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

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.

Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • Example 1: Referral
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Utilization Management Organization (UMO) Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Requester Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Subscriber Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Dependent Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Patient Event Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Patient Event Tracking Number
Max use 2
Optional
UM
0400
Health Care Services Review Information
Max use 1
Required
REF
0600
Previous Review Administrative Reference Number
Max use 1
Optional
REF
0600
Previous Review Authorization Number
Max use 1
Optional
DTP
0700
Accident Date
Max use 1
Optional
DTP
0700
Admission Date
Max use 1
Optional
DTP
0700
Discharge Date
Max use 1
Optional
DTP
0700
Estimated Date of Birth
Max use 1
Optional
DTP
0700
Event Date
Max use 1
Optional
DTP
0700
Last Menstrual Period Date
Max use 1
Optional
DTP
0700
Onset of Current Symptoms or Illness Date
Max use 1
Optional
HI
0800
Patient Diagnosis
Max use 1
Optional
HSD
0900
Health Care Services Delivery
Max use 1
Optional
CRC
1000
Activities Permitted Information
Max use 1
Optional
CRC
1000
Ambulance Certification Information
Max use 1
Optional
CRC
1000
Chiropractic Certification Information
Max use 1
Optional
CRC
1000
Durable Medical Equipment Information
Max use 1
Optional
CRC
1000
Functional Limitations Information
Max use 1
Optional
CRC
1000
Mental Status Information
Max use 1
Optional
CRC
1000
Oxygen Therapy Certification Information
Max use 1
Optional
CL1
1100
Institutional Claim Code
Max use 1
Optional
CR1
1200
Ambulance Transport Information
Max use 1
Optional
CR2
1300
Spinal Manipulation Service Information
Max use 1
Optional
CR5
1400
Home Oxygen Therapy Information
Max use 1
Optional
CR6
1500
Home Health Care Information
Max use 1
Optional
PWK
1550
Additional Patient Information
Max use 10
Optional
MSG
1600
Message Text
Max use 1
Optional
SE
2800
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

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

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

Code identifying the type of information in the Authorization Information

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

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

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

Code identifying the type of information in the Security Information

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

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

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

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

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

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

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

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

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

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

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

Date of the interchange

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

Time of the interchange

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

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

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

Code specifying the version number of the interchange control segments

00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

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

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

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

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

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

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

Code identifying a group of application related transaction sets

HI
Health Care Services Review Information (278)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

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

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

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

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

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

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

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

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

Assigned number originated and maintained by the sender

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

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

005010X217

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

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

Usage notes
  • Use this segment to indicate the start of a health care services review request transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management request.
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
278
Health Care Services Review Information
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

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

Usage notes
  • The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.
ST-03
1705
Implementation Guide Version Name
Required
String (AN)

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
Usage notes
  • This element must be populated with the guide identifier named in Section 1.2.
  • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
005010X217
BHT
0200
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

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

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

0007
Information Source, Information Receiver, Subscriber, Dependent, Event, Services
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

13
Request
BHT-03
127
Submitter Transaction Identifier
Required
String (AN)
Min 1Max 50

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

  • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
Usage notes
  • Use this element to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier must be returned in the corresponding 278 response transaction's BHT03. This identifier will only be returned by the last entity to handle the 278. This identifier will not be passed through the complete life of the transaction. All recipients of 278 request transactions are required to return the Submitter Transaction Identifier in their 278 response if one is submitted.
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

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

  • BHT04 is the date the transaction was created within the business application system.
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

  • BHT05 is the time the transaction was created within the business application system.
BHT-06
640
Transaction Type Code
Optional
Identifier (ID)

Code specifying the type of transaction

RU
Medical Services Reservation
Heading end

Detail

2000A Utilization Management Organization (UMO) Level Loop
RequiredMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
20
Information Source
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2010A Utilization Management Organization (UMO) Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Utilization Management Organization (UMO) Name Loop > NM1

Utilization Management Organization (UMO) Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment identifies the source of information. In the case of a request transaction, the source of information would normally be the payer or utilization review organization making the decision on the request.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

X3
Utilization Management Organization
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

PI
Payor Identification

Use when UMO is a payer and XV is not used.

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

Code identifying a party or other code

06111
UHC Payer ID
87726
UHC Payer ID
061118515
Oxford Payer ID
2010A Utilization Management Organization (UMO) Name Loop end
2000B Requester Level Loop
RequiredMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
21
Information Receiver
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2010B Requester Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > NM1

Requester Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment identifies the receiver of information. In the case of a request transaction, the receiver would normally be the entity who will ultimately be receiving the decision.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

1P
Provider

Use when the requester is an individual provider.

FA
Facility

Use when the requester is a facility, such as a clinic or hospital.

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

Code qualifying the type of entity

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

Individual last name or organizational name

Usage notes

The name of the provider or facility submitting the request is required.

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

Usage notes

NPI is required

XX
Centers for Medicare and Medicaid Services National Provider Identifier

Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI;
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI;
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it;
If not required by this implementation guide, do not send.

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

Code identifying a party or other code

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

Requester Supplemental Identification

OptionalMax use 8

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the UMO to identify the provider;
    OR
    Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an identifier is necessary for the UMO to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number

Facility Tax Identification Number (TIN).
Not used if NM108 = 24.

ZH
Carrier Assigned Reference Number

Unique provider identifier assigned by payer (MPIN).

Required when necessary to provide the requester/provider ID as assigned by the UMO identified in Loop 2000A. If not required, do not send.

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

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

Usage notes

Must be padded with leading zeros to equal 9 digits

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

Requester Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Use to identify a specific location when the requester has multiple locations and authority varies based on location.
  • Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
Example
N3-01
166
Requester Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the requester's address.
N3-02
166
Requester Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

Requester City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
Example
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 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
PER
2200
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > PER

Requester Contact Information

OptionalMax use 1

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

Usage notes
  • Required when the UMO must direct requests for additional information to a specific requester contact, electronic mail, facsimile, or telephone number. If not required by this implementation guide, do not send.
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
Example
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)

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

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

Free-form name

Usage notes

Free form contact name. This should be the name of an individual at the submitting provider/facility that UnitedHealthcare can contact if there are questions or more information is needed about this admission notification. If an individual contact name cannot be provided, please populate this field with the facility or provider name from NM103.

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

Code identifying the type of communication number

Usage notes

At least one contact phone number is required.

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

Complete communications number including country or area code when applicable

Usage notes

Phone number - Format 10 digits no punctuation or spaces

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

Code identifying the type of communication number

Usage notes

If applicable

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

Complete communications number including country or area code when applicable

Usage notes

Extension (numeric only), if applicable

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

Code identifying the type of communication number

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

Must not contain any characters used as delimiters in this transaction.

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

Complete communications number including country or area code when applicable

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

Requester Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when needed to indicate the requester's role in the care of the patient and the requesting provider's specialty. If not required by this implementation guide, do not send.
Example
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)

Code identifying the type of provider

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)

Code qualifying the Reference Identification

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

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

2010B Requester Name Loop end
2000C Subscriber Level Loop
RequiredMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
22
Subscriber
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2010C Subscriber Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment conveys the name and identification number of the subscriber (who may also be the patient).
  • The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
    Subscriber Last Name (NM103)
    Subscriber First Name (NM104)
    Subscriber Birth Date (DMG01 and DMG02)
  • Refer to Section 2.2.2.1 Identifying the Patient for specific information on how to identify an individual to a UMO.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

Usage notes

Subscriber Last name (Required)

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

Individual first name

Usage notes

Subscriber First name. Required if member has a legal first name. If member has only 1 legal name, send member name in Last Name and do not populate first name.

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

Individual middle name or initial

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

Prefix to individual name

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

Suffix to individual name

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

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

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms:
Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

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

Code identifying a party or other code

Usage notes

Member Identification preferably from UnitedHealth insurance card.

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

Subscriber Supplemental Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.
  • The primary identifier is the Member Identification Number in the NM1 segment.
  • Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
  • If the requester values this segment with the Patient Account Number (REF01="EJ") on the request, the UMO is required to return the same value in this segment on the response.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1L
Group or Policy Number

Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

6P
Group Number

preferred

HJ
Identity Card Number

Referral only

Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.

IG
Insurance Policy Number

Referral only

N6
Plan Network Identification Number
REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50

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

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

Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the Subscriber mailing address.
N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Subscriber City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DMG
2500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
  • Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

Usage notes

Gender Code is required.

F
Female
M
Male
U
Unknown
INS
2600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Subscriber Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when the subscriber's role in the military is necessary to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
Y
Yes
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

18
Self
INS-08
584
Employment Status Code
Required
Identifier (ID)

Code showing the general employment status of an employee/claimant

Usage notes
  • Use to qualify the patient's relationship to the military.
AO
Active Military - Overseas
AU
Active Military - USA
DI
Deceased
PV
Previous
RU
Retired Military - USA
2010C Subscriber Name Loop end
2000D Dependent Level Loop
OptionalMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
23
Dependent
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2010D Dependent Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment conveys the name of the dependent who is the patient.
  • The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
    Dependent Last Name (NM103)
    Dependent First Name (NM104)
    Dependent Birth Date (DMG01 and DMG02)
  • Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

Usage notes

Dependent’s Last Name

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

Individual first name

Usage notes

Dependent’s First Name - Required if dependent has a legal first name. If dependent has only 1 legal name, send dependent name in Last Name and do not populate first name.

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

Individual middle name or initial

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

Suffix to individual name

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

Dependent Supplemental Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
  • If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.
  • Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EJ
Patient Account Number

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

SY
Social Security Number

The social security number may not be used for Medicare.

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

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

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

Dependent Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Example
N3-01
166
Dependent Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the Dependent address.
N3-02
166
Dependent Address Line
Optional
String (AN)
Min 1Max 55

Address information

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

Dependent City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Example
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 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DMG
2500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

Dependent Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
  • Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

Usage notes

Gender Code is required

F
Female
M
Male
U
Unknown
INS
2600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

Dependent Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when patient relationship to insured or birth sequence is needed by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
  • This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
N
No
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

01
Spouse
19
Child
G8
Other Relationship
INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9

A generic number

  • INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
2010D Dependent Name Loop end
2000E Patient Event Level Loop
RequiredMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
EV
Event
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
TRN
0200
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 2

To uniquely identify a transaction to an application

Usage notes
  • Required when the requester needs to assign a unique trace number to the patient event request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
  • This enables the requester to
  • uniquely identify this patient event request
  • trace the request
  • match the response to the request
  • reference this request in any associated attachments containing additional patient information related to this patient event request.
  • If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
  • Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

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

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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
UM
0400
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

To specify health care services review information

Usage notes
  • This segment identifies the type of health care services review request.
Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

AR
Admission Review

Required if requesting an admission to a facility.

HS
Health Services Review

Required if requesting a review of services related to an episode of care.

SC
Specialty Care Review

Required if requesting a referral to a specialty provider.

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

Code indicating the type of certification

Usage notes

If submitting a change to a previously submitted and approved authorization, please provide the administrative Reference Number from the original authorization request in the following REF segment. This is required when submitting a revision or update.)

I
Initial
S
Revised

Use if the requester is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.

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

Code identifying the classification of service

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
OptionalMax 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

Required when UM04 is not valued at 2000F. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

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

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

Usage notes
  • Use to indicate a facility code value from the code source referenced in UM04-2.
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)

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
A
Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
UM-05
C024
Related Causes Information
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes

Required when the patient's condition is accident or employment related. If not required by this implementation guide, do not send.

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

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

Usage notes
  • Always use this data element if the related cause is an auto accident.
AA
Auto Accident
AP
Another Party Responsible
EM
Employment
C024-02
1362
Related Causes Code
Optional
Identifier (ID)

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

AP
Another Party Responsible
EM
Employment
C024-03
1362
Related Causes Code
Optional
Identifier (ID)

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

AP
Another Party Responsible
C024-04
156
State or Province Code
Optional
Identifier (ID)
Min 2Max 2

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

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

Code identifying the country

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

Code specifying the level of service rendered

03
Emergency
E
Elective
U
Urgent
UM-07
1213
Current Health Condition Code
Optional
Identifier (ID)

Code indicating current health condition of the individual

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)

Code indicating physician's prognosis for the patient

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)

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

Usage notes
  • The Release of Information response is limited to the information carried in this service review.
M
The Provider has Limited or Restricted Ability to Release Data Related to a Claim

For professional service, this value is only used when state or federal laws supersede the HIPAA privacy rule by requiring that the provider collect a signature and the patient is either not present or physically unable to sign at the time the provider submits the request.

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)

Code indicating the reason why a request was delayed

1
Proof of Eligibility Unknown or Unavailable
2
Litigation
3
Authorization Delays
4
Delay in Certifying Provider
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
REF
0600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Previous Review Administrative Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when submitting a follow-up to a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFPrevious Review Authorization Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

NT
Administrator's Reference Number
REF-02
127
Previous Administrative Reference Number
Required
String (AN)
Min 1Max 50

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

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

Previous Review Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • This is the authorization number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
  • Required when submitting an additional health care services review request associated with a request already processed by the UMO. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Accident Date

OptionalMax use 1

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

Usage notes
  • Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35

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

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

Admission Date

OptionalMax use 1

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

Usage notes
  • Required when requesting an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

435
Admission
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use this for the range of dates when admission can occur. Use the HSD segment for the length of stay.;

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

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

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

Discharge Date

OptionalMax use 1

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

Usage notes
  • Required when requesting an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

096
Discharge
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Proposed or Actual Discharge Date
Required
String (AN)
Min 1Max 35

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

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

Estimated Date of Birth

OptionalMax use 1

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

Usage notes
  • Required when the certification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

ABC
Estimated Date of Birth
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Estimated Birth Date
Required
String (AN)
Min 1Max 35

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

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

Event Date

OptionalMax use 1

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

Usage notes
  • Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
  • If UM01 = AR use Admit Date.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Proposed or Actual Event Date
Required
String (AN)
Min 1Max 35

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

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

Last Menstrual Period Date

OptionalMax use 1

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

Usage notes
  • Required when the certification is pregnancy related. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

484
Last Menstrual Period
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Last Menstrual Period Date
Required
String (AN)
Min 1Max 35

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

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

Onset of Current Symptoms or Illness Date

OptionalMax use 1

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

Usage notes
  • Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

431
Onset of Current Symptoms or Illness
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Onset Date
Required
String (AN)
Min 1Max 35

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

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

Patient Diagnosis

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when known by the requester to convey diagnosis information. If not required by this implementation guide, do not send.
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes

ICD-10 is to be used with DATE OF SERVICE AS OF OCT 1, 2015 - In order to assign appropriate resources to the case; UnitedHealthcare needs to
understand why the patient is being treated. A Principal or Admitting diagnosis code is required. Please send it in this HI segment.

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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Usage notes

ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

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

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes

ICD-10 to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.

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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Usage notes

ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

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

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes

ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.

ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
Usage notes

CD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes

ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.

ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
Usage notes

ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

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)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
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 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

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

Health Care Services Delivery

OptionalMax use 1

To specify the delivery pattern of health care services

Usage notes
  • An explanation of the uses of this segment follows.

HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".

Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".

An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".

  • Required when requesting services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
Example
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)

Code specifying the type of quantity

DY
Days
FL
Units
HS
Hours
MN
Month
VS
Visits
HSD-02
380
Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • If this is a request for an extension to an existing certification (UM02 = 4), then HSD02 represents the number of visits by which the certification is extended. If this is a request to revise an existing certification (UM02 = S), then HSD02 represents the new total.
HSD-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DA
Days
MO
Months
WK
Week
HSD-04
1167
Sample Selection Modulus
Optional
Decimal number (R)
Min 1Max 6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

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

Code defining periods

6
Hour
7
Day
21
Years
26
Episode
27
Visit
34
Month
35
Week
HSD-06
616
Period Count
Optional
Numeric (N0)
Min 1Max 3

Total number of periods

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

Code which specifies the routine shipments, deliveries, or calendar pattern

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)

Code which specifies the time for routine shipments or deliveries

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

Activities Permitted Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when the assessing provider has defined activities permitted for the patient. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
76
Activities Permitted
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC
1000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Ambulance Certification Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when health care services review is requesting ambulance certification. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
07
Ambulance Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC
1000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Chiropractic Certification Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when health care services review is requesting chiropractic certification. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
08
Chiropractic Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC
1000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Durable Medical Equipment Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when health care services is requesting durable medical equipment. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
09
Durable Medical Equipment Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC
1000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Functional Limitations Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when the assessing provider has defined function limitation for the patient. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
75
Functional Limitations
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC
1000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Mental Status Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when the patient mental status is relevant to the health care services review. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
77
Mental Status
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC
1000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Oxygen Therapy Certification Information

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when health care services review is requesting oxygen therapy certification. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
11
Oxygen Therapy Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

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 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use codes listed in CRC03.
CL1
1100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CL1

Institutional Claim Code

OptionalMax use 1

To supply information specific to hospital claims

Usage notes
  • Required when requesting certification for admission (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
Example
CL1-01
1315
Admission Type Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating the priority of this admission

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

Code indicating the source of this admission

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

Code indicating patient status as of the "statement covers through date"

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

Code specifying the status of a nursing home resident at the time of service

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

Ambulance Transport Information

OptionalMax use 1

To supply information related to the ambulance service rendered to a patient

Usage notes
  • Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
  • When the CR1 segment is used, then Loop 2010EB is required.
Example
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)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

KG
Kilogram
LB
Pound
CR1-02
81
Patient Weight
Optional
Decimal number (R)
Min 1Max 10

Numeric value of weight

  • CR102 is the weight of the patient at time of transport.
CR1-03
1316
Ambulance Transport Code
Required
Identifier (ID)

Code indicating the type of ambulance transport

I
Initial Trip
R
Return Trip
T
Transfer Trip
X
Round Trip
CR1-04
1317
Ambulance Transport Reason Code
Optional
Identifier (ID)

Code indicating the reason for ambulance transport

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)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DH
Miles
DK
Kilometers
CR1-06
380
Transport Distance
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR106 is the distance traveled during transport.
CR1-09
352
Round Trip Purpose Description
Optional
String (AN)
Min 1Max 80

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

  • CR109 is the purpose for the round trip ambulance service.
CR1-10
352
Stretcher Purpose Description
Optional
String (AN)
Min 1Max 80

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

  • CR110 is the purpose for the usage of a stretcher during ambulance service.
CR2
1300
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

To supply information related to the chiropractic service rendered to a patient

Usage notes
  • Required when requesting certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.
Example
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 1Max 9

Occurrence counter

  • CR201 is the number this treatment is in the series.
CR2-02
380
Treatment Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR202 is the total number of treatments in the series.
CR2-03
1367
Subluxation Level Code
Optional
Identifier (ID)

Code identifying the specific level of subluxation

  • When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.
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)

Code identifying the specific level of subluxation

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)

Code indicating the nature of a patient's condition

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)

Code indicating a Yes or No condition or response

  • CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an uncomplicated condition.
N
No
Y
Yes
CR2-10
352
Patient Condition Description
Optional
String (AN)
Min 1Max 80

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

  • CR210 is a description of the patient's condition.
CR2-11
352
Patient Condition Description
Optional
String (AN)
Min 1Max 80

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

  • CR211 is an additional description of the patient's condition.
CR2-12
1073
X-ray Availability Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier review; an "N" value indicates X-rays are not maintained and available for carrier review.
N
No
Y
Yes
CR5
1400
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR5

Home Oxygen Therapy Information

OptionalMax use 1

To supply information regarding certification of medical necessity for home oxygen therapy

Usage notes
  • Required when requesting initial, extended, or revised certification of;home oxygen therapy. If not required by this implementation guide, do not send.
  • Use the UM segment data element UM02 instead of CR501 to specify the;Certification Type Code.
  • Use the HSD segment instead of CR502 to specify the treatment period.
Example
CR5-03
1348
Oxygen Equipment Type Code
Required
Identifier (ID)

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

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)

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

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 1Max 80

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

  • CR505 is the reason for equipment.
CR5-06
380
Oxygen Flow Rate
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR506 is the oxygen flow rate in liters per minute.
CR5-07
380
Daily Oxygen Use Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR507 is the number of times per day the patient must use oxygen.
CR5-08
380
Oxygen Use Period Hour Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR508 is the number of hours per period of oxygen use.
CR5-09
352
Respiratory Therapist Order Text
Optional
String (AN)
Min 1Max 80

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

  • CR509 is the special orders for the respiratory therapist.
CR5-10
380
Arterial Blood Gas Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR510 is the arterial blood gas.
Usage notes
  • Either CR510 or CR511 is required.
CR5-11
380
Oxygen Saturation Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR511 is the oxygen saturation.
Usage notes
  • Either CR510 or CR511 is required.
CR5-12
1349
Oxygen Test Condition Code
Optional
Identifier (ID)

Code indicating the conditions under which a patient was tested

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)

Code indicating the findings of oxygen tests performed on a patient

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)

Code indicating the findings of oxygen tests performed on a patient

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)

Code indicating the findings of oxygen tests performed on a patient

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 1Max 15

Numeric value of quantity

  • CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
CR5-17
1382
Oxygen Delivery System Code
Required
Identifier (ID)

Code to indicate if a particular form of delivery was prescribed

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)

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

A
Concentrator
B
Liquid Stationary
C
Gaseous Stationary
D
Liquid Portable
E
Gaseous Portable
O
Other
CR6
1500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR6

Home Health Care Information

OptionalMax use 1

To supply information related to the certification of a home health care patient

Usage notes
  • Required when requesting for certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
  • Requests for home health care must include a principal diagnosis (HI01=BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
Example
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)

Code indicating physician's prognosis for the patient

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

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

  • CR602 is the date covered home health services began.
CR6-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
CR6-04
1251
Home Health Certification Period
Optional
String (AN)
Min 1Max 35

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

  • CR604 is the certification period covered by this plan of treatment.
CR6-07
1073
Medicare Coverage Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
W
Not Applicable
CR6-08
1322
Certification Type Code
Required
Identifier (ID)

Code indicating the type of certification

Usage notes
  • This element must have the same value as UM02.
1
Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

2
Appeal - Standard

Use this value for appeals of review decisions where the level of service required is not emergency or urgent.

3
Cancel
4
Extension

Indicates that this is an extension request to a prior approved service.

6
Verification

This code is used to request the UMO to reconsider a previously denied referral or certification request.

I
Initial
R
Renewal

Indicates that this is a request to renew a prior approved service.

S
Revised

Use if the requester is revising the specifics of a certification for which services have not been rendered.

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

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

  • CR609 is the date that the surgery identified in CR611 was performed.
CR6-10
235
Product or Service ID Qualifier
Optional
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • CR610 qualifies CR611.
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

ID
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
CR6-11
1137
Surgical Procedure Code
Optional
String (AN)
Min 1Max 15

Code value for describing a medical condition or procedure

  • CR611 is the surgical procedure most relevant to the care being rendered.
CR6-12
373
Physician Order Date
Optional
Date (DT)
CCYYMMDD format

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

  • CR612 is the date the agency received the verbal orders from the physician for start of care.
CR6-13
373
Last Visit Date
Optional
Date (DT)
CCYYMMDD format

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

  • CR613 is the date that the patient was last seen by the physician.
CR6-14
373
Physician Contact Date
Optional
Date (DT)
CCYYMMDD format

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

  • CR614 is the date of the home health agency's most recent contact with the physician.
CR6-15
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
CR6-16
1251
Last Admission Period
Optional
String (AN)
Min 1Max 35

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

  • CR616 is the date range of the most recent inpatient stay.
CR6-17
1384
Patient Location Code
Optional
Identifier (ID)

Code identifying the location where patient is receiving medical treatment

  • CR617 indicates the type of facility from which the patient was most recently discharged.
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
PWK
1550
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > PWK

Additional Patient Information

OptionalMax use 10

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

Usage notes
  • Required when needed to report missing teeth on requests for dental services, or if the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
  • This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
  • The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

Refer to Section 2.5 for more information on using this PWK segment.

Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

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

03
Report Justifying Treatment Beyond Utilization Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals

Expected outcomes of rehabilitative services.

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

Use for medical or dental equipment rental.

59
Benefit Letter
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification

Information to support necessity of ambulance trip.

AS
Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

AT
Purchase Order Attachment

Use for purchase of medical or dental equipment.

B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

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

Required when using the PWK segment to provide missing teeth information.

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)

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

AA
Available on Request at Provider Site

Required when using the PWK segment to provide missing teeth information.

This means that the paperwork is not being sent with the request at this time. Instead, it is available to the UMO (or appropriate entity) on request.

BM
By Mail
EL
Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FX
By Fax
VO
Voice

Use this for voicemail or phone communication.

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

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

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

Code identifying a party or other code

Usage notes
  • The requester can use it when PWK02 equals "AA" if the requester wants to send a document control number for an attachment remaining at the Provider's office.
PWK-07
352
Attachment Description
Optional
String (AN)
Min 1Max 80

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

  • PWK07 may be used to indicate special information to be shown on the specified report.
Usage notes
  • To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.
MSG
1600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > MSG

Message Text

OptionalMax use 1

To provide a free-form format that allows the transmission of text information

Usage notes
  • Required when needed to transmit a text message to the UMO about the patient event. If not required by this implementation guide, do not send.
  • Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Example
MSG-01
933
Free Form Message Text
Required
String (AN)
Min 1Max 264

Free-form message text

2010EA Patient Event Provider Name Loop
OptionalMax 14
NM1
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

Patient Event Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
  • If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
  • Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
Example
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)

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

71
Attending Physician
72
Operating Physician
73
Other Physician
77
Service Location
AAJ
Admitting Services
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider

Do not use if the entity identified in 2010B is the 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)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Prefix to individual name

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

Suffix to individual name

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

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

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

Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.

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

Code identifying a party or other code

REF
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

Patient Event Provider Supplemental Information

OptionalMax use 7

To specify identifying information

Usage notes
  • Use the NM1 Segment for the primary identifier.
  • Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
    OR
    Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider.
    OR
    Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number
1J
Facility ID Number
EI
Employer's Identification Number

Not used if NM108 = 24.

N5
Provider Plan Network Identification Number
N7
Facility Network Identification Number
SY
Social Security Number

The social security number may not be used for Medicare. Not used if NM108 = 34.

ZH
Carrier Assigned Reference Number

Use when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010A has assigned its own identifier for this provider.

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

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

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

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

N3
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

Patient Event Provider Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
Example
N3-01
166
Patient Event Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the provider's address.
N3-02
166
Patient Event Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
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

Patient Event Provider City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
Example
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 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Patient Event Provider Contact Information

OptionalMax use 1

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

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
  • Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
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)

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

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

Free-form name

Usage notes
  • Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required, do not send.
PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

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 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-06
364
Patient Event Provider Contact Communications Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-08
364
Patient Event Provider Contact Communications Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PRV
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

Patient Event Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AD
Admitting

Use only when NM101 = AAJ.

AS
Assistant Surgeon

Use only when NM101 = DD.

AT
Attending

Use only when NM101 = 71.

OP
Operating

Use only when NM101 = 72.

OR
Ordering

Use only when NM101 = DK.

OT
Other Physician

Use only when NM101 = 73.

PC
Primary Care Physician

Use only when NM101 = P3.

PE
Performing

Use only when NM101 = SJ.

RF
Referring

Use only when NM101 = DN.

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

Code qualifying the Reference Identification

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

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

2010EA Patient Event Provider Name Loop end
2010EB Patient Event Transport Information Loop
OptionalMax 5
NM1
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

Patient Event Transport Information

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
  • At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
  • When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:

a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop

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

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

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)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Patient Event Transport Location Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

N3
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

Patient Event Transport Location Address

RequiredMax use 1

To specify the location of the named party

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

Address information

Usage notes
  • Use this element for the first line of the Transport Location address.
N3-02
166
Patient Event Transport Location Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
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

Patient Event Transport Location City/State/ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

2010EB Patient Event Transport Information Loop end
2010EC Patient Event Other UMO Name Loop
OptionalMax 3
NM1
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

Patient Event Other UMO Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

00
Alternate Insurer

Use this code to indicate that the other UMO is commercial insurance.

CA
Carrier

Use this code to indicate that the other UMO is Medicare Part B.

GG
Intermediary

Use this code to indicate that the other UMO is Medicare Part A.

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

Code qualifying the type of entity

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

Individual last name or organizational name

REF
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

Other UMO Denial Reason

RequiredMax use 1

To specify identifying information

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

Code qualifying the Reference Identification

ZZ
Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

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

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

REF-04
C040
Reference Identifier
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.

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)

Code qualifying the Reference Identification

ZZ
Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

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

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

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

Code qualifying the Reference Identification

ZZ
Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

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

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

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

Code qualifying the Reference Identification

ZZ
Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

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

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

DTP
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

Other UMO Denial Date

RequiredMax use 1

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

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

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

598
Rejected
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Other UMO Denial Date
Required
String (AN)
Min 1Max 35

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

2010EC Patient Event Other UMO Name Loop end
2000F Service Level Loop
OptionalMax >1
HL
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

Hierarchical Level

RequiredMax use 1

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

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

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
SS
Services
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
TRN
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

Service Trace Number

OptionalMax use 2

To uniquely identify a transaction to an application

Usage notes
  • Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
  • This enables the requester to
  • uniquely identify this service line request
  • trace the request
  • match the response to the request
  • reference this request in any associated attachments containing additional service information related to this service line request.
  • If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
  • Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
  • If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

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

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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
UM
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

Health Care Services Review Information

OptionalMax use 1

To specify health care services review information

Usage notes
  • Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

HS
Health Services Review

Required if requesting a review of services related to an episode of care.

SC
Specialty Care Review

Required if requesting a referral to a specialty provider.

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

Code indicating the type of certification

1
Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

2
Appeal - Standard

Use this value for appeals of review decisions where the level of service is not emergency or urgent.

3
Cancel
4
Extension

A "UM02 = 4" indicates that this is an extension request to a prior approved service.

I
Initial
N
Reconsideration
R
Renewal

Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

S
Revised

Use if the requester is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.

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

Code identifying the classification of service

Usage notes
  • Values at the Service Level override the values entered at the Patient Event Level for this service.
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

Use for restorative dental services.

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
OptionalMax 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

Required when different from the UM04 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

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

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

Usage notes
  • Use to indicate a facility code value from the code source referenced in UM04-2.
C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
A
Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
REF
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

Previous Review Administrative Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
  • This is the administrative number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
Example
Variants (all may be used)
REFPrevious Review Authorization Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

NT
Administrator's Reference Number
REF-02
127
Previous Administrative Reference Number
Required
String (AN)
Min 1Max 50

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

REF
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

Previous Review Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
  • Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

DTP
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

Service Date

OptionalMax use 1

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

Usage notes
  • Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Proposed or Actual Service Date
Required
String (AN)
Min 1Max 35

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

SV1
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

Professional Service

OptionalMax use 1

To specify the service line item detail for a health care professional

Usage notes
  • Required when requesting a specific Professional Service. If not required by this implementation guide, do not send.
Example
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
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

This code is required when reporting CPT codes and Level 1 HCPCS codes.
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.

N4
National Drug Code in 5-4-2 Format
WK
Advanced Billing Concepts (ABC) Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For service reviews which are not covered under HIPAA.

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

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this modifier for the first procedure code modifier.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this modifier for the second procedure code modifier.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this modifier for the third procedure code modifier.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this modifier for the fourth procedure code modifier.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
C003-08
234
Procedure Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • C003-08 represents the ending value in the range in which the code occurs.
Usage notes
  • Use SV101-2 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.
SV1-02
782
Service Line Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV102 is the submitted service line item amount.
SV1-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

F2
International Unit

International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

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

Numeric value of quantity

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

Required when this procedure relates to a specific diagnosis reported in HI Loop 2000E to point to the specific diagnosis. If not required by the implementation, do not send.

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

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

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

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

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

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

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

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

  • C004-04 identifies the fourth diagnosis code for this service line.
Usage notes
  • Use this pointer for the fourth diagnosis code pointer.
SV1-11
1073
EPSDT Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
N
No
Y
Yes
SV1-20
1337
Nursing Home Level of Care
Optional
Identifier (ID)

Code specifying the level of care provided by a nursing home facility

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
SV2
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

Institutional Service Line

OptionalMax use 1

To specify the service line item detail for a health care institution

Usage notes
  • Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.
Example
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 1Max 48

Identifying number for a product or service

  • SV201 is the revenue code.
Usage notes
  • See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
SV2-02
C003
Composite Medical Procedure Identifier
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required when requesting approval for a specific procedure code. If not required by this implementation guide, do not send.

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

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

This code is required when reporting CPT codes and Level 1 HCPCS codes.
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

ID
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.

N4
National Drug Code in 5-4-2 Format
WK
Advanced Billing Concepts (ABC) Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For service reviews which are not covered under HIPAA.

ZZ
Mutually Defined

Use this code when reporting ICD-10-PCS. This code can only be used if mandated by HIPAA or for services not covered under HIPAA.

CODE SOURCE: 896 International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

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

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the first procedure code modifier.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the second procedure code modifier.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the third procedure code modifier.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the fourth procedure code modifier.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
C003-08
234
Procedure Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • C003-08 represents the ending value in the range in which the code occurs.
Usage notes
  • Use SV202-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.
SV2-03
782
Service Line Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV203 is the submitted service line item amount.
SV2-04
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DA
Days
F2
International Unit

Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g. blood factors).

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

Numeric value of quantity

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

The rate per unit of associate revenue for hospital accommodation

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

Code specifying the status of a nursing home resident at the time of service

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)

Code specifying the level of care provided by a nursing home facility

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
SV3
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

Dental Service

OptionalMax use 1

To specify the service line item detail for dental work

Usage notes
  • Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.
Example
SV3-01
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
AD
American Dental Association Codes

CDT = Current Dental Terminology

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

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the first procedure code modifier.
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the second procedure code modifier.
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the third procedure code modifier.
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
Usage notes
  • Use this data element for the fourth procedure code modifier.
  • A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
C003-08
234
Procedure Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • C003-08 represents the ending value in the range in which the code occurs.
Usage notes
  • Use SV301-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.
SV3-02
782
Service Line Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV302 is the submitted service line item amount.
SV3-04
C006
Oral Cavity Designation
OptionalMax use 1
To identify one or more areas of the oral cavity
Usage notes

Required when necessary to report areas of the mouth that are being treated. If not required by this implementation guide, do not send.

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

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

Usage notes
  • Code source 135: American Dental Association Codes
C006-02
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

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

Usage notes
  • Code source 135: American Dental Association Codes
C006-03
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

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

Usage notes
  • Code source 135: American Dental Association Codes
C006-04
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

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

Usage notes
  • Code source 135: American Dental Association Codes
C006-05
1361
Oral Cavity Designation Code
Optional
Identifier (ID)
Min 1Max 3

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

Usage notes
  • Code source 135: American Dental Association Codes
SV3-05
1358
Prosthesis, Crown, or Inlay Code
Optional
Identifier (ID)

Code specifying the placement status for the dental work

I
Initial Placement
R
Replacement
SV3-06
380
Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SV306 is the number of procedures.
Usage notes
  • Number of procedures
SV3-07
352
Description
Optional
String (AN)
Min 1Max 80

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

  • SV307 is the reason for replacement.
TOO
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

Tooth Information

OptionalMax use 32

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

Usage notes
  • Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.
Example
TOO-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

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

Code indicating a code from a specific industry code list

Usage notes
  • Code source 135: American Dental Association Codes
TOO-03
C005
Tooth Surface
OptionalMax use 1
To identify one or more tooth surface codes
Usage notes

Required when reporting tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.

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

Code identifying the area of the tooth that was treated

B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
C005-02
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

Usage notes
  • Use code values from TOO03-1.
C005-03
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

Usage notes
  • Use code values from TOO03-1.
C005-04
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

Usage notes
  • Use code values from TOO03-1.
C005-05
1369
Tooth Surface Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the area of the tooth that was treated

Usage notes
  • Use code values from TOO03-1.
HSD
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

Health Care Services Delivery

OptionalMax use 1

To specify the delivery pattern of health care services

Usage notes
  • An explanation of the uses of this segment follows.

HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".

Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".

An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".

  • Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.
Example
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)

Code specifying the type of quantity

DY
Days
FL
Units
HS
Hours
MN
Month
VS
Visits
HSD-02
380
Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • If this is a request for an extension to an existing certification (UM02 = 4), then HSD02 represents the number of visits by which the certification is extended. If this is a request to revise an existing certification (UM02 = S), then HSD02 represents the new total.
HSD-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DA
Days
MO
Months
WK
Week
HSD-04
1167
Sample Selection Modulus
Optional
Decimal number (R)
Min 1Max 6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

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

Code defining periods

6
Hour
7
Day
21
Years
26
Episode
27
Visit
34
Month
35
Week
HSD-06
616
Period Count
Optional
Numeric (N0)
Min 1Max 3

Total number of periods

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

Code which specifies the routine shipments, deliveries, or calendar pattern

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)

Code which specifies the time for routine shipments or deliveries

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)
PWK
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

Additional Service Information

OptionalMax use 10

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

Usage notes
  • Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop, and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
  • Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.
  • This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
  • The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

Refer to Section 2.5 for more information on using this PWK segment.

Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

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

03
Report Justifying Treatment Beyond Utilization Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals

Expected outcomes of rehabilitative services.

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

Use for medical or dental equipment rental.

59
Benefit Letter
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification

Information to support necessity of ambulance trip.

AS
Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

AT
Purchase Order Attachment

Use for purchase of medical or dental equipment.

B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

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)

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

AA
Available on Request at Provider Site

This means that the paperwork is not being sent with the request at this time. Instead, it is available to the UMO (or appropriate entity) on request.

BM
By Mail
EL
Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FX
By Fax
VO
Voice

Use this for voicemail or phone communication.

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

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

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

Code identifying a party or other code

Usage notes
  • The requester can use it when PWK02 equals "AA" if the requester wants to send a document control number for an attachment remaining at the Provider's office.
PWK-07
352
Attachment Description
Optional
String (AN)
Min 1Max 80

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

  • PWK07 may be used to indicate special information to be shown on the specified report.
MSG
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

Message Text

OptionalMax use 1

To provide a free-form format that allows the transmission of text information

Usage notes
  • Required when needed to transmit a message to the UMO about the service. If not required by this implementation guide, do not send.
  • Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Example
MSG-01
933
Free Form Message Text
Required
String (AN)
Min 1Max 264

Free-form message text

2010F Service Provider Name Loop
OptionalMax 10
NM1
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

Service Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
  • Required when requesting a service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
  • If this loop is not valued, loop 2010E is required to identify the service provider, specialist, or speciality entity to provide services.
Example
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)

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

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)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Prefix to individual name

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

Suffix to individual name

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

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

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

Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.

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

Code identifying a party or other code

REF
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

Service Provider Supplemental Identification

OptionalMax use 8

To specify identifying information

Usage notes
  • Use the NM1 Segment for the primary identifier.
  • Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
    OR
    Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the service provider.
    OR
    Required prior to the mandated NPI implementation date when necessary for the UMO to identify the service provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number
1J
Facility ID Number
EI
Employer's Identification Number

Not used if NM108 = 24.

N5
Provider Plan Network Identification Number
N7
Facility Network Identification Number
SY
Social Security Number

The social security number may not be used for Medicare. Not used if NM108 = 34.

ZH
Carrier Assigned Reference Number

Required when necessary to provide the provider ID as assigned by the UMO identified in Loop 2000A.

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

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

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

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

Usage notes
  • See code source 22: State and Outlying Areas of the US.
N3
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

Service Provider Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
Example
N3-01
166
Service Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the provider's address.
N3-02
166
Service Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
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

Service Provider City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
Example
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 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Service Provider Contact Information

OptionalMax use 1

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

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
  • Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
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)

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

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

Free-form name

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

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-04
364
Service Provider Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-06
364
Service Provider Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-08
364
Service Provider Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PRV
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

Service Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AS
Assistant Surgeon

Use only when NM101 = DD.

OP
Operating

Use only when NM101 = 72.

OR
Ordering

Use only when NM101 = DK.

OT
Other Physician

Use only when NM101 = 73.

PC
Primary Care Physician

Use only when NM101 = P3.

PE
Performing

Use only when NM101 = SJ.

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

Code qualifying the Reference Identification

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

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

2010F Service Provider Name Loop end
2000F Service Level Loop end
2000E Patient Event Level Loop end
2000D Dependent Level Loop end
2000C Subscriber Level Loop end
2000B Requester Level Loop end
2000A Utilization Management Organization (UMO) Level Loop end
SE
2800
Detail > SE

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

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

Total number of segments included in a transaction set including ST and SE segments

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

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

Usage notes
  • The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

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

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

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

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

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

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

A count of the number of functional groups included in an interchange

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

A control number assigned by the interchange sender

EDI Samples

Example 1: 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~

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