assistant Surgeon Secondary Identifier
Max use 3
Required
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV3
3800
Dental Service
Max use 1
Required
TOO
3820
Tooth Information
Max use 32
Optional
DTP
4550
Date - Appliance Placement
Max use 1
Optional
DTP
4550
Date - Prior Placement
Max use 1
Optional
DTP
4550
Date - Replacement
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Optional
DTP
4550
Date - Treatment Completion
Max use 1
Optional
DTP
4550
Date - Treatment Start
Max use 1
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Adjusted Repriced Claim Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Repriced Claim Number
Max use 1
Optional
REF
4700
Service Predetermination Identification
Max use 5
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
PRV
5050
Rendering Provider Specialty Information
Max use 1
Required
REF
5250
Rendering Provider Secondary Identification
Max use 20
Optional
Assistant Surgeon Name Loop
NM1
5000
Assistant Surgeon Name
Max use 1
Required
PRV
5050
Assistant Surgeon Specialty Information
Max use 1
Optional
REF
5250
Assistant Surgeon Secondary Identification
Max use 20
Optional
Supervising Provider Name Loop
NM1
5000
Supervising Provider Name
Max use 1
Required
REF
5250
Supervising Provider Secondary Identification
Max use 20
Optional
Service Facility Location Name Loop
NM1
5000
Service Facility Location Name
Max use 1
Required
N3
5140
Service Facility Location Address
Max use 1
Required
N4
5200
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
5250
Service Facility Location Secondary Identification
Max use 20
Optional
Line Adjudication Information Loop
SVD
5400
Line Adjudication Information
Max use 1
Required
CAS
5450
Line Adjustment
Max use 5
Optional
DTP
5500
Line Check or Remittance Date
Max use 1
Required
AMT
5505
Remaining Patient Liability
Max use 1
Optional
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Patient Name Loop
NM1
0150
Patient Name
Max use 1
Required
N3
0250
Patient Address
Max use 1
Required
N4
0300
Patient City, State, ZIP Code
Max use 1
Required
DMG
0320
Patient Demographic Information
Max use 1
Required
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
REF
0350
Property and Casualty Patient Identifier
Max use 1
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Appliance Placement
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
DTP
1350
Date - Service Date
Max use 1
Optional
DN1
1450
Orthodontic Total Months of Treatment
Max use 1
Optional
DN2
1500
Tooth Status
Max use 35
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Predetermination Identification
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 5
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
PRV
2550
Referring Provider Specialty Information
Max use 1
Optional
REF
2710
Referring Provider Secondary Identification
Max use 3
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
PRV
2550
Rendering Provider Specialty Information
Max use 1
Required
REF
2710
Rendering Provider Secondary Identification
Max use 4
Optional
Service Facility Location Name Loop
NM1
2500
Service Facility Location Name
Max use 1
Required
N3
2650
Service Facility Location Address
Max use 1
Required
N4
2700
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
2710
Service Facility Location Secondary Identification
Max use 3
Optional
Assistant Surgeon Name Loop
NM1
2500
Assistant Surgeon Name
Max use 1
Required
PRV
2550
Assistant Surgeon Specialty Information
Max use 1
Required
REF
2710
Assistant Surgeon Secondary Identification
Max use 4
Optional
Supervising Provider Name Loop
NM1
2500
Supervising Provider Name
Max use 1
Required
REF
2710
Supervising Provider Secondary Identification
Max use 4
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Subscriber Name Loop
NM1
3250
Other Subscriber Name
Max use 1
Required
N3
3320
Other Subscriber Address
Max use 1
Optional
N4
3400
Other Subscriber City, State, ZIP Code
Max use 1
Optional
REF
3550
Other Subscriber Secondary Identification
Max use 2
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3500
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Predetermination Identification
Max use 1
Optional
REF
3550
Other Payer Prior Authorization Number
Max use 1
Optional
REF
3550
Other Payer Referral Number
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 3
Optional
Other Payer Referring Provider Loop
NM1
3250
Other Payer Referring Provider
Max use 1
Required
REF
3550
Other Payer Referring Provider Secondary Identification
Max use 3
Required
Other Payer Rendering Provider Loop
NM1
3250
Other Payer Rendering Provider
Max use 1
Required
REF
3550
Other Payer Rendering Provider Secondary Identification
Max use 3
Required
Other Payer Supervising Provider Loop
NM1
3250
Other Payer Supervising Provider
Max use 1
Required
REF
3550
Other Payer Supervising Provider Secondary Identification
Max use 3
Required
Other Payer Billing Provider Loop
NM1
3250
Other Payer Billing Provider
Max use 1
Required
REF
3550
Other Payer Billing Provider Secondary Identification
Max use 2
Required
Other Payer Service Facility Location Loop
NM1
3250
Other Payer Service Facility Location
Max use 1
Required
REF
3550
Other Payer Service Facility Location Secondary Identification
Max use 3
Required
Other Payer Assistant Surgeon Loop
NM1
3250
Other Payer Assistant Surgeon
Max use 1
Required
REF
3550
Other Payer Assistant Surgeon Secondary Identifier
Max use 3
Required
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV3
3800
Dental Service
Max use 1
Required
TOO
3820
Tooth Information
Max use 32
Optional
DTP
4550
Date - Appliance Placement
Max use 1
Optional
DTP
4550
Date - Prior Placement
Max use 1
Optional
DTP
4550
Date - Replacement
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Optional
DTP
4550
Date - Treatment Completion
Max use 1
Optional
DTP
4550
Date - Treatment Start
Max use 1
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Adjusted Repriced Claim Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Repriced Claim Number
Max use 1
Optional
REF
4700
Service Predetermination Identification
Max use 5
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
PRV
5050
Rendering Provider Specialty Information
Max use 1
Required
REF
5250
Rendering Provider Secondary Identification
Max use 20
Optional
Assistant Surgeon Name Loop
NM1
5000
Assistant Surgeon Name
Max use 1
Required
PRV
5050
Assistant Surgeon Specialty Information
Max use 1
Optional
REF
5250
Assistant Surgeon Secondary Identification
Max use 20
Optional
Supervising Provider Name Loop
NM1
5000
Supervising Provider Name
Max use 1
Required
REF
5250
Supervising Provider Secondary Identification
Max use 20
Optional
Service Facility Location Name Loop
NM1
5000
Service Facility Location Name
Max use 1
Required
N3
5140
Service Facility Location Address
Max use 1
Required
N4
5200
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
5250
Service Facility Location Secondary Identification
Max use 20
Optional
Line Adjudication Information Loop
SVD
5400
Line Adjudication Information
Max use 1
Required
CAS
5450
Line Adjustment
Max use 5
Optional
DTP
5500
Line Check or Remittance Date
Max use 1
Required
AMT
5505
Remaining Patient Liability
Max use 1
Optional
SE
5550
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1
—
Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)
—
00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10
—
ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)
—
00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10
—
ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
—
Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15
—
ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
—
Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15
—
ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format
—
ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format
—
ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1
—
^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)
—
00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9
—
ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1
—
0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1
—
I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1
—
>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1
—
Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)
—
HC
Health Care Claim (837)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15
—
GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15
—
GS-04
373
Date
Required
Date (DT)
CCYYMMDD format
—
GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9
—
GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2
—
T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)
—
005010X224A3

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1
—
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)
—
837
Health Care Claim
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9
—
Usage notes
—
ST-03
1705
Implementation Guide Version Name
Required
String (AN)
—
Usage notes
—
005010X224A3
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1
—
Usage notes
—
Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)
—
0019
Information Source, Subscriber, Dependent
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)
—
Usage notes
—
00
Original
—
18
Reissue
—
BHT-03
127
Originator Application Transaction Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format
—
Usage notes
—
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
BHT-06
640
Claim or Encounter Identifier
Required
Identifier (ID)
—
31
Subrogation Demand
—
CH
Chargeable
—
RP
Reporting
—
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name Loop
NM1
0200
Heading > Submitter Name Loop > NM1

Submitter Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
41
Submitter
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Submitter Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Submitter First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Submitter Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
46
Electronic Transmitter Identification Number (ETIN)
—
NM1-09
67
Submitter Identifier
Required
String (AN)
Min 2Max 80
—
Usage notes
—
PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IC
Information Contact
PER-02
93
Submitter Contact Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name Loop
NM1
0200
Heading > Receiver Name Loop > NM1

Receiver Name

RequiredMax use 1
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
40
Receiver
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Receiver Name
Required
String (AN)
—
Security Health Plan
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
46
Electronic Transmitter Identification Number (ETIN)
NM1-09
67
Receiver Primary Identifier
Required
String (AN)
—
Usage notes
—
39045
SHP
1000B Receiver Name Loop end
Heading end

Detail

2000A Billing Provider Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1
—
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
—
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
—
20
Information Source
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
—
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV

Billing Provider Specialty Information

OptionalMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
BI
Billing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1
—
Usage notes
—
Example
CUR-01
98
Entity Identifier Code
Required
Identifier (ID)
—
85
Billing Provider
CUR-02
100
Currency Code
Required
Identifier (ID)
Min 3Max 3
—
Usage notes
—
2010AA Billing Provider Name Loop
RequiredMax 1
Usage notes
—
Variants (all may be used)
Pay-to Address Name LoopPay-To Plan Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1

Billing Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Billing Provider Last or Organizational Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Billing Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Billing Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Billing Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Billing Provider Identifier
Optional
String (AN)
Min 2Max 80
—
Usage notes
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3

Billing Provider Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Billing Provider Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Billing Provider Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4

Billing Provider City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Billing Provider City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Billing Provider State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Billing Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider Tax Identification

RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider UPIN/License Information
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
EI
Employer's Identification Number
—
REF-02
127
Billing Provider Tax Identification Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider UPIN/License Information

OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
REF-02
127
Billing Provider License and/or UPIN Information
Required
String (AN)
Min 1Max 50
—
PER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER

Billing Provider Contact Information

OptionalMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IC
Information Contact
PER-02
93
Billing Provider Contact Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
2010AA Billing Provider Name Loop end
2010AB Pay-to Address Name Loop
OptionalMax 1
Variants (all may be used)
Billing Provider Name LoopPay-To Plan Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1

Pay-to Address Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
87
Pay-to Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3

Pay-to Address - ADDRESS

RequiredMax use 1
—
Example
N3-01
166
Pay-To Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Pay-To Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4

Pay-To Address City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Pay-To Address State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Pay-to Address City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Pay-To Address State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Pay-to Address Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2010AB Pay-to Address Name Loop end
2010AC Pay-To Plan Name Loop
OptionalMax 1
Variants (all may be used)
Billing Provider Name LoopPay-to Address Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1

Pay-To Plan Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
PE
Payee
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Pay-To Plan Organizational Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
Usage notes
—
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Pay-To Plan Primary Identifier
Required
String (AN)
Min 2Max 80
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3

Pay-to Plan Address

RequiredMax use 1
—
Example
N3-01
166
Pay-To Plan Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Pay-To Plan Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4

Pay-To Plan City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Pay-To Plan City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Pay-To Plan State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Pay-To Plan Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-to Plan Secondary Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFPay-To Plan Tax Identification Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
—
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Pay-to Plan Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-To Plan Tax Identification Number

RequiredMax use 1
—
Example
Variants (all may be used)
REFPay-to Plan Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
EI
Employer's Identification Number
—
REF-02
127
Pay-To Plan Tax Identification Number
Required
String (AN)
Min 1Max 50
—
2010AC Pay-To Plan Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1
—
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
—
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12
—
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
—
22
Subscriber
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
—
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR

Subscriber Information

RequiredMax use 1
—
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
—
Usage notes
—
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
—
SBR-02
1069
Individual Relationship Code
Optional
Identifier (ID)
—
18
Self
SBR-03
127
Subscriber Group or Policy Number
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
SBR-04
93
Subscriber Group Name
Optional
String (AN)
Min 1Max 60
—
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)
—
12
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
14
Medicare Secondary, No-fault Insurance including Auto is Primary
15
Medicare Secondary Worker's Compensation
16
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veteran's Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47
Medicare Secondary, Other Liability Insurance is Primary
SBR-09
1032
Claim Filing Indicator Code
Optional
Identifier (ID)
—
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization
AM
Automobile Medical
BL
Blue Cross/Blue Shield
CH
Champus
CI
Commercial Insurance Co.
DS
Disability
FI
Federal Employees Program
HM
Health Maintenance Organization
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
OF
Other Federal Program
—
TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined
—
2010BA Subscriber Name Loop
RequiredMax 1
Usage notes
—
Variants (all may be used)
Payer Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Subscriber Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Subscriber First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Subscriber Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Subscriber Name Suffix
Optional
String (AN)
Min 1Max 10
—
Usage notes
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
MI
Member Identification Number
—
NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 12
—
Usage notes
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Subscriber City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Subscriber State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Subscriber Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1
—
Usage notes
—
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Subscriber Birth Date
Required
String (AN)
Min 1Max 35
—
DMG-03
1068
Subscriber Gender Code
Required
Identifier (ID)
—
F
Female
M
Male
U
Unknown
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Property and Casualty Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFSubscriber Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Subscriber Secondary Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
SY
Social Security Number
—
REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50
—
2010BA Subscriber Name Loop end
2010BB Payer Name Loop
RequiredMax 1
Usage notes
—
Variants (all may be used)
Subscriber Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1

Payer Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Payer Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
Usage notes
—
PI
Payor Identification
NM1-09
67
Payer Identifier
Required
String (AN)
—
Usage notes
—
35202
39045
SHP
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3

Payer Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Payer Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Payer Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4

Payer City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Payer City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Payer State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Billing Provider Secondary Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFPayer Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Payer Secondary Identification

OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
—
EI
Employer's Identification Number
—
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Payer Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2010BB Payer Name Loop end
2300 Claim Information Loop
OptionalMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM

Claim Information

RequiredMax use 1
—
Usage notes
—
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38
—
Usage notes
—
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
CLM-05
C023
Health Care Service Location Information
RequiredMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Place of Service Code
Required
String (AN)
Min 1Max 2
—
C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)
—
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
—
Usage notes
—
1
The first time a claim is submitted to Security Health Plan
7
This claim is replacing a previously submitted claim
8
The previously submitted claim is to be voided
CLM-06
1073
Provider or Supplier Signature Indicator
Required
Identifier (ID)
—
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)
—
Usage notes
—
A
Assigned
—
C
Not Assigned
—
CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)
—
Usage notes
—
N
No
W
Not Applicable
—
Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)
—
Usage notes
—
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
—
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
—
CLM-11
C024
Related Causes Information
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
C024-01
1362
Related Causes Code
Required
Identifier (ID)
—
AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3
—
C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)
—
01
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
02
Physically Handicapped Children's Program
—
03
Special Federal Funding
—
05
Disability
—
CLM-19
1383
Predetermination of Benefits Code
Optional
Identifier (ID)
—
PB
Predetermination of Dental Benefits
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)
—
1
Proof of Eligibility Unknown or Unavailable
2
Litigation
3
Authorization Delays
4
Delay in Certifying Provider
5
Delay in Supplying Billing Forms
6
Delay in Delivery of Custom-made Appliances
7
Third Party Processing Delay
8
Delay in Eligibility Determination
9
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10
Administration Delay in the Prior Approval Process
11
Other
15
Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Accident

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Appliance Placement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Repricer Received Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Service Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35
—
DN1
1450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DN1

Orthodontic Total Months of Treatment

OptionalMax use 1
—
Usage notes
—
Example
DN1-01
380
Orthodontic Treatment Months Count
Optional
Decimal number (R)
Min 1Max 15
—
DN1-02
380
Orthodontic Treatment Months Remaining Count
Optional
Decimal number (R)
Min 1Max 15
—
DN1-04
352
Orthodontic Treatment Indicator
Optional
String (AN)
Min 1Max 80
—
Usage notes
—
DN2
1500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DN2

Tooth Status

OptionalMax use 35
—
Usage notes
—
Example
DN2-01
127
Tooth Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
DN2-02
1368
Tooth Status Code
Required
Identifier (ID)
—
E
To Be Extracted
M
Missing
DN2-06
1270
Code List Qualifier Code
Required
Identifier (ID)
—
JP
Universal National Tooth Designation System
PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10
—
Usage notes
—
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)
—
B4
Referral Form
DA
Dental Models
DG
Diagnostic Report
EB
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
OZ
Support Data for Claim
P6
Periodontal Charts
RB
Radiology Films
RR
Radiology Reports
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)
—
AA
Available on Request at Provider Site
—
BM
By Mail
EL
Electronically Only
—
EM
E-Mail
FT
File Transfer
—
FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)
—
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80
—
Usage notes
—
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1
—
Usage notes
—
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)
—
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15
—
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50
—
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30
—
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT

Patient Amount Paid

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
F5
Patient Amount Paid
AMT-02
782
Patient Amount Paid
Required
Decimal number (R)
Min 1Max 15
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Claim Identifier For Transmission Intermediaries

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
Usage notes
—
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Payer Claim Control Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Predetermination Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Prior Authorization

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Referral Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Service Authorization Exception Code

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50
—
Usage notes
—
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10
—
Usage notes
—
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80
—
NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 5
—
Usage notes
—
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)
—
ADD
Additional Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Health Care Diagnosis Code

OptionalMax use 1
—
Usage notes
—
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
—
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
—
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)
—
C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
—
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
—
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)
—
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3
—
Usage notes
—
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3
—
Usage notes
—
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1
—
Usage notes
—
Example
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)
—
Usage notes
—
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15
—
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9
—
Usage notes
—
HCP-06
127
Repriced Approved Ambulatory Patient Group Code
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)
—
Usage notes
—
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)
—
Usage notes
—
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)
—
Usage notes
—
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2310A Referring Provider Name Loop
OptionalMax 2
Variants (all may be used)
Rendering Provider Name LoopService Facility Location Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DN
Referring Provider
—
P3
Primary Care Provider
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Referring Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Referring Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Referring Provider Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > PRV

Referring Provider Specialty Information

OptionalMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
RF
Referring
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310A Referring Provider Name Loop end
2310B Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopService Facility Location Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Rendering Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Rendering Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

RequiredMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80
—
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55
—
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310C Service Facility Location Name Loop end
2310D Assistant Surgeon Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > NM1

Assistant Surgeon Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Assistant Surgeon Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Assistant Surgeon Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10
—
Usage notes
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > PRV

Assistant Surgeon Specialty Information

RequiredMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > REF

Assistant Surgeon Secondary Identification

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310D Assistant Surgeon Name Loop end
2310E Supervising Provider Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopAssistant Surgeon Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DQ
Supervising Physician
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Supervising Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Supervising Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Supervising Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310E Supervising Provider Name Loop end
2320 Other Subscriber Information Loop
OptionalMax 10
Usage notes
—
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1
—
Usage notes
—
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
—
Usage notes
—
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
—
SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)
—
01
Spouse
18
Self
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
SBR-03
127
Insured Group or Policy Number
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60
—
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)
—
12
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
14
Medicare Secondary, No-fault Insurance including Auto is Primary
15
Medicare Secondary Worker's Compensation
16
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veteran's Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47
Medicare Secondary, Other Liability Insurance is Primary
SBR-09
1032
Claim Filing Indicator Code
Optional
Identifier (ID)
—
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization
AM
Automobile Medical
BL
Blue Cross/Blue Shield
CH
Champus
CI
Commercial Insurance Co.
DS
Disability
FI
Federal Employees Program
HM
Health Maintenance Organization
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
OF
Other Federal Program
—
TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined
—
CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS

Claim Level Adjustments

OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)
—
CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5
—
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15
—
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Payer Paid Amount

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Total Non-Covered AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Total Non-Covered Amount

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
A8
Noncovered Charges - Actual
AMT-02
782
Non-Covered Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTCoordination of Benefits (COB) Total Non-Covered Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15
—
OI
3100
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI

Other Insurance Coverage Information

RequiredMax use 1
—
Usage notes
—
Example
OI-03
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)
—
Usage notes
—
N
No
W
Not Applicable
—
Y
Yes
OI-06
1363
Release of Information Code
Required
Identifier (ID)
—
Usage notes
—
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
—
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
—
MOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA

Outpatient Adjudication Information

OptionalMax use 1
—
Usage notes
—
Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10
—
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15
—
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15
—
2330A Other Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Other Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1

Other Subscriber Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Other Insured Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Other Insured First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Other Insured Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Other Insured Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
II
Standard Unique Health Identifier for each Individual in the United States
—
MI
Member Identification Number
—
NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80
—
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3

Other Subscriber Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Other Insured Address Line
Optional
String (AN)
Min 1Max 55
—
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4

Other Subscriber City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Other Insured City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Other Insured State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Other Insured Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF

Other Subscriber Secondary Identification

OptionalMax use 2
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
SY
Social Security Number
—
REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50
—
2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1

Other Payer Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Other Payer Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
Usage notes
—
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80
—
Usage notes
—
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3

Other Payer Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Other Payer Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Other Payer Address Line
Optional
String (AN)
Min 1Max 55
—
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4

Other Payer City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Other Payer City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Other Payer State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Other Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP

Claim Check or Remittance Date

OptionalMax use 1
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Adjustment Indicator

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Control Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
F8
Original Reference Number
—
REF-02
127
Other Payer's Claim Control Number
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Predetermination Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G3
Predetermination of Benefits Identification Number
REF-02
127
Other Payer Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Prior Authorization Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G1
Prior Authorization Number
REF-02
127
Other Payer Prior Authorization Number
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Referral Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9F
Referral Number
REF-02
127
Other Payer Referral Number
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Secondary Identifier

OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Referral Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
EI
Employer's Identification Number
—
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Other Payer Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330B Other Payer Name Loop end
2330C Other Payer Referring Provider Loop
OptionalMax 2
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1

Other Payer Referring Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DN
Referring Provider
—
P3
Primary Care Provider
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF

Other Payer Referring Provider Secondary Identification

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
REF-02
127
Other Payer Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330C Other Payer Referring Provider Loop end
2330D Other Payer Rendering Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > NM1

Other Payer Rendering Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > REF

Other Payer Rendering Provider Secondary Identification

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330D Other Payer Rendering Provider Loop end
2330E Other Payer Supervising Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > NM1

Other Payer Supervising Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DQ
Supervising Physician
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > REF

Other Payer Supervising Provider Secondary Identification

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330E Other Payer Supervising Provider Loop end
2330F Other Payer Billing Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1

Other Payer Billing Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF

Other Payer Billing Provider Secondary Identification

RequiredMax use 2
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330F Other Payer Billing Provider Loop end
2330G Other Payer Service Facility Location Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1

Other Payer Service Facility Location

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF

Other Payer Service Facility Location Secondary Identification

RequiredMax use 3
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Service Facility Location Identifier
Required
String (AN)
Min 1Max 50
—
2330G Other Payer Service Facility Location Loop end
2330H Other Payer Assistant Surgeon Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Assistant Surgeon Loop > NM1

Other Payer Assistant Surgeon

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Assistant Surgeon Loop > REF

Other Payer Assistant Surgeon Secondary Identifier

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330H Other Payer Assistant Surgeon Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 50
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX

Service Line Number

RequiredMax use 1
—
Usage notes
—
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6
—
SV3
3800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV3

Dental Service

RequiredMax use 1
—
Example
SV3-01
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)
—
AD
American Dental Association Codes
—
C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48
—
Usage notes
—
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80
—
SV3-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SV3-03
1331
Place of Service Code
Optional
String (AN)
Min 1Max 2
—
Usage notes
—
SV3-04
C006
Oral Cavity Designation
OptionalMax use 1
To identify one or more areas of the oral cavity
Usage notes
—
C006-01
1361
Oral Cavity Designation Code
Required
Identifier (ID)
Min 1Max 3
—
C006-02
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
C006-03
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
C006-04
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
C006-05
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
SV3-05
1358
Prosthesis, Crown, or Inlay Code
Optional
Identifier (ID)
—
I
Initial Placement
R
Replacement
—
SV3-06
380
Procedure Count
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SV3-11
C004
Composite Diagnosis Code Pointer
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes
—
C004-01
1328
Diagnosis Code Pointer
Required
Numeric (N0)
Min 1Max 2
—
C004-02
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2
—
C004-03
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2
—
C004-04
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2
—
TOO
3820
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > TOO

Tooth Information

OptionalMax use 32
—
Usage notes
—
Example
TOO-01
1270
Code List Qualifier Code
Required
Identifier (ID)
—
JP
Universal National Tooth Designation System
TOO-02
1271
Tooth Code
Required
String (AN)
Min 1Max 30
—
Usage notes
—
TOO-03
C005
Tooth Surface
OptionalMax use 1
To identify one or more tooth surface codes
Usage notes
—
C005-01
1369
Tooth Surface Code
Required
Identifier (ID)
—
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
C005-02
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
Usage notes
—
C005-03
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
C005-04
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
C005-05
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Appliance Placement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Prior Placement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
139
Estimated
—
441
Prior Placement
—
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Prior Placement Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Replacement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - Service DateDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
446
Replacement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Replacement Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Service Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35
—
Usage notes
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Treatment Completion

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
198
Completion
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Treatment Completion Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Treatment Start

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment Completion
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
196
Start
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Treatment Start Date
Required
String (AN)
Min 1Max 35
—
CN1
4650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1

Contract Information

OptionalMax use 1
—
Usage notes
—
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)
—
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15
—
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50
—
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Line Item Control Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
6R
Provider Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Prior Authorization

OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFReferral NumberREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Referral Number

OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFPrior AuthorizationREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Service Predetermination Identification

OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Sales Tax Amount

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
T
Tax
AMT-02
782
Sales Tax Amount
Required
Decimal number (R)
Min 1Max 15
—
K3
4800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3

File Information

OptionalMax use 10
—
Usage notes
—
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80
—
HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP

Line Pricing/Repricing Information

OptionalMax use 1
—
Usage notes
—
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)
—
Usage notes
—
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15
—
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15
—
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50
—
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9
—
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)
—
AD
American Dental Association Codes
HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48
—
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)
—
UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)
—
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)
—
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)
—
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2420A Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Assistant Surgeon Name LoopSupervising Provider Name LoopService Facility Location Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Rendering Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Rendering Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

RequiredMax use 1
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420A Rendering Provider Name Loop end
2420B Assistant Surgeon Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopSupervising Provider Name LoopService Facility Location Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > NM1

Assistant Surgeon Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Assistant Surgeon Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Assistant Surgeon Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > PRV

Assistant Surgeon Specialty Information

OptionalMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > REF

Assistant Surgeon Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420B Assistant Surgeon Name Loop end
2420C Supervising Provider Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopAssistant Surgeon Name LoopService Facility Location Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DQ
Supervising Physician
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Supervising Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Supervising Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Supervising Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420C Supervising Provider Name Loop end
2420D Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80
—
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55
—
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Service Facility Location Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420D Service Facility Location Name Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD

Line Adjudication Information

RequiredMax use 1
—
Usage notes
—
Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80
—
Usage notes
—
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SVD-03
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)
—
AD
American Dental Association Codes
ER
Jurisdiction Specific Procedure and Supply Codes
C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48
—
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80
—
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SVD-06
554
Bundled or Unbundled Line Number
Optional
Numeric (N0)
Min 1Max 6
—
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS

Line Adjustment

OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)
—
CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5
—
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15
—
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP

Line Check or Remittance Date

RequiredMax use 1
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35
—
AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15
—
2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop
OptionalMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1
—
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
—
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12
—
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
—
23
Dependent
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
—
0
No Subordinate HL Segment in This Hierarchical Structure.
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT

Patient Information

RequiredMax use 1
—
Example
PAT-01
1069
Individual Relationship Code
Required
Identifier (ID)
—
01
Spouse
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
2010CA Patient Name Loop
RequiredMax 1
Usage notes
—
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1

Patient Name

RequiredMax use 1
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
QC
Patient
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Patient Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Patient First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Patient Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Patient Name Suffix
Optional
String (AN)
Min 1Max 10
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3

Patient Address

RequiredMax use 1
—
Example
N3-01
166
Patient Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Patient Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4

Patient City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Patient City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Patient State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Patient Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG

Patient Demographic Information

RequiredMax use 1
—
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Patient Birth Date
Required
String (AN)
Min 1Max 35
—
DMG-03
1068
Patient Gender Code
Required
Identifier (ID)
—
F
Female
M
Male
U
Unknown
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF

Property and Casualty Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Patient Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF

Property and Casualty Patient Identifier

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
1W
Member Identification Number
—
SY
Social Security Number
—
REF-02
127
Property and Casualty Patient Identifier
Required
String (AN)
Min 1Max 50
—
2010CA Patient Name Loop end
2300 Claim Information Loop
RequiredMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM

Claim Information

RequiredMax use 1
—
Usage notes
—
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38
—
Usage notes
—
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
CLM-05
C023
Health Care Service Location Information
RequiredMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Place of Service Code
Required
String (AN)
Min 1Max 2
—
C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)
—
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1
—
CLM-06
1073
Provider or Supplier Signature Indicator
Required
Identifier (ID)
—
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)
—
Usage notes
—
A
Assigned
—
C
Not Assigned
—
CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)
—
Usage notes
—
N
No
W
Not Applicable
—
Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)
—
Usage notes
—
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
—
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
—
CLM-11
C024
Related Causes Information
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
C024-01
1362
Related Causes Code
Required
Identifier (ID)
—
AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3
—
C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)
—
01
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
02
Physically Handicapped Children's Program
—
03
Special Federal Funding
—
05
Disability
—
CLM-19
1383
Predetermination of Benefits Code
Optional
Identifier (ID)
—
PB
Predetermination of Dental Benefits
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)
—
1
Proof of Eligibility Unknown or Unavailable
2
Litigation
3
Authorization Delays
4
Delay in Certifying Provider
5
Delay in Supplying Billing Forms
6
Delay in Delivery of Custom-made Appliances
7
Third Party Processing Delay
8
Delay in Eligibility Determination
9
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10
Administration Delay in the Prior Approval Process
11
Other
15
Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Date - Accident

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Date - Appliance Placement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Repricer Received Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Date - Service Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35
—
DN1
1450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DN1

Orthodontic Total Months of Treatment

OptionalMax use 1
—
Usage notes
—
Example
DN1-01
380
Orthodontic Treatment Months Count
Optional
Decimal number (R)
Min 1Max 15
—
DN1-02
380
Orthodontic Treatment Months Remaining Count
Optional
Decimal number (R)
Min 1Max 15
—
DN1-04
352
Orthodontic Treatment Indicator
Optional
String (AN)
Min 1Max 80
—
Usage notes
—
DN2
1500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DN2

Tooth Status

OptionalMax use 35
—
Usage notes
—
Example
DN2-01
127
Tooth Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
DN2-02
1368
Tooth Status Code
Required
Identifier (ID)
—
E
To Be Extracted
M
Missing
DN2-06
1270
Code List Qualifier Code
Required
Identifier (ID)
—
JP
Universal National Tooth Designation System
PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10
—
Usage notes
—
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)
—
B4
Referral Form
DA
Dental Models
DG
Diagnostic Report
EB
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
OZ
Support Data for Claim
P6
Periodontal Charts
RB
Radiology Films
RR
Radiology Reports
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)
—
AA
Available on Request at Provider Site
—
BM
By Mail
EL
Electronically Only
—
EM
E-Mail
FT
File Transfer
—
FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)
—
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80
—
Usage notes
—
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1
—
Usage notes
—
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)
—
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15
—
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50
—
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30
—
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT

Patient Amount Paid

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
F5
Patient Amount Paid
AMT-02
782
Patient Amount Paid
Required
Decimal number (R)
Min 1Max 15
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Claim Identifier For Transmission Intermediaries

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
Usage notes
—
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Payer Claim Control Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Predetermination Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Prior Authorization

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Referral Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Service Authorization Exception Code

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50
—
Usage notes
—
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10
—
Usage notes
—
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80
—
NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 5
—
Usage notes
—
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)
—
ADD
Additional Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Health Care Diagnosis Code

OptionalMax use 1
—
Usage notes
—
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
—
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
—
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)
—
C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
—
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
—
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)
—
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3
—
Usage notes
—
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3
—
Usage notes
—
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
—
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1
—
Usage notes
—
Example
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)
—
Usage notes
—
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15
—
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9
—
Usage notes
—
HCP-06
127
Repriced Approved Ambulatory Patient Group Code
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)
—
Usage notes
—
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)
—
Usage notes
—
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)
—
Usage notes
—
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2310A Referring Provider Name Loop
OptionalMax 2
Variants (all may be used)
Rendering Provider Name LoopService Facility Location Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DN
Referring Provider
—
P3
Primary Care Provider
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Referring Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Referring Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Referring Provider Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > PRV

Referring Provider Specialty Information

OptionalMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
RF
Referring
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310A Referring Provider Name Loop end
2310B Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopService Facility Location Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Rendering Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Rendering Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

RequiredMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80
—
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55
—
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310C Service Facility Location Name Loop end
2310D Assistant Surgeon Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopSupervising Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > NM1

Assistant Surgeon Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Assistant Surgeon Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Assistant Surgeon Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10
—
Usage notes
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > PRV

Assistant Surgeon Specialty Information

RequiredMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > REF

Assistant Surgeon Secondary Identification

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310D Assistant Surgeon Name Loop end
2310E Supervising Provider Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopAssistant Surgeon Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DQ
Supervising Physician
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Supervising Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Supervising Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Supervising Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2310E Supervising Provider Name Loop end
2320 Other Subscriber Information Loop
OptionalMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1
—
Usage notes
—
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
—
Usage notes
—
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
—
SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)
—
01
Spouse
18
Self
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
SBR-03
127
Insured Group or Policy Number
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60
—
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)
—
12
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
14
Medicare Secondary, No-fault Insurance including Auto is Primary
15
Medicare Secondary Worker's Compensation
16
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veteran's Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47
Medicare Secondary, Other Liability Insurance is Primary
SBR-09
1032
Claim Filing Indicator Code
Optional
Identifier (ID)
—
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization
AM
Automobile Medical
BL
Blue Cross/Blue Shield
CH
Champus
CI
Commercial Insurance Co.
DS
Disability
FI
Federal Employees Program
HM
Health Maintenance Organization
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
OF
Other Federal Program
—
TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined
—
CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS

Claim Level Adjustments

OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)
—
CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5
—
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15
—
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Payer Paid Amount

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Total Non-Covered AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Total Non-Covered Amount

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
A8
Noncovered Charges - Actual
AMT-02
782
Non-Covered Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTCoordination of Benefits (COB) Total Non-Covered Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15
—
OI
3100
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI

Other Insurance Coverage Information

RequiredMax use 1
—
Usage notes
—
Example
OI-03
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)
—
Usage notes
—
N
No
W
Not Applicable
—
Y
Yes
OI-06
1363
Release of Information Code
Required
Identifier (ID)
—
Usage notes
—
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
—
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
—
MOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA

Outpatient Adjudication Information

OptionalMax use 1
—
Usage notes
—
Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10
—
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15
—
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50
—
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15
—
2330A Other Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Other Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1

Other Subscriber Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Other Insured Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Other Insured First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Other Insured Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Other Insured Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
II
Standard Unique Health Identifier for each Individual in the United States
—
MI
Member Identification Number
—
NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80
—
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3

Other Subscriber Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Other Insured Address Line
Optional
String (AN)
Min 1Max 55
—
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4

Other Subscriber City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Other Insured City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Other Insured State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Other Insured Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF

Other Subscriber Secondary Identification

OptionalMax use 2
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
SY
Social Security Number
—
REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50
—
2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1

Other Payer Name

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Other Payer Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
Usage notes
—
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80
—
Usage notes
—
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3

Other Payer Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Other Payer Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Other Payer Address Line
Optional
String (AN)
Min 1Max 55
—
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4

Other Payer City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Other Payer City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Other Payer State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Other Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP

Claim Check or Remittance Date

OptionalMax use 1
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Adjustment Indicator

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Control Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
F8
Original Reference Number
—
REF-02
127
Other Payer's Claim Control Number
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Predetermination Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G3
Predetermination of Benefits Identification Number
REF-02
127
Other Payer Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Prior Authorization Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G1
Prior Authorization Number
REF-02
127
Other Payer Prior Authorization Number
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Referral Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9F
Referral Number
REF-02
127
Other Payer Referral Number
Required
String (AN)
Min 1Max 50
—
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Secondary Identifier

OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Predetermination IdentificationREFOther Payer Prior Authorization NumberREFOther Payer Referral Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
EI
Employer's Identification Number
—
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Other Payer Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330B Other Payer Name Loop end
2330C Other Payer Referring Provider Loop
OptionalMax 2
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1

Other Payer Referring Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DN
Referring Provider
—
P3
Primary Care Provider
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF

Other Payer Referring Provider Secondary Identification

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
REF-02
127
Other Payer Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330C Other Payer Referring Provider Loop end
2330D Other Payer Rendering Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > NM1

Other Payer Rendering Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > REF

Other Payer Rendering Provider Secondary Identification

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330D Other Payer Rendering Provider Loop end
2330E Other Payer Supervising Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > NM1

Other Payer Supervising Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DQ
Supervising Physician
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > REF

Other Payer Supervising Provider Secondary Identification

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330E Other Payer Supervising Provider Loop end
2330F Other Payer Billing Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Service Facility Location LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1

Other Payer Billing Provider

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF

Other Payer Billing Provider Secondary Identification

RequiredMax use 2
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330F Other Payer Billing Provider Loop end
2330G Other Payer Service Facility Location Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Assistant Surgeon Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1

Other Payer Service Facility Location

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF

Other Payer Service Facility Location Secondary Identification

RequiredMax use 3
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Service Facility Location Identifier
Required
String (AN)
Min 1Max 50
—
2330G Other Payer Service Facility Location Loop end
2330H Other Payer Assistant Surgeon Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Referring Provider LoopOther Payer Rendering Provider LoopOther Payer Supervising Provider LoopOther Payer Billing Provider LoopOther Payer Service Facility Location Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Assistant Surgeon Loop > NM1

Other Payer Assistant Surgeon

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Assistant Surgeon Loop > REF

Other Payer Assistant Surgeon Secondary Identifier

RequiredMax use 3
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Other Payer Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
—
2330H Other Payer Assistant Surgeon Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 50
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX

Service Line Number

RequiredMax use 1
—
Usage notes
—
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6
—
SV3
3800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV3

Dental Service

RequiredMax use 1
—
Example
SV3-01
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)
—
AD
American Dental Association Codes
—
C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48
—
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80
—
SV3-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SV3-03
1331
Place of Service Code
Optional
String (AN)
Min 1Max 2
—
Usage notes
—
SV3-04
C006
Oral Cavity Designation
OptionalMax use 1
To identify one or more areas of the oral cavity
Usage notes
—
C006-01
1361
Oral Cavity Designation Code
Required
Identifier (ID)
Min 1Max 3
—
C006-02
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
C006-03
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
C006-04
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
C006-05
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3
—
SV3-05
1358
Prosthesis, Crown, or Inlay Code
Optional
Identifier (ID)
—
I
Initial Placement
R
Replacement
—
SV3-06
380
Procedure Count
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SV3-11
C004
Composite Diagnosis Code Pointer
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes
—
C004-01
1328
Diagnosis Code Pointer
Required
Numeric (N0)
Min 1Max 2
—
C004-02
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2
—
C004-03
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2
—
C004-04
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2
—
TOO
3820
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > TOO

Tooth Information

OptionalMax use 32
—
Usage notes
—
Example
TOO-01
1270
Code List Qualifier Code
Required
Identifier (ID)
—
JP
Universal National Tooth Designation System
TOO-02
1271
Tooth Code
Required
String (AN)
Min 1Max 30
—
Usage notes
—
TOO-03
C005
Tooth Surface
OptionalMax use 1
To identify one or more tooth surface codes
Usage notes
—
C005-01
1369
Tooth Surface Code
Required
Identifier (ID)
—
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
C005-02
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
Usage notes
—
C005-03
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
C005-04
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
C005-05
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Appliance Placement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Prior Placement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
139
Estimated
—
441
Prior Placement
—
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Prior Placement Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Replacement

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - Service DateDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
446
Replacement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Replacement Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Service Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Treatment CompletionDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Treatment Completion

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment Start
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
198
Completion
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Treatment Completion Date
Required
String (AN)
Min 1Max 35
—
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Treatment Start

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Prior PlacementDTPDate - ReplacementDTPDate - Service DateDTPDate - Treatment Completion
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
196
Start
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Treatment Start Date
Required
String (AN)
Min 1Max 35
—
CN1
4650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1

Contract Information

OptionalMax use 1
—
Usage notes
—
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)
—
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15
—
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50
—
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Line Item Control Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
6R
Provider Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Prior Authorization

OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFReferral NumberREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Referral Number

OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFPrior AuthorizationREFRepriced Claim NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Repriced Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFService Predetermination Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Service Predetermination Identification

OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Sales Tax Amount

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
T
Tax
AMT-02
782
Sales Tax Amount
Required
Decimal number (R)
Min 1Max 15
—
K3
4800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3

File Information

OptionalMax use 10
—
Usage notes
—
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80
—
HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP

Line Pricing/Repricing Information

OptionalMax use 1
—
Usage notes
—
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)
—
Usage notes
—
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15
—
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15
—
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50
—
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9
—
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)
—
AD
American Dental Association Codes
HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48
—
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)
—
UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)
—
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)
—
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)
—
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2420A Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Assistant Surgeon Name LoopSupervising Provider Name LoopService Facility Location Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Rendering Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Rendering Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

RequiredMax use 1
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420A Rendering Provider Name Loop end
2420B Assistant Surgeon Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopSupervising Provider Name LoopService Facility Location Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > NM1

Assistant Surgeon Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Assistant Surgeon Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Assistant Surgeon Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80
—
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > PRV

Assistant Surgeon Specialty Information

OptionalMax use 1
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > REF

Assistant Surgeon Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420B Assistant Surgeon Name Loop end
2420C Supervising Provider Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopAssistant Surgeon Name LoopService Facility Location Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
DQ
Supervising Physician
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Supervising Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Supervising Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Supervising Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420C Supervising Provider Name Loop end
2420D Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopAssistant Surgeon Name LoopSupervising Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80
—
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55
—
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 20
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
1G
Provider UPIN Number
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Service Facility Location Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes
—
C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
2420D Service Facility Location Name Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD

Line Adjudication Information

RequiredMax use 1
—
Usage notes
—
Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80
—
Usage notes
—
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SVD-03
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)
—
AD
American Dental Association Codes
ER
Jurisdiction Specific Procedure and Supply Codes
C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48
—
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2
—
Usage notes
—
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80
—
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
SVD-06
554
Bundled or Unbundled Line Number
Optional
Numeric (N0)
Min 1Max 6
—
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS

Line Adjustment

OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)
—
CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5
—
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15
—
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5
—
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15
—
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15
—
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP

Line Check or Remittance Date

RequiredMax use 1
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35
—
AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15
—
2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop end
2000B Subscriber Hierarchical Level Loop end
2000A Billing Provider Hierarchical Level Loop end
SE
5550
Detail > SE

Transaction Set Trailer

RequiredMax use 1
—
Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10
—
SE-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9
—
Usage notes
—
Detail end
GE

Functional Group Trailer

RequiredMax use 1
—
Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6
—
GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9
—
IEA

Interchange Control Trailer

RequiredMax use 1
—
Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5
—
IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9
—
EDI Samples

Example 1: Commercial Health Insurance

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0233*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023314*000000001*X*005010X224A3~
ST*837*3456*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*INSURANCE COMPANY XYZ*****PI*35202~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*150***11>B>1*Y*A*Y*I~
DTP*472*D8*20061029~
REF*D9*17312345600006351~
NM1*82*1*KILDARE*BEN****XX*9876543210~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D2150*100****1~
TOO*JP*12*M>O~
LX*2~
SV3*AD>D1110*50****1~
SE*31*3456~
GE*1*000000001~
IEA*1*000000001~

Example 2a: Claim From Billing Provider to Payer A

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0235*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023516*000000001*X*005010X224A3~
ST*837*0002*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*JS0011122333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*35202~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*200***11>B>1*Y*A*Y*I~
DTP*472*D8*20061109~
REF*D9*111222333444~
NM1*82*1*KILDARE*BEN****XX*6789012345~
PRV*PE*PXC*1223P0221X~
LX*1~
SV3*AD>D3320*200****1~
TOO*JP*5~
SE*29*0002~
GE*1*000000001~
IEA*1*000000001~

Example 2b: Claim from Billing Provider to Payer B

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0236*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023642*000000001*X*005010X224A3~
ST*837*0123*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*S********CI~
NM1*IL*1*SMITH*JACK****MI*T55TY666~
NM1*PR*2*GREAT PRAIRIES HEALTH*****PI*35202~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*200***11>B>1*Y*A*Y*I~
DTP*472*D8*20061109~
REF*D9*444333222111~
NM1*82*1*KILDARE*BEN****XX*6789012345~
PRV*PE*PXC*1223P0221X~
SBR*P*19*******CI~
CAS*PR*1*50*1~
AMT*D*150~
OI***Y***I~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
DTP*573*D8*20061122~
LX*1~
SV3*AD>D3320*200****1~
TOO*JP*5~
SE*38*0123~
GE*1*000000001~
IEA*1*000000001~

Example 3: Predetermination of Benefits

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0237*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023721*000000001*X*005010X224A3~
ST*837*0321*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*ABC CLEARINGHOUSE*****46*ABC123~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
PRV*BI*PXC*1223G0001X~
NM1*85*1*JOHN*DOE****XX*2345678901~
N3*123 TOOTH DRIVE~
N4*MIAMI*FL*33411~
REF*EI*587654321~
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*35202~
CLM*SMITH878*750***11>B>1*Y*A*Y*I**********PB~
PWK*RB*BM***AC*SMITHJANE11122333~
REF*D9*123123123~
LX*1~
SV3*AD>D2750*750***I*1~
TOO*JP*13~
SE*25*0321~
GE*1*000000001~
IEA*1*000000001~

Example 4: Orthodontic Treatment Plan

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0238*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023814*000000001*X*005010X224A3~
ST*837*0322*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*JOHN DOE*****46*940001~
PER*IC*SALLY*TE*7175555555~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
PRV*BI*PXC*1223G0001X~
NM1*85*1*JOHN*DOE****XX*2345678901~
N3*123 TOOTH DRIVE~
N4*MIAMI*FL*33411~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*35202~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19911029*M~
CLM*SMITH788*4000***11>B>1*Y*A*Y*I~
DTP*452*D8*20061115~
DN1*36~
LX*1~
SV3*AD>D8080*4000****1~
SE*27*0322~
GE*1*000000001~
IEA*1*000000001~

Example 5: Sales Tax

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0239*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023922*000000001*X*005010X224A3~
ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*BLUE EXAMPLE*****PI*35202~
CLM*119033233*293.19***11>B>1*Y*C*Y*Y~
PWK*OZ*EL***AC*NEA123456798~
REF*D9*0001958960000001~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D7140*150~
TOO*JP*31~
REF*6R*01~
LX*2~
SV3*AD>D0140*130~
REF*6R*02~
LX*3~
SV3*AD>D9985*13.19~
REF*6R*03~
SE*34*0001~
GE*1*000000001~
IEA*1*000000001~

Example 6: Multiple Tooth Numbers

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0239*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023946*000000001*X*005010X224A3~
ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*ACME DENTAL PAYER*****PI*35202~
CLM*1191*900***11>B>1*Y*C*Y*Y~
PWK*OZ*EL***AC*NEA123456798~
REF*D9*0001958960000001~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D5214*900~
TOO*JP*31~
TOO*JP*30~
TOO*JP*21~
TOO*JP*19~
TOO*JP*18~
SE*31*0001~
GE*1*000000001~
IEA*1*000000001~

Example 7: Quantity Greater Than 1

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0240*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*024045*000000001*X*005010X224A3~
ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*BLUE EXAMPLE*****PI*35202~
CLM*22*44***11>B>1*Y*C*Y*Y~
DTP*472*D8*20140303~
REF*D9*0001958960000001~
HI*BK>5273~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
REF*0B*321654~
LX*1~
SV3*AD>D0230*44***I*4~
REF*6R*123456-01~
SE*29*0001~
GE*1*000000001~
IEA*1*000000001~

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