X12 276 Health Care Claim Status Request (X212)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Status Request Transaction Set (276) for use within the context of an Electronic Data Interchange (EDI) environment.
This transaction set can be used by a provider, recipient of health care products or services, or their authorized agent to request the status of a health care claim or encounter from a health care payer. This transaction set is not intended to replace the Health Care Claim Transaction Set (837), but rather to occur after the receipt of a claim or encounter information.
The request may occur at the summary or service line detail level.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HR
- Health Care Claim Status Request (276)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X212
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 276
- Health Care Claim Status Request
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the implementation guide Version/Release/Industry Identifier Code named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X212
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0010
- Information Source, Information Receiver, Provider of Service, Subscriber, Dependent
Code identifying purpose of transaction set
- 13
- Request
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Payer Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
- SECURITY HEALTH PLAN
- SHP
Code designating the system/method of code structure used for Identification Code (67)
- PI
- Payor Identification
Payer identification number established through trading partner agreement.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
- The ETIN is established through Trading Partner agreement.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 19
- Provider of Service
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Provider Name
To supply the full name of an individual or organizational entity
- Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider). The provider identified facilitates identification of the claim within a payer's system.
- During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
- After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop may be sent with the NPI reported in the NM109 and NM108=XX.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
- SV
- Service Provider Number
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required value when the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes must be used.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Demographic Information
To supply demographic information
- Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
Subscriber Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Use the value "2" in an employer-subscriber situation, such as Worker's Compensation.
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
Code identifying a party or other code
Medicaid ID
Subscriber ID
Claim Status Tracking Number
To uniquely identify a transaction to an application
- This segment conveys a unique trace or reference number for each 2200D loop. This number will be returned in the 277 response.
- Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
- When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Application or Location System Identifier
To specify identifying information
- Required when the application or location system identifier is known. If not required by this implementation guide, do not send.
- This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.
Code qualifying the Reference Identification
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
To specify identifying information
- Required when a Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Group Number
To specify identifying information
- Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.
Institutional Bill Type Identification
To specify identifying information
- Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code qualifying the Reference Identification
- BLT
- Billing Type
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code
Patient Control Number
To specify identifying information
- Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.
- The maximum number of characters supported for the Patient Control Number is `20'.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Claim Control Number
To specify identifying information
- This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
- Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1K
- Payor's Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pharmacy Prescription Number
To specify identifying information
- Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Submitted Charges
To indicate the total monetary amount
- Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
- Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.
Claim Service Date
To specify any or all of a date, a time, or a time period
- For professional claims, this date is derived from the service level dates.
- Required for institutional claims or for professional and dental claims when the service date (Loop 2210) is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
Expression of a date, a time, or range of dates, times or dates and times
Service Line Information
To supply payment and control information to a provider for a particular service
- For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
- Required when requesting status for Service Lines. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - N4
- National Drug Code in 5-4-2 Format
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
This code is the NUBC Revenue Code.
- WK
- Advanced Billing Concepts (ABC) Codes
At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Monetary amount
- SVC02 is the submitted service charge.
- This amount is the original submitted charge.
Identifying number for a product or service
- SVC04 is the National Uniform Billing Committee Revenue Code.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Service Line Item Identification
To specify identifying information
- Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- FJ
- Line Item Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
Expression of a date, a time, or range of dates, times or dates and times
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Dependent Demographic Information
To supply demographic information
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
Dependent Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Claim Status Tracking Number
To uniquely identify a transaction to an application
- This segment conveys a unique trace or reference for each 2200E Loop. This number will be returned in the 277 response.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Application or Location System Identifier
To specify identifying information
- Required when the application or location system identifier is known. If not required by this implementation guide, do not send.
- This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.
Code qualifying the Reference Identification
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
To specify identifying information
- Required when a Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Group Number
To specify identifying information
- Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.
Institutional Bill Type Identification
To specify identifying information
- Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code qualifying the Reference Identification
- BLT
- Billing Type
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code
Patient Control Number
To specify identifying information
- Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.
- The maximum number of characters supported for the Patient Control Number is `20'.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Claim Control Number
To specify identifying information
- This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
- Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1K
- Payor's Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pharmacy Prescription Number
To specify identifying information
- Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Submitted Charges
To indicate the total monetary amount
- Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.
- Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
Claim Service Date
To specify any or all of a date, a time, or a time period
- For professional claims, this date is derived from the service level dates.
- Required for institutional claims or for professional and dental claims when the service date (Loop 2210) is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
Expression of a date, a time, or range of dates, times or dates and times
Service Line Information
To supply payment and control information to a provider for a particular service
- For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
- Required when requesting status for Service Lines. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - N4
- National Drug Code in 5-4-2 Format
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
This code is the NUBC Revenue Code.
- WK
- Advanced Billing Concepts (ABC) Codes
At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Monetary amount
- SVC02 is the submitted service charge.
- This amount is the original submitted charge.
Identifying number for a product or service
- SVC04 is the National Uniform Billing Committee Revenue Code.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Service Line Item Identification
To specify identifying information
- Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- FJ
- Line Item Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
Expression of a date, a time, or range of dates, times or dates and times
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- Data value in SE02 must be identical to ST02.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Claim Level Status
GS*HR*SENDERGS*RECEIVERGS*20231103*021550*000000001*X*005010X212~
ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*SECURITY HEALTH PLAN*****PI*SHP~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
DMG*D8*19301210*M~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*EJ*SM123456~
AMT*T3*8513.88~
DTP*472*RD8*20050831-20050906~
HL*5*3*22*0~
DMG*D8*19301115*F~
NM1*IL*1*JONES*MARY****MI*234567890A~
TRN*1*ABCXYZ2~
REF*BLT*111~
REF*EJ*JO234567~
AMT*T3*7599~
DTP*472*RD8*20050731-20050809~
HL*6*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~
HL*7*6*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
HL*8*7*23~
DMG*D8*19951101*M~
NM1*QC*1*MANN*JOSEPH~
TRN*1*ABCXYZ3~
REF*EJ*MA345678~
SVC*HC>99203*150*****1~
DTP*472*D8*20050501~
SE*36*0001~
GE*1*000000001~
IEA*1*000000001~
Example 2: Provider Level Status
GS*HR*SENDERGS*RECEIVERGS*20231103*021611*000000001*X*005010X212~
ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*SECURITY HEALTH PLAN*****PI*SHP~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
DMG*D8*19301210*M~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*EJ*SM123456~
AMT*T3*8513.88~
DTP*472*RD8*20050831-20050906~
HL*5*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~
HL*6*5*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
HL*7*6*23~
DMG*D8*19951101*M~
NM1*QC*1*MANN*JOSEPH~
TRN*1*ABCXYZ3~
REF*EJ*MA345678~
SVC*HC>99203*150*****1~
DTP*472*D8*20050501~
SE*28*0001~
GE*1*000000001~
IEA*1*000000001~
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