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

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

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

To start and identify an interchange of zero or more functional groups and interchange-related control segments

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

Code identifying the type of information in the Authorization Information

00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10

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)

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

Code identifying the type of information in the Security Information

00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10

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)

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

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

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

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

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

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

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

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

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

Date of the interchange

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

Time of the interchange

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

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

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1

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
GS

Functional Group Header

RequiredMax use 1

To indicate the beginning of a functional group and to provide control information

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

Code identifying a group of application related transaction sets

HC
Health Care Claim (837)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

Code identifying party sending transmission; codes agreed to by trading partners

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

Code identifying party receiving transmission; codes agreed to by trading partners

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

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

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

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)

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

Assigned number originated and maintained by the sender

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

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

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

005010X224A3

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1

To indicate the start of a transaction set and to assign a control number

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

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).
837
Health Care Claim
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
ST-03
1705
Implementation Guide Version Name
Required
String (AN)

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.
Usage notes
  • This element must be populated with the guide identifier 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 used at translation time.
005010X224A3
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

Usage notes
  • The second example denotes the case where the entire transaction set contains ENCOUNTERS.
Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

0019
Information Source, Subscriber, Dependent
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

Usage notes
  • BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.
00
Original

Original transmissions are transmissions which have never been sent to the receiver.

18
Reissue

If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent.

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

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.
Usage notes
  • The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
  • This field is limited to 30 characters.
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

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.
Usage notes
  • This is the date that the original submitter created the claim file from their business application system.
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

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.
Usage notes
  • This is the time that the original submitter created the claim file from their business application system.
BHT-06
640
Claim or Encounter Identifier
Required
Identifier (ID)

Code specifying the type of transaction

31
Subrogation Demand

The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.
NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction.

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

To supply the full name of an individual or organizational entity

Usage notes
  • The submitter is the entity responsible for the creation and formatting of this transaction.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

41
Submitter
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Submitter Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Code designating the system/method of code structure used for Identification Code (67)

46
Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

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

Code identifying a party or other code

PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
  • The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
  • There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
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)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-02
93
Submitter Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

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

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

To supply the full name of an individual or organizational entity

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

Code identifying an organizational entity, a physical location, property or an individual

40
Receiver
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Receiver Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Code designating the system/method of code structure used for Identification Code (67)

46
Electronic Transmitter Identification Number (ETIN)
NM1-09
67
Receiver Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To identify dependencies among and the content of hierarchically related groups of data segments

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

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

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

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.
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV

Billing Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when the Billing Provider is also the Rendering Provider for at least one of the claims in this transaction.
    If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

BI
Billing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1

To specify the currency (dollars, pounds, francs, etc.) used in a transaction

Usage notes
  • Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.
  • It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.
Example
CUR-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

85
Billing Provider
CUR-02
100
Currency Code
Required
Identifier (ID)
Min 3Max 3

Code (Standard ISO) for country in whose currency the charges are specified

Usage notes
  • The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.
2010AA Billing Provider Name Loop
RequiredMax 1
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

To supply the full name of an individual or organizational entity

Usage notes
  • Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
  • Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
  • The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
  • The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
  • When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
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)

Code identifying an organizational entity, a physical location, property or an individual

85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Billing Provider Last or Organizational Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Billing Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3

Billing Provider Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
Example
N3-01
166
Billing Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes

Follow the 5010 Implementation Guide; Dental recommends sending the full street address.

N3-02
166
Billing Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4

Billing Provider City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Billing Provider State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Billing Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider Tax Identification

RequiredMax use 1

To specify identifying information

Usage notes
  • This is the tax identification number (TIN) of the entity to be paid for the submitted services.
Example
Variants (all may be used)
REFBilling Provider UPIN/License Information
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

REF-02
127
Billing Provider Tax Identification Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

This segment must contain tax identification 2010ABnumber of the billing provider.

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider UPIN/License Information

OptionalMax use 2

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification.
Example
Variants (all may be used)
REFBilling Provider Tax Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

REF-02
127
Billing Provider License and/or UPIN Information
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

PER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER

Billing Provider Contact Information

OptionalMax use 2

To identify a person or office to whom administrative communications should be directed

Usage notes
  • Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
  • There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
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)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-02
93
Billing Provider Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

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

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
  • The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

87
Pay-to Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify the location of the named party

Example
N3-01
166
Pay-To Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes

Follow the 5010 Implementation Guide. Dental recommends sending the full street address rather than a PO Box address.

N3-02
166
Pay-To Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4

Pay-To Address City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Pay-To Address State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Pay-to Address Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when willing trading partners agree to use this implementation for their subrogation payment requests.
  • This loop may only be used when BHT06 = 31.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

PE
Payee

PE is used to indicate the subrogated payee.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Pay-To Plan Organizational Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:

  1. Both the sender and receiver agree to use the National Plan ID,
  2. The receiver has a National Plan ID, and
  3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

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

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3

Pay-to Plan Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Pay-To Plan Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Pay-To Plan Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4

Pay-To Plan City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Pay-To Plan State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Pay-To Plan Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-to Plan Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFPay-To Plan Tax Identification Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number

This code is only allowed when the National Plan Identifier is reported in NM109 of this loop.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-To Plan Tax Identification Number

RequiredMax use 1

To specify identifying information

Example
Variants (all may be used)
REFPay-to Plan Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

REF-02
127
Pay-To Plan Tax Identification Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To identify dependencies among and the content of hierarchically related groups of data segments

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

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

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

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

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.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR

Subscriber Information

RequiredMax use 1

To record information specific to the primary insured and the insurance carrier for that insured

Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Usage notes
  • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
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

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

SBR-02
1069
Individual Relationship Code
Optional
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
18
Self
SBR-03
127
Subscriber Group or Policy Number
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
SBR-04
93
Subscriber Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)

Code identifying the type of insurance policy within a specific insurance program

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)

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined

Use Code ZZ when Type of Insurance is not known.

2010BA Subscriber Name Loop
RequiredMax 1
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

To supply the full name of an individual or organizational entity

Usage notes
  • In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
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)

Code identifying an organizational entity, a physical location, property or an individual

IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Subscriber Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

Usage notes
  • Examples: I, II, III, IV, Jr, Sr
    This data element is used only to indicate generation or patronymic.
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

II
Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Subscriber State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Subscriber Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Subscriber Birth Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
DMG-03
1068
Subscriber Gender Code
Required
Identifier (ID)

Code indicating the sex of the individual

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

To specify identifying information

Usage notes
  • Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
  • This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
  • This segment is not a HIPAA requirement as of this writing.
Example
Variants (all may be used)
REFSubscriber Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Subscriber Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2010BA Subscriber Name Loop end
2010BB Payer Name Loop
RequiredMax 1
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

To supply the full name of an individual or organizational entity

Usage notes
  • This is the destination payer.
  • For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Payer Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:

  1. Both the sender and receiver agree to use the National Plan ID,
  2. The receiver has a National Plan ID, and
  3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Payer Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3

Payer Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
N3-01
166
Payer Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Payer Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4

Payer City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Payer State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Billing Provider Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFPayer Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Payer Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFBilling Provider Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number

This code is only allowed when the National Plan Identifier is reported in NM109 of this loop.

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Payer Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify basic data about the claim

Usage notes
  • The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
  • For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38

Identifier used to track a claim from creation by the health care provider through payment

Usage notes
  • The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
  • When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
  • The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CLM02 is the total amount of all submitted charges of service segments for this claim.
Usage notes
  • The Total Claim Charge Amount must be greater than or equal to zero.
  • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
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

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

CLM-06
1073
Provider or Supplier Signature Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)

Code indicating whether the provider accepts assignment

Usage notes
  • Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
A
Assigned

Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

C
Not Assigned

Required when code `A' does not apply.

CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Usage notes
  • The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

For this Implementation Guide, this also applies to dental 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

Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.

C024-01
1362
Related Causes Code
Required
Identifier (ID)

Code identifying an accompanying cause of an illness, injury or an accident

AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying an accompanying cause of an illness, injury or an accident

C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)

Code indicating the Special Program under which the services rendered to the patient were performed

01
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
02
Physically Handicapped Children's Program

This code is used for Medicaid claims only.

03
Special Federal Funding

This code is used for Medicaid claims only.

05
Disability

This code is used for Medicaid claims only.

CLM-19
1383
Predetermination of Benefits Code
Optional
Identifier (ID)

Code identifying reason for claim submission

PB
Predetermination of Dental Benefits
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)

Code indicating the reason why a request was delayed

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when CLM11-1 or CLM11-2 has a value of AA' or OA'.
    OR
    Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Appliance Placement

OptionalMax use 1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting the date orthodontic appliances were placed. If not required by this implementation guide, do not send.
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Repricer Received Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Service Date

OptionalMax use 1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. If not required by this implementation guide, do not send.
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

Expression of a date, a time, or range of dates, times or dates and times

DN1
1450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DN1

Orthodontic Total Months of Treatment

OptionalMax use 1

To supply orthodontic information

Usage notes
  • Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
  • When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
Example
DN1-01
380
Orthodontic Treatment Months Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • DN101 is the estimated number of treatment months.
DN1-02
380
Orthodontic Treatment Months Remaining Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • DN102 is the number of treatment months remaining.
DN1-04
352
Orthodontic Treatment Indicator
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • DN104 is the appliance description.
Usage notes
  • The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.
DN2
1500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DN2

Tooth Status

OptionalMax use 35

To specify the status of individual teeth

Usage notes
  • Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
Example
DN2-01
127
Tooth Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • DN201 is the tooth number.
Usage notes
  • The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
DN2-02
1368
Tooth Status Code
Required
Identifier (ID)

Code specifying the status of the tooth

E
To Be Extracted
M
Missing
DN2-06
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • DN206 designates the code set used to identify the tooth in DN201.
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

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when there is a paper attachment following this claim.
    OR
    Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    OR
    Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
    If not required by this implementation guide, do not send.
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)

Code indicating the title or contents of a document, report or supporting item

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)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1

To specify basic data about the contract or contract line item

Usage notes
  • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
  • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

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

Monetary amount

  • CN102 is the contract amount.
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

  • CN103 is the allowance or charge percent.
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • CN104 is the contract code.
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT

Patient Amount Paid

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
  • Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

F5
Patient Amount Paid
AMT-02
782
Patient Amount Paid
Required
Decimal number (R)
Min 1Max 15

Monetary amount

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Claim Identifier For Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
  • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
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)

Code qualifying the Reference Identification

Usage notes
  • Number assigned by clearinghouse, van, etc.
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Predetermination Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
  • Reference numbers at this position apply to the entire claim.
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)

Code qualifying the Reference Identification

G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Prior Authorization

OptionalMax use 1

To specify identifying information

Usage notes
  • Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
  • Required when an authorization number is assigned by the payer or UMO
    AND
    the services on this claim were preauthorized.
    If not required by this implementation guide, do not send.
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
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)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
    AND
    a referral is involved.
    If not required by this implementation guide, do not send.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
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)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Service Authorization Exception Code

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Allowable values for this element are:
    1 Immediate/Urgent Care
    2 Services Rendered in a Retroactive Period
    3 Emergency Care
    4 Client has Temporary Medicaid
    5 Request from County for Second Opinion to Determine
    if Recipient Can Work
    6 Request for Override Pending
    7 Special Handling
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10

To transmit a fixed-format record or matrix contents

Usage notes
  • Required when ALL of the following conditions are met:
  • A regulatory agency concludes it must use the K3 to meet an emergency
    legislative requirement;
  • The administering regulatory agency or other state organization has
    completed each one of the following steps:
    contacted the X12N workgroup,
    requested a review of the K3 data requirement to ensure there is not
    an existing method within the implementation guide to meet this
    requirement
  • X12N determines that there is no method to meet the requirement.
    If not required by this implementation guide, do not send.
  • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
    Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 5

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
    If not required by this implementation guide, do not send.
  • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ADD
Additional Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Health Care Diagnosis Code

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

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 ICD-10-CM 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.

BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)

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 SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

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 ICD-10-CM 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.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)

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 SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes
  • See element HI02-1 for a list of valid values.
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes
  • See element HI02-1 for a list of valid values.
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Example
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
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

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP04 is the repricing organization identification number.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-06
127
Repriced Approved Ambulatory Patient Group Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code specifying policy compliance

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when this claim involves a referral. If not required by this implementation guide, do not send.
  • When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
  • When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
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)

Code identifying an organizational entity, a physical location, property or an individual

DN
Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

P3
Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Referring Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

RF
Referring
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. If not required by this implementation guide, do not send.
  • Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
    If not required by this implementation guide, do not send.
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
  • When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
  • The purpose of this loop is to identify specifically where the service was rendered.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

Usage notes

UnitedHealthcare Dental will use the code 77

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes

Follow the 5010 Implementation Guide. Dental recommends sending the full street address rather than a PO Box address.

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider provided these services in the role of the Assisting Surgeon.
    If not required by this implementation guide, do not send.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Assistant Surgeon Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35

Individual first name

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

Individual middle name or initial

NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

Usage notes
  • Examples: I, II, III, IV, Jr, Sr
    This data element is used only to indicate generation or patronymic.
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the rendering provider is supervised by a physician or dentist. If not required by this implementation guide, do not send.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify identifying information

Usage notes
  • Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop;
    OR
    Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider;
    OR
    Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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 > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1

To record information specific to the primary insured and the insurance carrier for that insured

Usage notes
  • Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
  • All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Usage notes
  • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
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

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)

Code identifying the type of insurance policy within a specific insurance program

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)

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined

Use Code ZZ when Type of Insurance is not known.

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

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
  • Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
  • Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
  • Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
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)

Code identifying the general category of payment adjustment

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

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
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

To indicate the total monetary amount

Usage notes
  • Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
    OR
    Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
    If not required by this implementation guide, do not send.;
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)

Code to qualify amount

D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • It is acceptable to show "0" as the amount paid.
  • When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
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

To indicate the total monetary amount

Usage notes
  • Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
  • When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

A8
Noncovered Charges - Actual
AMT-02
782
Non-Covered Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To indicate the total monetary amount

Usage notes
  • Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
    OR
    Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
    If not required by this implementation guide, do not send.
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  • This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
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)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To specify information associated with other health insurance coverage

Usage notes
  • All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Example
OI-03
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
  • This is a crosswalk from CLM08 when doing COB.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
OI-06
1363
Release of Information Code
Required
Identifier (ID)

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Usage notes
  • The Release of Information response is limited to the information carried in this claim.
  • This is a crosswalk from CLM09 when doing COB.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

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

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Usage notes
  • Required when outpatient adjudication information is reported in the remittance advice
    OR
    Required when it is necessary to report remark codes.
    If not required by this implementation guide, do not send.
Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

  • MOA01 is the reimbursement rate.
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA09 is the professional component amount billed but not payable.
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

To supply the full name of an individual or organizational entity

Usage notes
  • If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
  • If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Other Insured Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Other Insured First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Other Insured Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Other Insured Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

II
Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the location of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Insured Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Other Insured State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Other Insured Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Other Payer Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:

  1. Both the sender and receiver agree to use the National Plan ID,
  2. The receiver has a National Plan ID, and
  3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
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

To specify the location of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
N3-01
166
Other Payer Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Payer Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Other Payer State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Other Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify identifying information

Usage notes
  • Required when the claim is being sent in the payer-to-payer COB model,
    AND
    the destination payer is secondary to the payer identified in this Loop ID-2330B,
    AND
    the payer identified in this Loop ID-2330B has re-adjudicated the claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The only valid value for this element is `Y'.
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

To specify identifying information

Usage notes
  • Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
    OR
    Required when the Other Payer's Claim Control Number is available.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

F8
Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a predetermination identification number to this claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

G3
Predetermination of Benefits Identification Number
REF-02
127
Other Payer Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
  • Required when the payer identified in this loop has assigned a prior authorization number to this claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Other Payer Prior Authorization Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a referral number to this claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Other Payer Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

2U
Payer Identification Number
EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DN
Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

P3
Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

REF-02
127
Other Payer Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

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

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Service Facility Location Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To reference a line number in a transaction set

Usage notes
  • The LX functions as a line counter.
  • The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
  • LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

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

To specify the service line item detail for dental work

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)

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

CDT = Current Dental Terminology

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

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

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • C003-07 is the description of the procedure identified in C003-02.
SV3-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV302 is the submitted service line item amount.
Usage notes
  • This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
  • Zero "0" is an acceptable value for this element.
SV3-03
1331
Place of Service Code
Optional
String (AN)
Min 1Max 2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

  • SV303 is the place of service code representing the location where the dental treatment was rendered.
Usage notes
  • See CODE SOURCE 237: Place of Service Codes for Professional Claims
SV3-04
C006
Oral Cavity Designation
OptionalMax use 1
To identify one or more areas of the oral cavity
Usage notes

Required when the nomenclature associated with the procedure reported in SV301-2 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments.

C006-01
1361
Oral Cavity Designation Code
Required
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-02
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-03
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-04
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-05
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

SV3-05
1358
Prosthesis, Crown, or Inlay Code
Optional
Identifier (ID)

Code specifying the placement status for the dental work

I
Initial Placement
R
Replacement

When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.

SV3-06
380
Procedure Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SV306 is the number of procedures.
Usage notes
  • Number of procedures
SV3-11
C004
Composite Diagnosis Code Pointer
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes

Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send.

C004-01
1328
Diagnosis Code Pointer
Required
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-01 identifies the primary diagnosis code for this service line.
C004-02
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-02 identifies the second diagnosis code for this service line.
C004-03
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-03 identifies the third diagnosis code for this service line.
C004-04
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-04 identifies the fourth diagnosis code for this service line.
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

To identify a tooth by number and, if applicable, one or more tooth surfaces

Usage notes
  • Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
  • Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.
Example
TOO-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

JP
Universal National Tooth Designation System
TOO-02
1271
Tooth Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

Usage notes
  • See Appendix A for code source 135: American Dental Association Codes.
  • This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.
TOO-03
C005
Tooth Surface
OptionalMax use 1
To identify one or more tooth surface codes
Usage notes

Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.

C005-01
1369
Tooth Surface Code
Required
Identifier (ID)

Code identifying the area of the tooth that was treated

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

Code identifying the area of the tooth that was treated

Usage notes
  • Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.
C005-03
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

C005-04
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

C005-05
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;
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)

Code specifying type of date or time, or both date and time

452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.
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)

Code specifying type of date or time, or both date and time

139
Estimated

Required when the exact Prior Placement Date is not known.

441
Prior Placement

Required when the exact Prior Placement Date is known.

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

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
DTP-03
1251
Prior Placement Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.
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)

Code specifying type of date or time, or both date and time

446
Replacement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Replacement Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
  • Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
  • Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
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)

Code specifying type of date or time, or both date and time

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
  • When the Treatment Completion Date is used, the Date of Service must not be used.
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)

Code specifying type of date or time, or both date and time

198
Completion
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Treatment Completion Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting initial impression or preparation for a crown or denture.
    OR
    Required when reporting initial endodontic treatment.
    OR
    Required when reporting the implant fixture placement.
    If not required by this implementation guide, do not send.
  • When the Treatment Start Date is used, the Date of Service must not be used.
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)

Code specifying type of date or time, or both date and time

196
Start
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Treatment Start Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify basic data about the contract or contract line item

Usage notes
  • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
  • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

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

Monetary amount

  • CN102 is the contract amount.
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

  • CN103 is the allowance or charge percent.
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • CN104 is the contract code.
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
  • The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
  • Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
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)

Code qualifying the Reference Identification

6R
Provider Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
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

To specify identifying information

Usage notes
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
  • Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
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)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To specify identifying information

Usage notes
  • Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.
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)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the Referral Number reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
  • Reference numbers at this position apply to the current line item only.
  • When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
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)

Code qualifying the Reference Identification

G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the Predetermination Identification reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To indicate the total monetary amount

Usage notes
  • Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
  • When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV302) for this service line must include the amount reported in the Sales Tax Amount.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

T
Tax
AMT-02
782
Sales Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To transmit a fixed-format record or matrix contents

Usage notes
  • Required when ALL of the following conditions are met:
  • A regulatory agency concludes it must use the K3 to meet an emergency
    legislative requirement;
  • The administering regulatory agency or other state organization has
    completed each one of the following steps:
    contacted the X12N workgroup,
    requested a review of the K3 data requirement to ensure there is not
    an existing method within the implementation guide to meet this
    requirement
  • X12N determines that there is no method to meet the requirement.
    If not required by this implementation guide, do not send.
  • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
    Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

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

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
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)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
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

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP04 is the repricing organization identification number.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

AD
American Dental Association Codes
HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP10 is the approved procedure code.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
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)

Code specifying policy compliance

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)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present
    OR
    Required when each of the following conditions apply:
  • the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA)
  • this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider
  • the Assistant Surgeon loop (Loop ID-2420C) is not used.
    If not required by this implementation guide, do not send.
  • Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
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)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D.
    If not required by this implementation guide, do not send.;
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)

Code identifying an organizational entity, a physical location, property or an individual

DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Assistant Surgeon Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35

Individual first name

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

Individual middle name or initial

NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the rendering provider is supervised by a physician or dentist and the supervising physician or dentist is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
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)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To supply the full name of an individual or organizational entity

Usage notes
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
  • Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
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)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify identifying information

Usage notes
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Service Facility Location Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

Usage notes
  • Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
  • To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • SVD01 is the payer identification code.
Usage notes
  • This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVD02 is the amount paid for this service line.
Usage notes
  • Zero "0" is an acceptable value for this element.
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)

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

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

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.
Usage notes
  • This is the first procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

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

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.
Usage notes
  • This is the second procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

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

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.
Usage notes
  • This is the third procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

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

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.
Usage notes
  • This is the fourth procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • C003-07 is the description of the procedure identified in C003-02.
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVD05 is the paid units of service.
Usage notes
  • This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SVD-06
554
Bundled or Unbundled Line Number
Optional
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

  • SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
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

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
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)

Code identifying the general category of payment adjustment

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

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
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

To specify any or all of a date, a time, or a time period

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

Code specifying type of date or time, or both date and time

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To indicate the total monetary amount

Usage notes
  • Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
  • This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To identify dependencies among and the content of hierarchically related groups of data segments

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

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

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

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

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.
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT

Patient Information

RequiredMax use 1

To supply patient information

Example
PAT-01
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

01
Spouse
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
2010CA Patient Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1

Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

Code identifying an organizational entity, a physical location, property or an individual

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Patient Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

To specify the location of the named party

Example
N3-01
166
Patient Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Patient Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Patient State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Patient Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To supply demographic information

Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Patient Birth Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
DMG-03
1068
Patient Gender Code
Required
Identifier (ID)

Code indicating the sex of the individual

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

To specify identifying information

Usage notes
  • Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
  • This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
  • This segment is not a HIPAA requirement as of this writing.
Example
Variants (all may be used)
REFProperty and Casualty Patient Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1W
Member Identification Number

This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim.

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Property and Casualty Patient Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify basic data about the claim

Usage notes
  • The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
  • For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38

Identifier used to track a claim from creation by the health care provider through payment

Usage notes
  • The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
  • When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
  • The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CLM02 is the total amount of all submitted charges of service segments for this claim.
Usage notes
  • The Total Claim Charge Amount must be greater than or equal to zero.
  • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
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

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

CLM-06
1073
Provider or Supplier Signature Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)

Code indicating whether the provider accepts assignment

Usage notes
  • Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
A
Assigned

Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

C
Not Assigned

Required when code `A' does not apply.

CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Usage notes
  • The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

For this Implementation Guide, this also applies to dental 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

Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.

C024-01
1362
Related Causes Code
Required
Identifier (ID)

Code identifying an accompanying cause of an illness, injury or an accident

AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying an accompanying cause of an illness, injury or an accident

C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)

Code indicating the Special Program under which the services rendered to the patient were performed

01
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
02
Physically Handicapped Children's Program

This code is used for Medicaid claims only.

03
Special Federal Funding

This code is used for Medicaid claims only.

05
Disability

This code is used for Medicaid claims only.

CLM-19
1383
Predetermination of Benefits Code
Optional
Identifier (ID)

Code identifying reason for claim submission

PB
Predetermination of Dental Benefits
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)

Code indicating the reason why a request was delayed

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when CLM11-1 or CLM11-2 has a value of AA' or OA'.
    OR
    Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - Appliance PlacementDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting the date orthodontic appliances were placed. If not required by this implementation guide, do not send.
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Repricer Received DateDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Service Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Repricer Received Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. If not required by this implementation guide, do not send.
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

Expression of a date, a time, or range of dates, times or dates and times

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

To supply orthodontic information

Usage notes
  • Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
  • When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
Example
DN1-01
380
Orthodontic Treatment Months Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • DN101 is the estimated number of treatment months.
DN1-02
380
Orthodontic Treatment Months Remaining Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • DN102 is the number of treatment months remaining.
DN1-04
352
Orthodontic Treatment Indicator
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • DN104 is the appliance description.
Usage notes
  • The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.
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

To specify the status of individual teeth

Usage notes
  • Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
Example
DN2-01
127
Tooth Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • DN201 is the tooth number.
Usage notes
  • The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
DN2-02
1368
Tooth Status Code
Required
Identifier (ID)

Code specifying the status of the tooth

E
To Be Extracted
M
Missing
DN2-06
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • DN206 designates the code set used to identify the tooth in DN201.
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

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when there is a paper attachment following this claim.
    OR
    Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    OR
    Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
    If not required by this implementation guide, do not send.
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)

Code indicating the title or contents of a document, report or supporting item

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)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
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

To specify basic data about the contract or contract line item

Usage notes
  • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
  • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

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

Monetary amount

  • CN102 is the contract amount.
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

  • CN103 is the allowance or charge percent.
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • CN104 is the contract code.
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
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

To indicate the total monetary amount

Usage notes
  • Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
  • Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

F5
Patient Amount Paid
AMT-02
782
Patient Amount Paid
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
  • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
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)

Code qualifying the Reference Identification

Usage notes
  • Number assigned by clearinghouse, van, etc.
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
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

To specify identifying information

Usage notes
  • Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
  • Reference numbers at this position apply to the entire claim.
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)

Code qualifying the Reference Identification

G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
  • Required when an authorization number is assigned by the payer or UMO
    AND
    the services on this claim were preauthorized.
    If not required by this implementation guide, do not send.
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
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)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
    AND
    a referral is involved.
    If not required by this implementation guide, do not send.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
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)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Allowable values for this element are:
    1 Immediate/Urgent Care
    2 Services Rendered in a Retroactive Period
    3 Emergency Care
    4 Client has Temporary Medicaid
    5 Request from County for Second Opinion to Determine
    if Recipient Can Work
    6 Request for Override Pending
    7 Special Handling
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

To transmit a fixed-format record or matrix contents

Usage notes
  • Required when ALL of the following conditions are met:
  • A regulatory agency concludes it must use the K3 to meet an emergency
    legislative requirement;
  • The administering regulatory agency or other state organization has
    completed each one of the following steps:
    contacted the X12N workgroup,
    requested a review of the K3 data requirement to ensure there is not
    an existing method within the implementation guide to meet this
    requirement
  • X12N determines that there is no method to meet the requirement.
    If not required by this implementation guide, do not send.
  • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
    Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

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

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
    If not required by this implementation guide, do not send.
  • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ADD
Additional Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

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

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

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 ICD-10-CM 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.

BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)

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 SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

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 ICD-10-CM 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.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)

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 SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes
  • See element HI02-1 for a list of valid values.
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes
  • See element HI02-1 for a list of valid values.
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
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

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Example
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
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

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP04 is the repricing organization identification number.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-06
127
Repriced Approved Ambulatory Patient Group Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code specifying policy compliance

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when this claim involves a referral. If not required by this implementation guide, do not send.
  • When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
  • When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
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)

Code identifying an organizational entity, a physical location, property or an individual

DN
Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

P3
Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Referring Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

RF
Referring
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. If not required by this implementation guide, do not send.
  • Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
    If not required by this implementation guide, do not send.
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
  • When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
  • The purpose of this loop is to identify specifically where the service was rendered.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider provided these services in the role of the Assisting Surgeon.
    If not required by this implementation guide, do not send.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Assistant Surgeon Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35

Individual first name

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

Individual middle name or initial

NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

Usage notes
  • Examples: I, II, III, IV, Jr, Sr
    This data element is used only to indicate generation or patronymic.
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the rendering provider is supervised by a physician or dentist. If not required by this implementation guide, do not send.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
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)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify identifying information

Usage notes
  • Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop;
    OR
    Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider;
    OR
    Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To record information specific to the primary insured and the insurance carrier for that insured

Usage notes
  • Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
  • All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Usage notes
  • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
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

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)

Code identifying the type of insurance policy within a specific insurance program

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)

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined

Use Code ZZ when Type of Insurance is not known.

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

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
  • Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
  • Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
  • Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
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)

Code identifying the general category of payment adjustment

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

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
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

To indicate the total monetary amount

Usage notes
  • Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
    OR
    Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
    If not required by this implementation guide, do not send.;
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)

Code to qualify amount

D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • It is acceptable to show "0" as the amount paid.
  • When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
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

To indicate the total monetary amount

Usage notes
  • Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
  • When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

A8
Noncovered Charges - Actual
AMT-02
782
Non-Covered Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To indicate the total monetary amount

Usage notes
  • Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
    OR
    Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
    If not required by this implementation guide, do not send.
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  • This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
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)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To specify information associated with other health insurance coverage

Usage notes
  • All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Example
OI-03
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
  • This is a crosswalk from CLM08 when doing COB.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
OI-06
1363
Release of Information Code
Required
Identifier (ID)

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Usage notes
  • The Release of Information response is limited to the information carried in this claim.
  • This is a crosswalk from CLM09 when doing COB.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

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

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Usage notes
  • Required when outpatient adjudication information is reported in the remittance advice
    OR
    Required when it is necessary to report remark codes.
    If not required by this implementation guide, do not send.
Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

  • MOA01 is the reimbursement rate.
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA09 is the professional component amount billed but not payable.
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

To supply the full name of an individual or organizational entity

Usage notes
  • If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
  • If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Other Insured Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Other Insured First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Other Insured Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Other Insured Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

II
Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the location of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Insured Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Other Insured State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Other Insured Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Other Payer Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:

  1. Both the sender and receiver agree to use the National Plan ID,
  2. The receiver has a National Plan ID, and
  3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
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

To specify the location of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
N3-01
166
Other Payer Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Payer Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Other Payer State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Other Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify identifying information

Usage notes
  • Required when the claim is being sent in the payer-to-payer COB model,
    AND
    the destination payer is secondary to the payer identified in this Loop ID-2330B,
    AND
    the payer identified in this Loop ID-2330B has re-adjudicated the claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The only valid value for this element is `Y'.
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

To specify identifying information

Usage notes
  • Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
    OR
    Required when the Other Payer's Claim Control Number is available.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

F8
Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a predetermination identification number to this claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

G3
Predetermination of Benefits Identification Number
REF-02
127
Other Payer Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
  • Required when the payer identified in this loop has assigned a prior authorization number to this claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Other Payer Prior Authorization Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a referral number to this claim.
    If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Other Payer Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
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)

Code qualifying the Reference Identification

2U
Payer Identification Number
EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DN
Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

P3
Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

REF-02
127
Other Payer Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

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

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Service Facility Location Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
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

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To reference a line number in a transaction set

Usage notes
  • The LX functions as a line counter.
  • The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
  • LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

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

To specify the service line item detail for dental work

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)

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

CDT = Current Dental Terminology

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

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

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • C003-07 is the description of the procedure identified in C003-02.
SV3-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV302 is the submitted service line item amount.
Usage notes
  • This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
  • Zero "0" is an acceptable value for this element.
SV3-03
1331
Place of Service Code
Optional
String (AN)
Min 1Max 2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

  • SV303 is the place of service code representing the location where the dental treatment was rendered.
Usage notes
  • See CODE SOURCE 237: Place of Service Codes for Professional Claims
SV3-04
C006
Oral Cavity Designation
OptionalMax use 1
To identify one or more areas of the oral cavity
Usage notes

Required when the nomenclature associated with the procedure reported in SV301-2 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments.

C006-01
1361
Oral Cavity Designation Code
Required
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-02
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-03
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-04
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

C006-05
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

Code Identifying the area of the oral cavity in which service is rendered

SV3-05
1358
Prosthesis, Crown, or Inlay Code
Optional
Identifier (ID)

Code specifying the placement status for the dental work

I
Initial Placement
R
Replacement

When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.

SV3-06
380
Procedure Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SV306 is the number of procedures.
Usage notes
  • Number of procedures
SV3-11
C004
Composite Diagnosis Code Pointer
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes

Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send.

C004-01
1328
Diagnosis Code Pointer
Required
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-01 identifies the primary diagnosis code for this service line.
C004-02
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-02 identifies the second diagnosis code for this service line.
C004-03
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-03 identifies the third diagnosis code for this service line.
C004-04
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

A pointer to the diagnosis code in the order of importance to this service

  • C004-04 identifies the fourth diagnosis code for this service line.
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

To identify a tooth by number and, if applicable, one or more tooth surfaces

Usage notes
  • Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
  • Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.
Example
TOO-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

JP
Universal National Tooth Designation System
TOO-02
1271
Tooth Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

Usage notes
  • See Appendix A for code source 135: American Dental Association Codes.
  • This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.
TOO-03
C005
Tooth Surface
OptionalMax use 1
To identify one or more tooth surface codes
Usage notes

Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.

C005-01
1369
Tooth Surface Code
Required
Identifier (ID)

Code identifying the area of the tooth that was treated

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

Code identifying the area of the tooth that was treated

Usage notes
  • Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.
C005-03
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

C005-04
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

C005-05
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;
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)

Code specifying type of date or time, or both date and time

452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.
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)

Code specifying type of date or time, or both date and time

139
Estimated

Required when the exact Prior Placement Date is not known.

441
Prior Placement

Required when the exact Prior Placement Date is known.

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

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
DTP-03
1251
Prior Placement Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.
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)

Code specifying type of date or time, or both date and time

446
Replacement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Replacement Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
  • Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
  • Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
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)

Code specifying type of date or time, or both date and time

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
  • When the Treatment Completion Date is used, the Date of Service must not be used.
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)

Code specifying type of date or time, or both date and time

198
Completion
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Treatment Completion Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when reporting initial impression or preparation for a crown or denture.
    OR
    Required when reporting initial endodontic treatment.
    OR
    Required when reporting the implant fixture placement.
    If not required by this implementation guide, do not send.
  • When the Treatment Start Date is used, the Date of Service must not be used.
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)

Code specifying type of date or time, or both date and time

196
Start
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Treatment Start Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To specify basic data about the contract or contract line item

Usage notes
  • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
  • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

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

Monetary amount

  • CN102 is the contract amount.
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

  • CN103 is the allowance or charge percent.
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • CN104 is the contract code.
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
  • The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
  • Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
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)

Code qualifying the Reference Identification

6R
Provider Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
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

To specify identifying information

Usage notes
  • This segment must not be used to report the Predetermination of Benefits Identification Number.
  • Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
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)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To specify identifying information

Usage notes
  • Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.
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)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the Referral Number reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
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)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
  • Reference numbers at this position apply to the current line item only.
  • When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
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)

Code qualifying the Reference Identification

G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the Predetermination Identification reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To indicate the total monetary amount

Usage notes
  • Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
  • When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV302) for this service line must include the amount reported in the Sales Tax Amount.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

T
Tax
AMT-02
782
Sales Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To transmit a fixed-format record or matrix contents

Usage notes
  • Required when ALL of the following conditions are met:
  • A regulatory agency concludes it must use the K3 to meet an emergency
    legislative requirement;
  • The administering regulatory agency or other state organization has
    completed each one of the following steps:
    contacted the X12N workgroup,
    requested a review of the K3 data requirement to ensure there is not
    an existing method within the implementation guide to meet this
    requirement
  • X12N determines that there is no method to meet the requirement.
    If not required by this implementation guide, do not send.
  • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
    Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

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

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
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)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
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

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP04 is the repricing organization identification number.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

AD
American Dental Association Codes
HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP10 is the approved procedure code.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
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)

Code specifying policy compliance

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)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present
    OR
    Required when each of the following conditions apply:
  • the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA)
  • this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider
  • the Assistant Surgeon loop (Loop ID-2420C) is not used.
    If not required by this implementation guide, do not send.
  • Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
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)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D.
    If not required by this implementation guide, do not send.;
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)

Code identifying an organizational entity, a physical location, property or an individual

DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Assistant Surgeon Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35

Individual first name

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

Individual middle name or initial

NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the identifying characteristics of a provider

Usage notes
  • Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the rendering provider is supervised by a physician or dentist and the supervising physician or dentist is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
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)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To supply the full name of an individual or organizational entity

Usage notes
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
  • Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
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)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

To specify the geographic place of the named party

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

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
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

To specify identifying information

Usage notes
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Service Facility Location Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

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

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
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

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

Usage notes
  • Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
  • To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • SVD01 is the payer identification code.
Usage notes
  • This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVD02 is the amount paid for this service line.
Usage notes
  • Zero "0" is an acceptable value for this element.
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)

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

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

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.
Usage notes
  • This is the first procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

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

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.
Usage notes
  • This is the second procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

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

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.
Usage notes
  • This is the third procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

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

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.
Usage notes
  • This is the fourth procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • C003-07 is the description of the procedure identified in C003-02.
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVD05 is the paid units of service.
Usage notes
  • This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SVD-06
554
Bundled or Unbundled Line Number
Optional
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

  • SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
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

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
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)

Code identifying the general category of payment adjustment

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

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
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

To specify any or all of a date, a time, or a time period

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

Code specifying type of date or time, or both date and time

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

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

To indicate the total monetary amount

Usage notes
  • Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
  • This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

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

Total number of segments included in a transaction set including ST and SE segments

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

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

To indicate the end of a functional group and to provide control information

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

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

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

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

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

A count of the number of functional groups included in an interchange

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

A control number assigned by the interchange sender

EDI Samples

Example 1: Commercial Health Insurance

ST*837*3456*005010X224A3~
BHT*0019*00*0123*20061123*1023*31~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~
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*66783JJT~
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~

Example 2a: Claim From Billing Provider to Payer A

ST*837*0002*005010X224A3~
BHT*0019*00*0123*20061123*1023*31~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
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*JS00111223333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
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~

Example 2b: Claim from Billing Provider to Payer B

ST*837*0123*005010X224A3~
BHT*0019*00*0123*20061123*1023*31~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*GREAT PRAIRIES HEALTH*****46*123456789~
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*123456789~
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~

Example 3: Predetermination of Benefits

ST*837*0321*005010X224A3~
BHT*0019*00*0123*20061123*1023*31~
NM1*41*2*ABC CLEARINGHOUSE*****46*ABC123~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
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*999996666~
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~

Example 4: Orthodontic Treatment Plan

ST*837*0322*005010X224A3~
BHT*0019*00*0123*20061123*1023*31~
NM1*41*2*JOHN DOE*****46*940001~
PER*IC*SALLY*TE*7175555555~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
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*999996666~
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~

Example 5: Sales Tax

ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*31~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
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*11111~
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~

Example 6: Multiple Tooth Numbers

ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*31~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
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*11111~
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~

Example 7: Quantity Greater Than 1

ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*31~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
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*11111~
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~

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