X12 278 Health Care Services Review Information - Review (X217)

X12 Release 5010

Delimiters

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

ISA Interchange Control Header

Required · Max use 1

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

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

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

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

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

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

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

Codes

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

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

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

Codes

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

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

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

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

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

• ^: Repetition Separator

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

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

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

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

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

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

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

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

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

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

• HI: Health Care Services Review Information (278)

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

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

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

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

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

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

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

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

005010X217

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

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

• 278: Health Care Services Review Information

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

ST-03 · 1705 · Implementation Guide Version Name · Required · String (AN)

005010X217

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

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

• 0007: Information Source, Information Receiver, Subscriber, Dependent, Event, Services

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

• 13: Request

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

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

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

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

• RU: Medical Services Reservation

Detail

2000A Utilization Management Organization (UMO) Level Loop Required Max 1

0100 Detail > Utilization Management Organization (UMO) Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

• 20: Information Source

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

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

2010A Utilization Management Organization (UMO) Name Loop Required Max 1

1700 Detail > Utilization Management Organization (UMO) Level Loop > Utilization Management Organization (UMO) Name Loop > NM1

NM1 Utilization Management Organization (UMO) Name

Required · Max use 1

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

• X3: Utilization Management Organization

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

• 2: Non-Person Entity

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

NM1-04 · 1036 · Utilization Management Organization (UMO) First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Utilization Management Organization (UMO) Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Utilization Management Organization (UMO) Name Suffix · Optional · String (AN) · Min 1 Max 10

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

• PI: Payor Identification

NM1-09 · 67 · Utilization Management Organization (UMO) Identifier · Required · String (AN)

• 06111: UHC Payer ID
• 87726: UHC Payer ID
• 061118515: Oxford Payer ID

2000B Requester Level Loop Required Max 1

0100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• 21: Information Receiver

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

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

2010B Requester Name Loop Required Max 1

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > NM1

NM1 Requester Name

Required · Max use 1

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

• 1P: Provider
• FA: Facility

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

• 1: Person
• 2: Non-Person Entity

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

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

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

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

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

• XX: Centers for Medicare and Medicaid Services National Provider Identifier

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

1800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > REF

REF Requester Supplemental Identification

Optional · Max use 8

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

• EI: Employer's Identification Number
• ZH: Carrier Assigned Reference Number

REF-02 · 127 · Requester Supplemental Identifier · Required · String (AN) · Min 1 Max 9

2000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > N3

N3 Requester Address

Optional · Max use 1

N3-01 · 166 · Requester Address Line · Required · String (AN) · Min 1 Max 55

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

2100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > N4

N4 Requester City, State, ZIP Code

Optional · Max use 1

Only one of Requester 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 · Requester City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Requester State or Province Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Requester Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

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

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

2200 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > PER

PER Requester Contact Information

Optional · Max use 1

If either Communication Number Qualifier (PER-03) or Requester Contact Communication Number (PER-04) is present, then the other is required

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

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

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

• IC: Information Contact

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

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

• TE: Telephone

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

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

• EX: Telephone Extension

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

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

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

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

2400 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > PRV

PRV Requester Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Provider Taxonomy Code (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AS: Assistant Surgeon
• AT: Attending
• CO: Consulting
• CV: Covering
• OP: Operating
• OR: Ordering
• OT: Other Physician
• PC: Primary Care Physician
• PE: Performing
• RF: Referring

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Taxonomy Code · Optional · String (AN) · Min 1 Max 50

2000C Subscriber Level Loop Required Max 1

0100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• 22: Subscriber

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

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

2010C Subscriber Name Loop Required Max 1

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

NM1 Subscriber Name

Required · Max use 1

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

• IL: Insured or Subscriber

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

• 1: Person

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

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

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

NM1-06 · 1038 · Subscriber Name Prefix · Optional · String (AN) · Min 1 Max 10

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

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

• MI: Member Identification Number

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

1800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

REF Subscriber Supplemental Identification

Optional · Max use 9

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

• 1L: Group or Policy Number
• 6P: Group Number
• HJ: Identity Card Number
• IG: Insurance Policy Number
• N6: Plan Network Identification Number

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

2000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

N3 Subscriber Address

Optional · Max use 1

N3-01 · 166 · Subscriber Address Line · Required · String (AN) · Min 1 Max 55

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

2100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

N4 Subscriber City, State, ZIP Code

Optional · Max use 1

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 2 Max 30

N4-02 · 156 · Subscriber State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Subscriber Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

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

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

2500 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

DMG Subscriber Demographic Information

Optional · Max use 1

DMG-01 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Subscriber Birth Date · Required · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Subscriber Gender Code · Required · Identifier (ID)

• F: Female
• M: Male
• U: Unknown

2600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

INS Subscriber Relationship

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• Y: Yes

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 18: Self

INS-08 · 584 · Employment Status Code · Required · Identifier (ID)

• AO: Active Military - Overseas
• AU: Active Military - USA
• DI: Deceased
• PV: Previous
• RU: Retired Military - USA

2000D Dependent Level Loop Optional Max 1

0100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• 23: Dependent

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

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

2010D Dependent Name Loop Required Max 1

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

NM1 Dependent Name

Required · Max use 1

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

• QC: Patient

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

• 1: Person

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

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

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

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

1800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

REF Dependent Supplemental Identification

Optional · Max use 3

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

• EJ: Patient Account Number
• SY: Social Security Number

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

2000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

N3 Dependent Address

Optional · Max use 1

N3-01 · 166 · Dependent Address Line · Required · String (AN) · Min 1 Max 55

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

2100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

N4 Dependent City, State, ZIP Code

Optional · Max use 1

Only one of Dependent 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 · Dependent City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Dependent State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Dependent Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

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

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

2500 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

DMG Dependent Demographic Information

Optional · Max use 1

DMG-01 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Dependent Birth Date · Required · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Dependent Gender Code · Required · Identifier (ID)

• F: Female
• M: Male
• U: Unknown

2600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

INS Dependent Relationship

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• N: No

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 01: Spouse
• 19: Child
• G8: Other Relationship

INS-17 · 1470 · Birth Sequence Number · Optional · Numeric (N0) · Min 1 Max 9

2000E Patient Event Level Loop Required Max 1

0100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• EV: Event

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

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

0200 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

TRN Patient Event Tracking Number

Optional · Max use 2

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

• 1: Current Transaction Trace Numbers

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0400 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

UM Health Care Services Review Information

Required · Max use 1

UM-01 · 1525 · Request Category Code · Required · Identifier (ID)

• AR: Admission Review
• HS: Health Services Review
• SC: Specialty Care Review

UM-02 · 1322 · Certification Type Code · Required · Identifier (ID)

• I: Initial
• S: Revised

UM-03 · 1365 · Service Type Code · Optional · Identifier (ID)

• 1: Medical Care
• 2: Surgical
• 4: Diagnostic X-Ray
• 5: Diagnostic Lab
• 12: Durable Medical Equipment Purchase
• 14: Renal Supplies in the Home
• 18: Durable Medical Equipment Rental
• 33: Chiropractic
• 37: Dental Accident
• 45: Hospice
• 54: Long Term Care
• 56: Medically Related Transportation
• 68: Well Baby Care
• 69: Maternity
• 70: Transplants
• 72: Inhalation Therapy
• 73: Diagnostic Medical
• 74: Private Duty Nursing
• 75: Prosthetic Device
• 78: Chemotherapy
• 88: Pharmacy
• 93: Podiatry
• A9: Rehabilitation
• AD: Occupational Therapy
• AF: Speech Therapy
• AG: Skilled Nursing Care
• AL: Vision (Optometry)
• NI: Neonatal Intensive Care
• PT: Physical Therapy

UM-04 · C023 · Health Care Service Location Information · Optional Max 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 · Usage notes

C023-01 · 1331 · Facility Type Code · Required · String (AN)

• 11: if UM04-2=A: Hospital Inpatient including Medicare Part A if UM04-2=B: Office
• 13: if UM04-2=A: Hospital Outpatient if UM04-2=B: Home
• 21: if UM04-2=A: Skilled Nursing Facility (SNF) Inpatient including Medicare Part A if UM04-2=B: Hospital Outpatient
• 61: if UM04-2=B: Rehab Facility Comprehensive Inpatient

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

• A: Uniform Billing Claim Form Bill Type
• B: Place of Service Codes for Professional or Dental Services

UM-05 · C024 · Related Causes Information · Optional Max use 1 · To identify one or more related causes and associated state or country information · Usage notes

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

• AA: Auto Accident
• AP: Another Party Responsible
• EM: Employment

C024-02 · 1362 · Related Causes Code · Optional · Identifier (ID)

• AP: Another Party Responsible
• EM: Employment

C024-03 · 1362 · Related Causes Code · Optional · Identifier (ID)

• AP: Another Party Responsible

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

C024-05 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

UM-06 · 1338 · Level of Service Code · Optional · Identifier (ID)

• 03: Emergency
• E: Elective
• U: Urgent

UM-07 · 1213 · Current Health Condition Code · Optional · Identifier (ID)

• 1: Acute
• 2: Stable
• 3: Chronic
• 4: Systemic
• 5: Localized
• 6: Mild Disease
• 7: Normal, Healthy
• 8: Severe Systemic disease
• 9: Severe Systemic Disease that is a Constant Threat to Life
• E: Excellent
• F: Fair
• G: Good
• P: Poor

UM-08 · 923 · Prognosis Code · Optional · Identifier (ID)

• 1: Poor
• 2: Guarded
• 3: Fair
• 4: Good
• 5: Very Good
• 6: Excellent
• 7: Less than 6 Months to Live
• 8: Terminal

UM-09 · 1363 · Release of Information Code · Optional · Identifier (ID)

• M: The Provider has Limited or Restricted Ability to Release Data Related to a Claim
• Y: Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

UM-10 · 1514 · Delay Reason Code · Optional · Identifier (ID)

• 1: Proof of Eligibility Unknown or Unavailable
• 2: Litigation
• 3: Authorization Delays
• 4: Delay in Certifying Provider
• 7: Third Party Processing Delay
• 8: Delay in Eligibility Determination
• 10: Administration Delay in the Prior Approval Process
• 11: Other
• 15: Natural Disaster
• 16: Lack of Information
• 17: No response to initial request

0600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

REF Previous Review Administrative Reference Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Authorization Number

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

• NT: Administrator's Reference Number

REF-02 · 127 · Previous Administrative Reference Number · Required · String (AN) · Min 1 Max 50

0600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

REF Previous Review Authorization Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Administrative Reference Number

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

• BB: Authorization Number

REF-02 · 127 · Previous Review Authorization Number · Required · String (AN) · Min 1 Max 50

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Accident Date

Optional · Max use 1

Variants (all may be used)

DTPAdmission DateDTPDischarge DateDTPEstimated Date of BirthDTPEvent DateDTPLast Menstrual Period DateDTPOnset of Current Symptoms or Illness Date

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

• 439: Accident

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

• D8: Date Expressed in Format CCYYMMDD

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

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Admission Date

Optional · Max use 1

Variants (all may be used)

DTPAccident DateDTPDischarge DateDTPEstimated Date of BirthDTPEvent DateDTPLast Menstrual Period DateDTPOnset of Current Symptoms or Illness Date

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

• 435: Admission

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

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

DTP-03 · 1251 · Proposed or Actual Admission Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Discharge Date

Optional · Max use 1

Variants (all may be used)

DTPAccident DateDTPAdmission DateDTPEstimated Date of BirthDTPEvent DateDTPLast Menstrual Period DateDTPOnset of Current Symptoms or Illness Date

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

• 096: Discharge

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Proposed or Actual Discharge Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Estimated Date of Birth

Optional · Max use 1

Variants (all may be used)

DTPAccident DateDTPAdmission DateDTPDischarge DateDTPEvent DateDTPLast Menstrual Period DateDTPOnset of Current Symptoms or Illness Date

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

• ABC: Estimated Date of Birth

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Estimated Birth Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Event Date

Optional · Max use 1

Variants (all may be used)

DTPAccident DateDTPAdmission DateDTPDischarge DateDTPEstimated Date of BirthDTPLast Menstrual Period DateDTPOnset of Current Symptoms or Illness Date

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

• AAH: Event

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

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

DTP-03 · 1251 · Proposed or Actual Event Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Last Menstrual Period Date

Optional · Max use 1

Variants (all may be used)

DTPAccident DateDTPAdmission DateDTPDischarge DateDTPEstimated Date of BirthDTPEvent DateDTPOnset of Current Symptoms or Illness Date

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

• 484: Last Menstrual Period

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Last Menstrual Period Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Onset of Current Symptoms or Illness Date

Optional · Max use 1

Variants (all may be used)

DTPAccident DateDTPAdmission DateDTPDischarge DateDTPEstimated Date of BirthDTPEvent DateDTPLast Menstrual Period Date

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

• 431: Onset of Current Symptoms or Illness

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

• D8: Date Expressed in Format CCYYMMDD

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

0800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HI

HI Patient Diagnosis

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max use 1 · To send health care codes and their associated dates, amounts and quantities · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
• ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-02 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-03 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-04 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-05 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-06 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-07 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-08 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-09 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-10 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-11 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-12 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes · If either Date Time Period Format Qualifier (C022 - 03) or Diagnosis Date (C022 - 04) is present, then the other is required

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
• DR: Diagnosis Related Group (DRG)
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

0900 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HSD

HSD Health Care Services Delivery

Optional · Max use 1

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

HSD-01 · 673 · Quantity Qualifier · Optional · Identifier (ID)

• DY: Days
• FL: Units
• HS: Hours
• MN: Month
• VS: Visits

HSD-02 · 380 · Service Unit Count · Optional · Decimal number (R) · Min 1 Max 15

HSD-03 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• DA: Days
• MO: Months
• WK: Week

HSD-04 · 1167 · Sample Selection Modulus · Optional · Decimal number (R) · Min 1 Max 6

HSD-05 · 615 · Time Period Qualifier · Optional · Identifier (ID)

• 6: Hour
• 7: Day
• 21: Years
• 26: Episode
• 27: Visit
• 34: Month
• 35: Week

HSD-06 · 616 · Period Count · Optional · Numeric (N0) · Min 1 Max 3

HSD-07 · 678 · Delivery Frequency Code · Optional · Identifier (ID)

• 1: 1st Week of the Month
• 2: 2nd Week of the Month
• 3: 3rd Week of the Month
• 4: 4th Week of the Month
• 5: 5th Week of the Month
• 6: 1st & 3rd Weeks of the Month
• 7: 2nd & 4th Weeks of the Month
• 8: 1st Working Day of Period
• 9: Last Working Day of Period
• A: Monday through Friday
• B: Monday through Saturday
• C: Monday through Sunday
• D: Monday
• E: Tuesday
• F: Wednesday
• G: Thursday
• H: Friday
• J: Saturday
• K: Sunday
• L: Monday through Thursday
• M: Immediately
• N: As Directed
• O: Daily Mon. through Fri.
• P: 1/2 Mon. & 1/2 Thurs.
• Q: 1/2 Tues. & 1/2 Thurs.
• R: 1/2 Wed. & 1/2 Fri.
• S: Once Anytime Mon. through Fri.
• SA: Sunday, Monday, Thursday, Friday, Saturday
• SB: Tuesday through Saturday
• SC: Sunday, Wednesday, Thursday, Friday, Saturday
• SD: Monday, Wednesday, Thursday, Friday, Saturday
• SG: Tuesday through Friday
• SL: Monday, Tuesday and Thursday
• SP: Monday, Tuesday and Friday
• SX: Wednesday and Thursday
• SY: Monday, Wednesday and Thursday
• SZ: Tuesday, Thursday and Friday
• T: 1/2 Tue. & 1/2 Fri.
• U: 1/2 Mon. & 1/2 Wed.
• V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
• W: Whenever Necessary
• X: 1/2 By Wed., Bal. By Fri.
• Y: None (Also Used to Cancel or Override a Previous Pattern)

HSD-08 · 679 · Delivery Pattern Time Code · Optional · Identifier (ID)

• A: 1st Shift (Normal Working Hours)
• B: 2nd Shift
• C: 3rd Shift
• D: A.M.
• E: P.M.
• F: As Directed
• G: Any Shift
• Y: None (Also Used to Cancel or Override a Previous Pattern)

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Activities Permitted Information

Optional · Max use 1

Variants (all may be used)

CRCAmbulance Certification InformationCRCChiropractic Certification InformationCRCDurable Medical Equipment InformationCRCFunctional Limitations InformationCRCMental Status InformationCRCOxygen Therapy Certification Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 76: Activities Permitted

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 10: Patient is ambulatory
• 13: Patient is Confined to a Room or an Area Without Bathroom Facilities
• 19: Patient can operate controls
• 21: Patient owns equipment
• 22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
• 27: Patient or a care-giver has been instructed in use of equipment
• 31: Patient has had a total knee replacement
• 40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
• BR: Bedrest BRP (Bathroom Privileges)
• CA: Cane Required
• CB: Complete Bedrest
• CR: Crutches Required
• EL: Endurance Limitations
• EP: Exercises Prescribed
• IH: Independent at Home
• NR: No Restrictions
• PA: Paralysis
• PW: Partial Weight Bearing
• TR: Transfer to Bed, or Chair, or Both
• UT: Up as Tolerated
• WA: Walker Required
• WR: Wheelchair Required

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Ambulance Certification Information

Optional · Max use 1

Variants (all may be used)

CRCActivities Permitted InformationCRCChiropractic Certification InformationCRCDurable Medical Equipment InformationCRCFunctional Limitations InformationCRCMental Status InformationCRCOxygen Therapy Certification Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 07: Ambulance Certification

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 01: Patient was admitted to a hospital
• 02: Patient was bed confined before the ambulance service
• 03: Patient was bed confined after the ambulance service
• 04: Patient was moved by stretcher
• 05: Patient was unconscious or in shock
• 5A: Treatment is rendered related to the terminal illness
• 06: Patient was transported in an emergency situation
• 07: Patient had to be physically restrained
• 08: Patient had visible hemorrhaging
• 09: Ambulance service was medically necessary
• 9D: Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
• 41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
• 43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
• 60: Transportation Was To the Nearest Facility

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Chiropractic Certification Information

Optional · Max use 1

Variants (all may be used)

CRCActivities Permitted InformationCRCAmbulance Certification InformationCRCDurable Medical Equipment InformationCRCFunctional Limitations InformationCRCMental Status InformationCRCOxygen Therapy Certification Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 08: Chiropractic Certification

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
• 12: Patient is confined to a bed or chair
• 14: Ambulation is Impaired and Walking Aid is Used for Mobility
• 24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
• 25: Item has been prescribed as part of a planned regimen of treatment in patient home
• 27: Patient or a care-giver has been instructed in use of equipment
• 30: Without the equipment, the patient would require surgery

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Durable Medical Equipment Information

Optional · Max use 1

Variants (all may be used)

CRCActivities Permitted InformationCRCAmbulance Certification InformationCRCChiropractic Certification InformationCRCFunctional Limitations InformationCRCMental Status InformationCRCOxygen Therapy Certification Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 09: Durable Medical Equipment Certification

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 01: Patient was admitted to a hospital
• 02: Patient was bed confined before the ambulance service
• 03: Patient was bed confined after the ambulance service
• 04: Patient was moved by stretcher
• 05: Patient was unconscious or in shock
• 06: Patient was transported in an emergency situation
• 07: Patient had to be physically restrained
• 08: Patient had visible hemorrhaging
• 09: Ambulance service was medically necessary
• 9D: Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
• 9H: Patient Requires Intensive IV Therapy
• 9J: Patient Requires Protective Isolation
• 9K: Patient Requires Frequent Monitoring
• 10: Patient is ambulatory
• 11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
• 12: Patient is confined to a bed or chair
• 13: Patient is Confined to a Room or an Area Without Bathroom Facilities
• 14: Ambulation is Impaired and Walking Aid is Used for Mobility
• 15: Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
• 16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
• 17: Patient's Ability to Breathe is Severely Impaired
• 18: Patient condition requires frequent and/or immediate changes in body positions
• 19: Patient can operate controls
• 20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
• 21: Patient owns equipment
• 22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
• 23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
• 24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
• 25: Item has been prescribed as part of a planned regimen of treatment in patient home
• 26: Patient is highly susceptible to decubitus ulcers
• 27: Patient or a care-giver has been instructed in use of equipment
• 29: A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds
• 30: Without the equipment, the patient would require surgery
• 31: Patient has had a total knee replacement
• 32: Patient has intractable lymphedema of the extremities
• 33: Patient is in a nursing home
• 35: This Feeding is the Only Form of Nutritional Intake for This Patient
• 37: Oxygen delivery equipment is stationary
• 38: Certification signed by the physician is on file at the supplier's office
• 40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
• 41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
• 42: Patient Requires Leg Elevation for Edema or Body Alignment
• 43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
• 44: Patient Requires Reclining Function of a Wheelchair
• 45: Patient is Unable to Operate a Wheelchair Manually
• 46: Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
• 58: Durable Medical Equipment (DME) Purchased New
• 59: Durable Medical Equipment (DME) Is Under Warranty
• 60: Transportation Was To the Nearest Facility
• IH: Independent at Home
• LB: Legally Blind
• SL: Speech Limitations

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Functional Limitations Information

Optional · Max use 1

Variants (all may be used)

CRCActivities Permitted InformationCRCAmbulance Certification InformationCRCChiropractic Certification InformationCRCDurable Medical Equipment InformationCRCMental Status InformationCRCOxygen Therapy Certification Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 75: Functional Limitations

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 02: Patient was bed confined before the ambulance service
• 03: Patient was bed confined after the ambulance service
• 04: Patient was moved by stretcher
• 05: Patient was unconscious or in shock
• 5A: Treatment is rendered related to the terminal illness
• 06: Patient was transported in an emergency situation
• 9E: Sudden Onset of Disorientation
• 9F: Sudden Onset of Severe, Incapacitating Pain
• 9H: Patient Requires Intensive IV Therapy
• 11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
• 12: Patient is confined to a bed or chair
• 14: Ambulation is Impaired and Walking Aid is Used for Mobility
• 15: Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
• 16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
• 17: Patient's Ability to Breathe is Severely Impaired
• 18: Patient condition requires frequent and/or immediate changes in body positions
• 19: Patient can operate controls
• 20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
• 21: Patient owns equipment
• 22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
• 23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
• 24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
• 25: Item has been prescribed as part of a planned regimen of treatment in patient home
• 26: Patient is highly susceptible to decubitus ulcers
• 27: Patient or a care-giver has been instructed in use of equipment
• 28: Patient has poor diabetic control
• 30: Without the equipment, the patient would require surgery
• 31: Patient has had a total knee replacement
• 32: Patient has intractable lymphedema of the extremities
• 35: This Feeding is the Only Form of Nutritional Intake for This Patient
• 37: Oxygen delivery equipment is stationary
• 39: Patient Has Mobilizing Respiratory Tract Secretions
• 40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
• 41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
• 42: Patient Requires Leg Elevation for Edema or Body Alignment
• 43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
• 44: Patient Requires Reclining Function of a Wheelchair
• 45: Patient is Unable to Operate a Wheelchair Manually
• 46: Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
• 68: Severe
• 69: Moderate
• AA: Amputation
• AL: Ambulation Limitations
• BL: Bowel Limitations, Bladder Limitations, or both (Incontinence)
• BPD: Beneficiary is Partially Dependent
• BTD: Beneficiary is Totally Dependent
• CA: Cane Required
• CB: Complete Bedrest
• CNJ: Cumulative Injury
• CO: Contracture
• DY: Dyspnea with Minimal Exertion
• EL: Endurance Limitations
• EP: Exercises Prescribed
• HL: Hearing Limitations
• LB: Legally Blind
• LE: Lethargic
• OL: Other Limitation
• PA: Paralysis
• PW: Partial Weight Bearing
• SL: Speech Limitations
• TNJ: Traumatic Injury
• WA: Walker Required
• WR: Wheelchair Required

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Mental Status Information

Optional · Max use 1

Variants (all may be used)

CRCActivities Permitted InformationCRCAmbulance Certification InformationCRCChiropractic Certification InformationCRCDurable Medical Equipment InformationCRCFunctional Limitations InformationCRCOxygen Therapy Certification Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 77: Mental Status

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 01: Patient was admitted to a hospital
• 05: Patient was unconscious or in shock
• 5A: Treatment is rendered related to the terminal illness
• 07: Patient had to be physically restrained
• 9E: Sudden Onset of Disorientation
• 9F: Sudden Onset of Severe, Incapacitating Pain
• 9J: Patient Requires Protective Isolation
• 9K: Patient Requires Frequent Monitoring
• 13: Patient is Confined to a Room or an Area Without Bathroom Facilities
• 20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
• 22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
• 23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
• 26: Patient is highly susceptible to decubitus ulcers
• 33: Patient is in a nursing home
• 34: Patient is conscious
• 68: Severe
• 69: Moderate
• AG: Agitated
• BPD: Beneficiary is Partially Dependent
• BTD: Beneficiary is Totally Dependent
• CB: Complete Bedrest
• CM: Comatose
• DI: Disoriented
• DP: Depressed
• FO: Forgetful
• HO: Hostile
• LE: Lethargic
• MC: Other Mental Condition
• OT: Oriented
• UN: Uncooperative

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

CRC Oxygen Therapy Certification Information

Optional · Max use 1

Variants (all may be used)

CRCActivities Permitted InformationCRCAmbulance Certification InformationCRCChiropractic Certification InformationCRCDurable Medical Equipment InformationCRCFunctional Limitations InformationCRCMental Status Information

CRC-01 · 1136 · Code Category · Required · Identifier (ID)

• 11: Oxygen Therapy Certification

CRC-02 · 1073 · Certification Condition Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CRC-03 · 1321 · Condition Code · Required · Identifier (ID)

• 5A: Treatment is rendered related to the terminal illness
• 06: Patient was transported in an emergency situation
• 9J: Patient Requires Protective Isolation
• 9K: Patient Requires Frequent Monitoring
• 16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
• 17: Patient's Ability to Breathe is Severely Impaired
• 25: Item has been prescribed as part of a planned regimen of treatment in patient home
• 33: Patient is in a nursing home
• 37: Oxygen delivery equipment is stationary
• 39: Patient Has Mobilizing Respiratory Tract Secretions
• DY: Dyspnea with Minimal Exertion

CRC-04 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-05 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-06 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

CRC-07 · 1321 · Condition Code · Optional · Identifier (ID) · Min 2 Max 3

1100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CL1

CL1 Institutional Claim Code

Optional · Max use 1

CL1-01 · 1315 · Admission Type Code · Optional · Identifier (ID) · Min 1 Max 1

CL1-02 · 1314 · Admission Source Code · Optional · Identifier (ID) · Min 1 Max 1

CL1-03 · 1352 · Patient Status Code · Optional · Identifier (ID) · Min 1 Max 2

CL1-04 · 1345 · Nursing Home Residential Status Code · Optional · Identifier (ID)

• 1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
• 2: Newly Admitted
• 3: Newly Eligible
• 4: No Longer Eligible
• 5: Still a Resident
• 6: Temporary Absence - Hospital
• 7: Temporary Absence - Other
• 8: Transferred to Intermediate Care Facility - Level II (ICF II)
• 9: Other

1200 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR1

CR1 Ambulance Transport Information

Optional · Max use 1

If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required

If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required

CR1-01 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• KG: Kilogram
• LB: Pound

CR1-02 · 81 · Patient Weight · Optional · Decimal number (R) · Min 1 Max 10

CR1-03 · 1316 · Ambulance Transport Code · Required · Identifier (ID)

• I: Initial Trip
• R: Return Trip
• T: Transfer Trip
• X: Round Trip

CR1-04 · 1317 · Ambulance Transport Reason Code · Optional · Identifier (ID)

• A: Patient was transported to nearest facility for care of symptoms, complaints, or both
• B: Patient was transported for the benefit of a preferred physician
• C: Patient was transported for the nearness of family members
• D: Patient was transported for the care of a specialist or for availability of specialized equipment
• E: Patient Transferred to Rehabilitation Facility
• F: Patient Transferred to Residential Facility

CR1-05 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• DH: Miles
• DK: Kilometers

CR1-06 · 380 · Transport Distance · Optional · Decimal number (R) · Min 1 Max 15

CR1-09 · 352 · Round Trip Purpose Description · Optional · String (AN) · Min 1 Max 80

CR1-10 · 352 · Stretcher Purpose Description · Optional · String (AN) · Min 1 Max 80

1300 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR2

CR2 Spinal Manipulation Service Information

Optional · Max use 1

If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required

If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required

CR2-01 · 609 · Treatment Series Number · Optional · Numeric (N0) · Min 1 Max 9

CR2-02 · 380 · Treatment Count · Optional · Decimal number (R) · Min 1 Max 15

CR2-03 · 1367 · Subluxation Level Code · Optional · Identifier (ID)

• C1: Cervical 1
• C2: Cervical 2
• C3: Cervical 3
• C4: Cervical 4
• C5: Cervical 5
• C6: Cervical 6
• C7: Cervical 7
• CO: Coccyx
• IL: Ilium
• L1: Lumbar 1
• L2: Lumbar 2
• L3: Lumbar 3
• L4: Lumbar 4
• L5: Lumbar 5
• OC: Occiput
• SA: Sacrum
• T1: Thoracic 1
• T10: Thoracic 10
• T11: Thoracic 11
• T12: Thoracic 12
• T2: Thoracic 2
• T3: Thoracic 3
• T4: Thoracic 4
• T5: Thoracic 5
• T6: Thoracic 6
• T7: Thoracic 7
• T8: Thoracic 8
• T9: Thoracic 9

CR2-04 · 1367 · Subluxation Level Code · Optional · Identifier (ID)

• C1: Cervical 1
• C2: Cervical 2
• C3: Cervical 3
• C4: Cervical 4
• C5: Cervical 5
• C6: Cervical 6
• C7: Cervical 7
• CO: Coccyx
• IL: Ilium
• L1: Lumbar 1
• L2: Lumbar 2
• L3: Lumbar 3
• L4: Lumbar 4
• L5: Lumbar 5
• OC: Occiput
• SA: Sacrum
• T1: Thoracic 1
• T10: Thoracic 10
• T11: Thoracic 11
• T12: Thoracic 12
• T2: Thoracic 2
• T3: Thoracic 3
• T4: Thoracic 4
• T5: Thoracic 5
• T6: Thoracic 6
• T7: Thoracic 7
• T8: Thoracic 8
• T9: Thoracic 9

CR2-08 · 1342 · Patient Condition Code · Required · Identifier (ID)

• A: Acute Condition
• C: Chronic Condition
• D: Non-acute
• E: Non-Life Threatening
• F: Routine
• G: Symptomatic
• M: Acute Manifestation of a Chronic Condition

CR2-09 · 1073 · Complication Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

CR2-10 · 352 · Patient Condition Description · Optional · String (AN) · Min 1 Max 80

CR2-11 · 352 · Patient Condition Description · Optional · String (AN) · Min 1 Max 80

CR2-12 · 1073 · X-ray Availability Indicator · Optional · Identifier (ID)

• N: No
• Y: Yes

1400 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR5

CR5 Home Oxygen Therapy Information

Optional · Max use 1

CR5-03 · 1348 · Oxygen Equipment Type Code · Required · Identifier (ID)

• A: Concentrator
• B: Liquid Stationary
• C: Gaseous Stationary
• D: Liquid Portable
• E: Gaseous Portable
• O: Other

CR5-04 · 1348 · Oxygen Equipment Type Code · Optional · Identifier (ID)

• A: Concentrator
• B: Liquid Stationary
• C: Gaseous Stationary
• D: Liquid Portable
• E: Gaseous Portable
• O: Other

CR5-05 · 352 · Equipment Reason Description · Optional · String (AN) · Min 1 Max 80

CR5-06 · 380 · Oxygen Flow Rate · Required · Decimal number (R) · Min 1 Max 15

CR5-07 · 380 · Daily Oxygen Use Count · Optional · Decimal number (R) · Min 1 Max 15

CR5-08 · 380 · Oxygen Use Period Hour Count · Optional · Decimal number (R) · Min 1 Max 15

CR5-09 · 352 · Respiratory Therapist Order Text · Optional · String (AN) · Min 1 Max 80

CR5-10 · 380 · Arterial Blood Gas Quantity · Optional · Decimal number (R) · Min 1 Max 15

CR5-11 · 380 · Oxygen Saturation Quantity · Optional · Decimal number (R) · Min 1 Max 15

CR5-12 · 1349 · Oxygen Test Condition Code · Optional · Identifier (ID)

• E: Exercising
• N: No special conditions for test
• O: On oxygen
• R: At rest on room air
• S: Sleeping
• W: Walking
• X: Other

CR5-13 · 1350 · Oxygen Test Findings Code · Optional · Identifier (ID)

• 1: Dependent edema suggesting congestive heart failure
• 2: "P" Pulmonale on Electrocardiogram (EKG)
• 3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-14 · 1350 · Oxygen Test Findings Code · Optional · Identifier (ID)

• 1: Dependent edema suggesting congestive heart failure
• 2: "P" Pulmonale on Electrocardiogram (EKG)
• 3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-15 · 1350 · Oxygen Test Findings Code · Optional · Identifier (ID)

• 1: Dependent edema suggesting congestive heart failure
• 2: "P" Pulmonale on Electrocardiogram (EKG)
• 3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-16 · 380 · Portable Oxygen System Flow Rate · Optional · Decimal number (R) · Min 1 Max 15

CR5-17 · 1382 · Oxygen Delivery System Code · Required · Identifier (ID)

• A: Nasal Cannula
• B: Oxygen Conserving Device
• C: Oxygen Conserving Device with Oxygen Pulse System
• D: Oxygen Conserving Device with Reservoir System
• E: Transtracheal Catheter

CR5-18 · 1348 · Oxygen Equipment Type Code · Optional · Identifier (ID)

• A: Concentrator
• B: Liquid Stationary
• C: Gaseous Stationary
• D: Liquid Portable
• E: Gaseous Portable
• O: Other

1500 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR6

CR6 Home Health Care Information

Optional · Max use 1

If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required

If either Surgery Date (CR6-09), Product or Service ID Qualifier (CR6-10) or Surgical Procedure Code (CR6-11) are present, then the others are required

If either Date Time Period Format Qualifier (CR6-15), Last Admission Period (CR6-16) or Patient Location Code (CR6-17) are present, then the others are required

CR6-01 · 923 · Prognosis Code · Required · Identifier (ID)

• 1: Poor
• 2: Guarded
• 3: Fair
• 4: Good
• 5: Very Good
• 6: Excellent
• 7: Less than 6 Months to Live
• 8: Terminal

CR6-02 · 373 · Home Health Start Date · Required · Date (DT) · CCYYMMDD format

CR6-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

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

CR6-04 · 1251 · Home Health Certification Period · Optional · String (AN) · Min 1 Max 35

CR6-07 · 1073 · Medicare Coverage Indicator · Required · Identifier (ID)

• W: Not Applicable

CR6-08 · 1322 · Certification Type Code · Required · Identifier (ID)

• 1: Appeal - Immediate
• 2: Appeal - Standard
• 3: Cancel
• 4: Extension
• 6: Verification
• I: Initial
• R: Renewal
• S: Revised

CR6-09 · 373 · Surgery Date · Optional · Date (DT) · CCYYMMDD format

CR6-10 · 235 · Product or Service ID Qualifier · Optional · Identifier (ID)

• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CR6-11 · 1137 · Surgical Procedure Code · Optional · String (AN) · Min 1 Max 15

CR6-12 · 373 · Physician Order Date · Optional · Date (DT) · CCYYMMDD format

CR6-13 · 373 · Last Visit Date · Optional · Date (DT) · CCYYMMDD format

CR6-14 · 373 · Physician Contact Date · Optional · Date (DT) · CCYYMMDD format

CR6-15 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

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

CR6-16 · 1251 · Last Admission Period · Optional · String (AN) · Min 1 Max 35

CR6-17 · 1384 · Patient Location Code · Optional · Identifier (ID)

• A: Acute Care Facility
• B: Boarding Home
• C: Hospice
• D: Intermediate Care Facility
• E: Long-term or Extended Care Facility
• F: Not Specified
• G: Nursing Home
• H: Sub-acute Care Facility
• L: Other Location
• M: Rehabilitation Facility
• O: Outpatient Facility
• P: Private Home
• R: Residential Treatment Facility
• S: Skilled Nursing Home
• T: Rest Home

1550 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > PWK

PWK Additional Patient Information

Optional · Max use 10

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)

• 03: Report Justifying Treatment Beyond Utilization Guidelines
• 04: Drugs Administered
• 05: Treatment Diagnosis
• 06: Initial Assessment
• 07: Functional Goals
• 08: Plan of Treatment
• 09: Progress Report
• 10: Continued Treatment
• 11: Chemical Analysis
• 13: Certified Test Report
• 15: Justification for Admission
• 21: Recovery Plan
• 48: Social Security Benefit Letter
• 55: Rental Agreement
• 59: Benefit Letter
• 77: Support Data for Verification
• A3: Allergies/Sensitivities Document
• A4: Autopsy Report
• AM: Ambulance Certification
• AS: Admission Summary
• AT: Purchase Order Attachment
• B2: Prescription
• B3: Physician Order
• BR: Benchmark Testing Results
• BS: Baseline
• BT: Blanket Test Results
• CB: Chiropractic Justification
• CK: Consent Form(s)
• D2: Drug Profile Document
• DA: Dental Models
• DB: Durable Medical Equipment Prescription
• DG: Diagnostic Report
• DJ: Discharge Monitoring Report
• DS: Discharge Summary
• FM: Family Medical History Document
• HC: Health Certificate
• HR: Health Clinic Records
• I5: Immunization Record
• IR: State School Immunization Records
• LA: Laboratory Results
• M1: Medical Record Attachment
• NN: Nursing Notes
• OB: Operative Note
• OC: Oxygen Content Averaging Report
• OD: Orders and Treatments Document
• OE: Objective Physical Examination (including vital signs) Document
• OX: Oxygen Therapy Certification
• P4: Pathology Report
• P5: Patient Medical History Document
• P6: Periodontal Charts
• P7: Periodontal Reports
• PE: Parenteral or Enteral Certification
• PN: Physical Therapy Notes
• PO: Prosthetics or Orthotic Certification
• PQ: Paramedical Results
• PY: Physician's Report
• PZ: Physical Therapy Certification
• QC: Cause and Corrective Action Report
• QR: Quality Report
• RB: Radiology Films
• RR: Radiology Reports
• RT: Report of Tests and Analysis Report
• RX: Renewable Oxygen Content Averaging Report
• SG: Symptoms Document
• V5: Death Notification
• XP: Photographs

PWK-02 · 756 · Report Transmission Code · Required · Identifier (ID)

• AA: Available on Request at Provider Site
• BM: By Mail
• EL: Electronically Only
• EM: E-Mail
• FX: By Fax
• VO: Voice

PWK-05 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• AC: Attachment Control Number

PWK-06 · 67 · Attachment Control Number · Optional · String (AN) · Min 2 Max 80

PWK-07 · 352 · Attachment Description · Optional · String (AN) · Min 1 Max 80

1600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > MSG

MSG Message Text

Optional · Max use 1

MSG-01 · 933 · Free Form Message Text · Required · String (AN) · Min 1 Max 264

2010EA Patient Event Provider Name Loop Optional Max 14

Variants (all may be used)

Patient Event Transport Information LoopPatient Event Other UMO Name Loop

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

NM1 Patient Event Provider Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Patient Event Provider Identifier (NM1-09) is present, then the other is required

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

• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• 77: Service Location
• AAJ: Admitting Services
• DD: Assistant Surgeon
• DK: Ordering Physician
• DN: Referring Provider
• FA: Facility
• G3: Clinic
• P3: Primary Care Provider
• QB: Purchase Service Provider
• QV: Group Practice
• SJ: Service Provider

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

• 1: Person
• 2: Non-Person Entity

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

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

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

NM1-06 · 1038 · Patient Event Provider Name Prefix · Optional · String (AN) · Min 1 Max 10

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

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

• 24: Employer's Identification Number
• 34: Social Security Number
• 46: Electronic Transmitter Identification Number (ETIN)
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Patient Event Provider Identifier · Optional · String (AN) · Min 2 Max 80

1800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

REF Patient Event Provider Supplemental Information

Optional · Max use 7

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

• 0B: State License Number
• 1G: Provider UPIN Number
• 1J: Facility ID Number
• EI: Employer's Identification Number
• N5: Provider Plan Network Identification Number
• N7: Facility Network Identification Number
• SY: Social Security Number
• ZH: Carrier Assigned Reference Number

REF-02 · 127 · Patient Event Provider Supplemental Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · License Number State Code · Optional · String (AN) · Min 1 Max 80

2000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N3

N3 Patient Event Provider Address

Optional · Max use 1

N3-01 · 166 · Patient Event Provider Address Line · Required · String (AN) · Min 1 Max 55

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

2100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N4

N4 Patient Event Provider City, State, ZIP Code

Optional · Max use 1

Only one of Patient Event Provider 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 Event Provider City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Patient Event Provider State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Patient Event Provider Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

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

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

2200 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PER

PER Patient Event Provider Contact Information

Optional · Max use 1

If either Communication Number Qualifier (PER-03) or Patient Event Provider Contact Communications Number (PER-04) is present, then the other is required

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

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

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

• IC: Information Contact

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

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

• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-04 · 364 · Patient Event Provider Contact Communications Number · Optional · String (AN) · Min 1 Max 256

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

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-06 · 364 · Patient Event Provider Contact Communications Number · Optional · String (AN) · Min 1 Max 256

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

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-08 · 364 · Patient Event Provider Contact Communications Number · Optional · String (AN) · Min 1 Max 256

2400 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

PRV Patient Event Provider Information

Optional · Max use 1

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AS: Assistant Surgeon
• AT: Attending
• OP: Operating
• OR: Ordering
• OT: Other Physician
• PC: Primary Care Physician
• PE: Performing
• RF: Referring

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

• PXC: Health Care Provider Taxonomy Code

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

2010EB Patient Event Transport Information Loop Optional Max 5

Variants (all may be used)

Patient Event Provider Name LoopPatient Event Other UMO Name Loop

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > NM1

NM1 Patient Event Transport Information

Required · Max use 1

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

• 45: Drop-off Location
• FS: Final Scheduled Destination
• ND: Next Destination
• PW: Pickup Address
• R3: Next Scheduled Destination

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

• 2: Non-Person Entity

NM1-03 · 1035 · Patient Event Transport Location Name · Optional · String (AN) · Min 1 Max 60

2000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N3

N3 Patient Event Transport Location Address

Required · Max use 1

N3-01 · 166 · Patient Event Transport Location Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Patient Event Transport Location Address Line · Optional · String (AN) · Min 1 Max 55

2100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N4

N4 Patient Event Transport Location City/State/ZIP Code

Required · Max use 1

N4-01 · 19 · Patient Event Transport Location City Name · Optional · String (AN) · Min 2 Max 30

N4-02 · 156 · Patient Event Transport Location State or Province Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Patient Event Transport Location Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

2010EC Patient Event Other UMO Name Loop Optional Max 3

Variants (all may be used)

Patient Event Provider Name LoopPatient Event Transport Information Loop

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > NM1

NM1 Patient Event Other UMO Name

Required · Max use 1

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

• 00: Alternate Insurer
• CA: Carrier
• GG: Intermediary

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

• 2: Non-Person Entity

NM1-03 · 1035 · Other UMO Name · Optional · String (AN) · Min 1 Max 60

1800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > REF

REF Other UMO Denial Reason

Required · Max use 1

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

• ZZ: Mutually Defined

REF-02 · 127 · Other UMO Denial Reason · Required · String (AN) · Min 1 Max 50

REF-04 · C040 · Reference Identifier · Optional Max 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 · If either Reference Identification Qualifier (C040 - 03) or Other UMO Denial Reason (C040 - 04) is present, then the other is required If either Reference Identification Qualifier (C040 - 05) or Reference Identification (C040 - 06) is present, then the other is required

C040-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• ZZ: Mutually Defined

C040-02 · 127 · Other UMO Denial Reason · Required · String (AN) · Min 1 Max 50

C040-03 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• ZZ: Mutually Defined

C040-04 · 127 · Other UMO Denial Reason · Optional · String (AN) · Min 1 Max 50

C040-05 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• ZZ: Mutually Defined

C040-06 · 127 · Reference Identification · Optional · String (AN) · Min 1 Max 50

2700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > DTP

DTP Other UMO Denial Date

Required · Max use 1

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

• 598: Rejected

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Other UMO Denial Date · Required · String (AN) · Min 1 Max 35

2000F Service Level Loop Optional Max >1

0100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• SS: Services

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

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

0200 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TRN

TRN Service Trace Number

Optional · Max use 2

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

• 1: Current Transaction Trace Numbers

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0400 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > UM

UM Health Care Services Review Information

Optional · Max use 1

UM-01 · 1525 · Request Category Code · Required · Identifier (ID)

• HS: Health Services Review
• SC: Specialty Care Review

UM-02 · 1322 · Certification Type Code · Optional · Identifier (ID)

• 1: Appeal - Immediate
• 2: Appeal - Standard
• 3: Cancel
• 4: Extension
• I: Initial
• N: Reconsideration
• R: Renewal
• S: Revised

UM-03 · 1365 · Service Type Code · Optional · Identifier (ID)

• 1: Medical Care
• 2: Surgical
• 3: Consultation
• 4: Diagnostic X-Ray
• 5: Diagnostic Lab
• 6: Radiation Therapy
• 7: Anesthesia
• 8: Surgical Assistance
• 11: Used Durable Medical Equipment
• 12: Durable Medical Equipment Purchase
• 14: Renal Supplies in the Home
• 15: Alternate Method Dialysis
• 16: Chronic Renal Disease (CRD) Equipment
• 17: Pre-Admission Testing
• 18: Durable Medical Equipment Rental
• 20: Second Surgical Opinion
• 21: Third Surgical Opinion
• 23: Diagnostic Dental
• 24: Periodontics
• 25: Restorative
• 26: Endodontics
• 27: Maxillofacial Prosthetics
• 28: Adjunctive Dental Services
• 33: Chiropractic
• 35: Dental Care
• 36: Dental Crowns
• 37: Dental Accident
• 38: Orthodontics
• 39: Prosthodontics
• 40: Oral Surgery
• 42: Home Health Care
• 44: Home Health Visits
• 45: Hospice
• 46: Respite Care
• 54: Long Term Care
• 56: Medically Related Transportation
• 61: In-vitro Fertilization
• 62: MRI/CAT Scan
• 63: Donor Procedures
• 64: Acupuncture
• 65: Newborn Care
• 66: Pathology
• 67: Smoking Cessation
• 68: Well Baby Care
• 69: Maternity
• 70: Transplants
• 71: Audiology Exam
• 72: Inhalation Therapy
• 73: Diagnostic Medical
• 74: Private Duty Nursing
• 75: Prosthetic Device
• 76: Dialysis
• 77: Otological Exam
• 78: Chemotherapy
• 79: Allergy Testing
• 80: Immunizations
• 82: Family Planning
• 83: Infertility
• 84: Abortion
• 85: AIDS
• 86: Emergency Services
• 87: Cancer
• 88: Pharmacy
• 93: Podiatry
• A4: Psychiatric
• A6: Psychotherapy
• A9: Rehabilitation
• AD: Occupational Therapy
• AE: Physical Medicine
• AF: Speech Therapy
• AG: Skilled Nursing Care
• AI: Substance Abuse
• AJ: Alcoholism
• AK: Drug Addiction
• AL: Vision (Optometry)
• AR: Experimental Drug Therapy
• B1: Burn Care
• BB: Partial Hospitalization (Psychiatric)
• BC: Day Care (Psychiatric)
• BD: Cognitive Therapy
• BE: Massage Therapy
• BF: Pulmonary Rehabilitation
• BG: Cardiac Rehabilitation
• BL: Cardiac
• BN: Gastrointestinal
• BP: Endocrine
• BQ: Neurology
• BS: Invasive Procedures
• BY: Physician Visit - Office: Sick
• BZ: Physician Visit - Office: Well
• C1: Coronary Care
• GY: Allergy
• IC: Intensive Care
• MH: Mental Health
• NI: Neonatal Intensive Care
• ON: Oncology
• PT: Physical Therapy
• PU: Pulmonary
• RN: Renal
• RT: Residential Psychiatric Treatment
• TC: Transitional Care
• TN: Transitional Nursery Care

UM-04 · C023 · Health Care Service Location Information · Optional Max 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 · Usage notes

C023-01 · 1331 · Facility Type Code · Required · String (AN) · Min 1 Max 2

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

• A: Uniform Billing Claim Form Bill Type
• B: Place of Service Codes for Professional or Dental Services

0600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

REF Previous Review Administrative Reference Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Authorization Number

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

• NT: Administrator's Reference Number

REF-02 · 127 · Previous Administrative Reference Number · Required · String (AN) · Min 1 Max 50

0600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

REF Previous Review Authorization Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Administrative Reference Number

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

• BB: Authorization Number

REF-02 · 127 · Previous Review Authorization Number · Required · String (AN) · Min 1 Max 50

0700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Service Date

Optional · Max use 1

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

• 472: Service

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

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

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

0810 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV1

SV1 Professional Service

Optional · Max use 1

If either Unit or Basis for Measurement Code (SV1-03) or Service Unit Count (SV1-04) is present, then the other is required

SV1-01 · C003 · Composite Medical Procedure Identifier · Required Max 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)

• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• WK: Advanced Billing Concepts (ABC) Codes

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

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

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

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

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

C003-07 · 352 · Procedure Code Description · Optional · String (AN) · Min 1 Max 80

C003-08 · 234 · Procedure Code · Optional · String (AN) · Min 1 Max 48

SV1-02 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 15

SV1-03 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• F2: International Unit
• MJ: Minutes
• UN: Unit

SV1-04 · 380 · Service Unit Count · Optional · Decimal number (R) · Min 1 Max 15

SV1-07 · C004 · Composite Diagnosis Code Pointer · Optional Max use 1 · To identify one or more diagnosis code pointers · Usage notes

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

C004-02 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-03 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-04 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

SV1-11 · 1073 · EPSDT Indicator · Optional · Identifier (ID)

• N: No
• Y: Yes

SV1-20 · 1337 · Nursing Home Level of Care · Optional · Identifier (ID)

• 1: Skilled Nursing Facility (SNF)
• 2: Intermediate Care Facility (ICF)
• 3: Intermediate Care Facility - Mentally Retarded (ICF-MR)
• 4: Chronic Disease Hospital (CD)
• 5: Intermediate Care Facility (ICF) Level II
• 6: Special Skilled Nursing Facility (SNF)
• 7: Nursing Facility (NF)
• 8: Hospice

0820 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV2

SV2 Institutional Service Line

Optional · Max use 1

At least one of Service Line Revenue Code (SV2-01) or Composite Medical Procedure Identifier (SV2-02) is required

If either Unit or Basis for Measurement Code (SV2-04) or Service Unit Count (SV2-05) is present, then the other is required

SV2-01 · 234 · Service Line Revenue Code · Optional · String (AN) · Min 1 Max 48

SV2-02 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

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

• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• WK: Advanced Billing Concepts (ABC) Codes
• ZZ: Mutually Defined

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

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

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

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

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

C003-07 · 352 · Procedure Code Description · Optional · String (AN) · Min 1 Max 80

C003-08 · 234 · Procedure Code · Optional · String (AN) · Min 1 Max 48

SV2-03 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 15

SV2-04 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• DA: Days
• F2: International Unit
• UN: Unit

SV2-05 · 380 · Service Unit Count · Optional · Decimal number (R) · Min 1 Max 15

SV2-06 · 1371 · Service Line Rate · Optional · Decimal number (R) · Min 1 Max 10

SV2-09 · 1345 · Nursing Home Residential Status Code · Optional · Identifier (ID)

• 1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
• 2: Newly Admitted
• 3: Newly Eligible
• 4: No Longer Eligible
• 5: Still a Resident
• 6: Temporary Absence - Hospital
• 7: Temporary Absence - Other
• 8: Transferred to Intermediate Care Facility - Level II (ICF II)

SV2-10 · 1337 · Nursing Home Level of Care · Optional · Identifier (ID)

• 1: Skilled Nursing Facility (SNF)
• 2: Intermediate Care Facility (ICF)
• 3: Intermediate Care Facility - Mentally Retarded (ICF-MR)
• 4: Chronic Disease Hospital (CD)
• 5: Intermediate Care Facility (ICF) Level II
• 6: Special Skilled Nursing Facility (SNF)
• 7: Nursing Facility (NF)
• 8: Hospice

0830 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV3

SV3 Dental Service

Optional · Max use 1

SV3-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers

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

• AD: American Dental Association Codes

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

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

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

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

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

C003-07 · 352 · Procedure Code Description · Optional · String (AN) · Min 1 Max 80

C003-08 · 234 · Procedure Code · Optional · String (AN) · Min 1 Max 48

SV3-02 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 15

SV3-04 · C006 · Oral Cavity Designation · Optional Max use 1 · To identify one or more areas of the oral cavity · Usage notes

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

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

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

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

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

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

• I: Initial Placement
• R: Replacement

SV3-06 · 380 · Service Unit Count · Required · Decimal number (R) · Min 1 Max 15

SV3-07 · 352 · Description · Optional · String (AN) · Min 1 Max 80

0840 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TOO

TOO Tooth Information

Optional · Max use 32

TOO-01 · 1270 · Code List Qualifier Code · Required · Identifier (ID)

• JP: Universal National Tooth Designation System

TOO-02 · 1271 · Tooth Code · Required · String (AN) · Min 1 Max 30

TOO-03 · C005 · Tooth Surface · Optional Max use 1 · To identify one or more tooth surface codes · Usage notes

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

• B: Buccal
• D: Distal
• F: Facial
• I: Incisal
• L: Lingual
• M: Mesial
• O: Occlusal

C005-02 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

C005-03 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

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

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

0900 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HSD

HSD Health Care Services Delivery

Optional · Max use 1

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

HSD-01 · 673 · Quantity Qualifier · Optional · Identifier (ID)

• DY: Days
• FL: Units
• HS: Hours
• MN: Month
• VS: Visits

HSD-02 · 380 · Service Unit Count · Optional · Decimal number (R) · Min 1 Max 15

HSD-03 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• DA: Days
• MO: Months
• WK: Week

HSD-04 · 1167 · Sample Selection Modulus · Optional · Decimal number (R) · Min 1 Max 6

HSD-05 · 615 · Time Period Qualifier · Optional · Identifier (ID)

• 6: Hour
• 7: Day
• 21: Years
• 26: Episode
• 27: Visit
• 34: Month
• 35: Week

HSD-06 · 616 · Period Count · Optional · Numeric (N0) · Min 1 Max 3

HSD-07 · 678 · Delivery Frequency Code · Optional · Identifier (ID)

• 1: 1st Week of the Month
• 2: 2nd Week of the Month
• 3: 3rd Week of the Month
• 4: 4th Week of the Month
• 5: 5th Week of the Month
• 6: 1st & 3rd Weeks of the Month
• 7: 2nd & 4th Weeks of the Month
• 8: 1st Working Day of Period
• 9: Last Working Day of Period
• A: Monday through Friday
• B: Monday through Saturday
• C: Monday through Sunday
• D: Monday
• E: Tuesday
• F: Wednesday
• G: Thursday
• H: Friday
• J: Saturday
• K: Sunday
• L: Monday through Thursday
• M: Immediately
• N: As Directed
• O: Daily Mon. through Fri.
• P: 1/2 Mon. & 1/2 Thurs.
• Q: 1/2 Tues. & 1/2 Thurs.
• R: 1/2 Wed. & 1/2 Fri.
• S: Once Anytime Mon. through Fri.
• SA: Sunday, Monday, Thursday, Friday, Saturday
• SB: Tuesday through Saturday
• SC: Sunday, Wednesday, Thursday, Friday, Saturday
• SD: Monday, Wednesday, Thursday, Friday, Saturday
• SG: Tuesday through Friday
• SL: Monday, Tuesday and Thursday
• SP: Monday, Tuesday and Friday
• SX: Wednesday and Thursday
• SY: Monday, Wednesday and Thursday
• SZ: Tuesday, Thursday and Friday
• T: 1/2 Tue. & 1/2 Fri.
• U: 1/2 Mon. & 1/2 Wed.
• V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
• W: Whenever Necessary
• X: 1/2 By Wed., Bal. By Fri.
• Y: None (Also Used to Cancel or Override a Previous Pattern)

HSD-08 · 679 · Delivery Pattern Time Code · Optional · Identifier (ID)

• A: 1st Shift (Normal Working Hours)
• B: 2nd Shift
• C: 3rd Shift
• D: A.M.
• E: P.M.
• F: As Directed
• G: Any Shift
• Y: None (Also Used to Cancel or Override a Previous Pattern)

1550 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > PWK

PWK Additional Service Information

Optional · Max use 10

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)

• 03: Report Justifying Treatment Beyond Utilization Guidelines
• 04: Drugs Administered
• 05: Treatment Diagnosis
• 06: Initial Assessment
• 07: Functional Goals
• 08: Plan of Treatment
• 09: Progress Report
• 10: Continued Treatment
• 11: Chemical Analysis
• 13: Certified Test Report
• 15: Justification for Admission
• 21: Recovery Plan
• 48: Social Security Benefit Letter
• 55: Rental Agreement
• 59: Benefit Letter
• 77: Support Data for Verification
• A3: Allergies/Sensitivities Document
• A4: Autopsy Report
• AM: Ambulance Certification
• AS: Admission Summary
• AT: Purchase Order Attachment
• B2: Prescription
• B3: Physician Order
• BR: Benchmark Testing Results
• BS: Baseline
• BT: Blanket Test Results
• CB: Chiropractic Justification
• CK: Consent Form(s)
• D2: Drug Profile Document
• DA: Dental Models
• DB: Durable Medical Equipment Prescription
• DG: Diagnostic Report
• DJ: Discharge Monitoring Report
• DS: Discharge Summary
• FM: Family Medical History Document
• HC: Health Certificate
• HR: Health Clinic Records
• I5: Immunization Record
• IR: State School Immunization Records
• LA: Laboratory Results
• M1: Medical Record Attachment
• NN: Nursing Notes
• OB: Operative Note
• OC: Oxygen Content Averaging Report
• OD: Orders and Treatments Document
• OE: Objective Physical Examination (including vital signs) Document
• OX: Oxygen Therapy Certification
• P4: Pathology Report
• P5: Patient Medical History Document
• P6: Periodontal Charts
• P7: Periodontal Reports
• PE: Parenteral or Enteral Certification
• PN: Physical Therapy Notes
• PO: Prosthetics or Orthotic Certification
• PQ: Paramedical Results
• PY: Physician's Report
• PZ: Physical Therapy Certification
• QC: Cause and Corrective Action Report
• QR: Quality Report
• RB: Radiology Films
• RR: Radiology Reports
• RT: Report of Tests and Analysis Report
• RX: Renewable Oxygen Content Averaging Report
• SG: Symptoms Document
• V5: Death Notification
• XP: Photographs

PWK-02 · 756 · Report Transmission Code · Required · Identifier (ID)

• AA: Available on Request at Provider Site
• BM: By Mail
• EL: Electronically Only
• EM: E-Mail
• FX: By Fax
• VO: Voice

PWK-05 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• AC: Attachment Control Number

PWK-06 · 67 · Attachment Control Number · Optional · String (AN) · Min 2 Max 80

PWK-07 · 352 · Attachment Description · Optional · String (AN) · Min 1 Max 80

1600 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > MSG

MSG Message Text

Optional · Max use 1

MSG-01 · 933 · Free Form Message Text · Required · String (AN) · Min 1 Max 264

2010F Service Provider Name Loop Optional Max 10

1700 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

NM1 Service Provider Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Service Provider Identifier (NM1-09) is present, then the other is required

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

• 1T: Physician, Clinic or Group Practice
• 72: Operating Physician
• 73: Other Physician
• 77: Service Location
• DD: Assistant Surgeon
• DK: Ordering Physician
• DQ: Supervising Physician
• FA: Facility
• G3: Clinic
• P3: Primary Care Provider
• QB: Purchase Service Provider
• QV: Group Practice
• SJ: Service Provider

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

• 1: Person
• 2: Non-Person Entity

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

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

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

NM1-06 · 1038 · Service Provider Name Prefix · Optional · String (AN) · Min 1 Max 10

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

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

• 24: Employer's Identification Number
• 34: Social Security Number
• 46: Electronic Transmitter Identification Number (ETIN)
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

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

1800 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > REF

REF Service Provider Supplemental Identification

Optional · Max use 8

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

• 0B: State License Number
• 1G: Provider UPIN Number
• 1J: Facility ID Number
• EI: Employer's Identification Number
• N5: Provider Plan Network Identification Number
• N7: Facility Network Identification Number
• SY: Social Security Number
• ZH: Carrier Assigned Reference Number

REF-02 · 127 · Service Provider Supplemental Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · License Number State Code · Optional · String (AN) · Min 1 Max 80

2000 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > N3

N3 Service Provider Address

Optional · Max use 1

N3-01 · 166 · Service Provider Address Line · Required · String (AN) · Min 1 Max 55

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

2100 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > N4

N4 Service Provider City, State, ZIP Code

Optional · Max use 1

Only one of Service 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 · Service Provider City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Service Provider State or Province Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Service Provider Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

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

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

2200 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PER

PER Service Provider Contact Information

Optional · Max use 1

If either Communication Number Qualifier (PER-03) or Service Provider Contact Communication Number (PER-04) is present, then the other is required

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

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

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

• IC: Information Contact

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

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

• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-04 · 364 · Service Provider Contact Communication Number · Optional · String (AN) · Min 1 Max 256

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

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

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

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

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

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

2400 Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PRV

PRV Service Provider Information

Optional · Max use 1

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AS: Assistant Surgeon
• OP: Operating
• OR: Ordering
• OT: Other Physician
• PC: Primary Care Physician
• PE: Performing

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

• PXC: Health Care Provider Taxonomy Code

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

2800 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

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

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

GE Functional Group Trailer

Required · Max use 1

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

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

IEA Interchange Control Trailer

Required · Max use 1

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

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

EDI Samples

Example 1: Referral

ST*278*0001*005010X217~
BHT*0007*13*A12345*20050502*1101~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*GARDENER*JAMES****XX*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*0~
TRN*1*111099*9012345678~
UM*SC*I*3*11>B*****Y~
HI*BF>41090>D8>20050430~
HSD*VS*1~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PER*IC**TE*4029993456~
SE*16*0001~

Example 2: Admission for Surgery

ST*278*0001*005010X217~
BHT*0007*13*B56789*20050502*1430~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*WATSON*SUSAN****XX*98765432~
PER*IC**TE*4029993456~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*1~
TRN*1*97021001*9012345678~
UM*AR*I*2*21>B*****Y~
DTP*435*D8*20050516~
HI*BF>41090>D8>20050125~
HSD*DY*7~
CL1*2~
NM1*FA*2*MONTGOMERY HOSPITAL*****24*000012121~
N3*475 MAIN STREET~
N4*ANYTOWN*PA*19087~
HL*5*4*SS*0~
UM*HS*I*2~
DTP*472*D8*20050516~
SV2**HC>33510~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PRV*PE*PXC*203BS0133X~
SE*26*0001~

Example 3: Request for Behavioral Health Emergency Admission

ST*278*0001*005010X217~
BHT*0007*13*YZZ345*20050502*1101~
HL*1**20*1~
NM1*X3*2*CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*FA*2*GENERAL HOSPITAL*****XX*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*MARY****MI*12345678901~
HL*4*3*EV*0~
TRN*1*YZZ099*9876543210~
UM*AR*I*A4*21>B**03***Y~
DTP*435*D8*20050505~
HI*BF>29603>D8>20050430~
HSD*DY*3~
CL1*1~
NM1*FA*2*GENERAL HOSPITAL*****46*987654321~
PER*IC**TE*4029993456~
NM1*71*1*JONES*MARCUS****24*453667654~
NM1*SJ*1*BROWN*JACOB****24*123454545~
SE*20*0001~

Example 4: Request for Home Health Care

ST*278*0001*005010X217~
BHT*0007*13*B56789*20050502*1430~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*WATSON*SUSAN****XX*98765432~
PER*IC**TE*4029993456~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*1~
UM*HS*I**12>B*****Y~
HI*BF>1831*BF>2630~
HSD*VS*3*WK**34*2~
CR6*1*20050502*RD8*20050502-20050801***W*I~
NM1*SJ*2*CARING HANDS HOME HEALTH AGENCY*****24*345678912~
HL*5*4*SS*0~
SV1*HC>G0154~
HL*6*4*SS*0~
SV1*HC>B4184~
SE*20*0001~

Example 5: Request for Non-emergency Transportation Service (Multi-destination Trip)

ST*278*0001*005010X217~
BHT*0007*13*165932*20050502*1525~
HL*1**20*1~
NM1*X3*2*ABC PAYER*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*XYZ AMBULANCE SVC*****XX*7759621873~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345689001~
REF*1L*6532214A76~
DMG*D8*19580322*M~
HL*4*3*EV*1~
UM*HS*I*56*41>B~
DTP*AAH*D8*20050510~
CRC*07*Y*09~
CR1***X*D*DH*27***TRIP FROM HOME TO OFFICE VISIT TO DIALYSIS TREATMENT AND BACK HOME~
NM1*PW*2*HOME~
N3*8652 Starwood Lane~
N4*SACRAMENTO*CA*95826~
NM1*ND*2*DR. GARDNER OFFICE~
N3*1921 FULTON AVENUE~
N4*SACRAMENTO*CA*95624~
NM1*R3*2*XYZ DIALYSIS CENTER~
N3*7622 MORSETOWN ROAD~
N4*SACRAMENTO*CA*95826~
NM1*FS*2*HOME~
N3*8652 Starwood Lane~
N4*SACRAMENTO*CA*95826~
HL*5*4*SS*0~
SV1*HC>A0428>RX**UN*5~
HL*6*5*SS*0~
SV1*HC>A0428>PD**UN*8~
HL*7*6*SS*0~
SV1*HC>A0428>DR**UN*14~
SE*34*0001~

Example 6: Request for Medical Services Reservation

ST*278*0001*005010X217~
BHT*0007*13*5269367*20050502*2243*RU~
HL*1**20*1~
NM1*X3*2*ABC PAYER*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*GARDNER*JAMES****XX*0010102364~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345689001~
DMG*D8*19580322*M~
HL*4*3*EV*1~
UM*IN*I*1*11>B~
HL*5*4*SS*0~
DTP*472*D8*20050510~
SV1*HC>99212**UN*1~
SE*15*0001~