Healthcare
- Payers
- Transaction enrollment
- Eligibility checks
- Claim submission
- Claim status
- Remittances
EDI platform
- Generate EDI
- Transactions
- File Executions
- Fragments
- Mappings
- Events
Professional Claims
This endpoint sends 837P (professional) claims to payers. Visit Submit professional claims for a full how-to guide.
- Call this endpoint with a JSON payload.
- Stedi translates your request to the X12 837 EDI format and sends it to the payer.
- The endpoint returns a response from Stedi in JSON format containing information about the claim you submitted and whether the submission was successful.
Send test claims
All claims you submit through this endpoint are sent to the payer as production claims unless you explicitly designate them as test data.
To send test claims, set the usageIndicator field in the test claim to T. This allows you to filter for test claims on the Transactions page in the Stedi app.
Note that you will receive a 277 Claim Acknowledgment in response to test claims, allowing you to test your workflow end to end, but you will not receive a test 835 (ERA) response.
Basic claim submission
The content of your claim submission depends on your use case and the payer’s requirements. However, a basic claim submission includes the following information in the request body:
| Information | Description |
|---|---|
tradingPartnerServiceId | This is the Payer ID. Visit the Payer Network for a complete list. |
tradingPartnerName | This is the payer’s business name, like Cigna or Aetna. |
submitter object | Information about the entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company. |
receiver object | Information about the payer, such as an insurance company or government agency. |
subscriber and/or dependent objects | Information about the patient who received the medical services. Note that if a dependent has their own, unique member ID for their health plan, you should submit their information in the subscriber object and omit the dependent object from the request. You can check whether the dependent has a unique member ID by submitting an Eligibility Check to the payer for the dependent. The payer will return the member ID in the dependents.memberId field, if present. |
claimInformation object | Information about the claim, such as the patient control number, claim charge amount, and place of service code. It also includes information about each individual service line included in the claim. |
billing object | Information about the billing provider, such as the NPI, taxonomy code, and organization name. |
Character restrictions
Don’t include the following characters in your request data: ~, *, : and ^. They are reserved for delimiters in the resulting X12 EDI transaction, and X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a 400 error if you include these restricted characters in your request.
Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP 400 errors.
The X12 Basic character set includes uppercase letters, digits, space, and some special characters. Lowercase letters and special language characters like ñ are not included.
The following special characters are included:
The Extended character set includes the characters listed in Basic, plus lowercase letters and additional special characters, such as @.
The following additional special characters are included:
Identify service lines
A claim can contain multiple service lines. Since the payer may accept, reject, or pay a subset of those lines, you can receive an 835 response that references a patientControlNumber, but only pertains to some of the service lines.
However, the claimInformation.serviceLines.providerControlNumber serves as a unique identifier for each service line in your claim submission. This value appears in the 277CA and 835 ERA responses as the lineItemControlNumber, allowing you to correlate these responses to specific service lines from the original claim. If you don’t set the providerControlNumber for a service line, Stedi uses a random UUID.
Stedi returns service line identifiers in the claimReference.serviceLines object of the synchronous API response.
Conditional requirements
Note that objects marked as required are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.
For example, you must always include the subscriber object in your request, but you only need to include the supervising object when the rendering provider is supervised by a physician.
Enhanced validation
You can optionally set the Stedi-Validation header to snip for enhanced validation on your claim submission.
Enhanced validation uses hundreds of additional edits (the industry term for validation rules) to increase claim acceptance rates. These include Strategic National Implementation Process (SNIP) validations. Stedi also automatically fixes common errors and monitors payer rejections to proactively build out new rules.
There is an additional cost per claim submission when you use enhanced validation. Please reach out to support for access and pricing information.
Authorizations
A Stedi API Key for authentication.
Headers
The outbound transaction setting ID. This option only needs to be specified if a non-default release of the Professional Claims guide needs to be used.
Set to snip for enhanced validation on this claim. Enhanced validation uses hundreds of additional 'edits' (the industry term for validation rules) to increase claims acceptance rates. Stedi also monitors your 277 rejections to proactively build rules based on previous failures. When possible, Stedi automatically fixes common errors (such as invalid date/time formats and character encoding issues) before sending the claim, reducing payer rejections. There is an additional cost per claim submission when you use enhanced validation. Please reach out to support for access and pricing information.
Body
This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.
1The entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company. You must submit at least organizationName or lastName properties and the contactInformation object. If you don't supply the submitterIdentification property, Stedi uses the value from billing.npi in the request.
Contact information for the person or office handling administrative communications regarding the claim. You can include a maximum of two objects in this array.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
The business name of the organization submitting the claim.
The last name of the individual submitting the claim.
The first name of the individual submitting the claim.
The middle name or initial of the individual submitting the claim.
The submitter's Electronic Transmitter Identification Number (ETIN), as assigned by the payer. For some payers, this may be the same as the submitter's NPI or TIN, but it can also be another unique identifier. Payers can refer to this identifier as the Provider Number, Submitter ID, Submitter Identifier, Submitter Primary Number, Sender Code, Certified Contracted Provider ID, and other names.
If you don't provide this property, Stedi uses the billing provider's NPI from billing.npi property.
The entity responsible for the payment of the claim, such as an insurance company or government agency.
The business name of the payer receiving the claim, such as Aetna or Cigna.
1The person or entity who is the primary policyholder for the health plan or a dependent with their own member ID. The subscriber can be an individual or a business entity.
- When a dependent has a unique, payer-assigned member ID, treat them as the
subscriberfor the claim submission - include their information here and omit thedependentobject from the request. Stedi treats the subscriber as an individual when the request doesn't contain a value for thesubscriber.organizationNameproperty. - You can only set the
dateOfBirthandgenderproperties when the subscriber is the patient. Stedi determines that the subscriber is the patient when thedependentobject is not included in the request. - If either
dateOfBirthorgenderis set, you must include both properties. You can either include both properties or neither within a single request.
The member ID for the subscriber's insurance policy. This property is required if the subscriber is an individual.
2 - 80The subscriber's Social Security Number. This must be a string of exactly nine numbers with no separators. For example, send 111002222 instead of 111-00-2222.
Code identifying the insurance carrier's level of responsibility for a payment of a claim. Stedi sets this property to P - Primary by default.
You only need to include this property when you need to submit codes other than P. This can happen when the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial plan first as P and then bill the Medicare payer second as S. Visit Claims code lists for a complete list of possible codes.
A, B, C, D, E, F, G, H, P, S, T, U The business name of the entity submitting the claim. When the subscriber is an organization, you should identify the patient in the dependent object.
Identifies the type of insurance policy within a specific insurance program. Visit Claims code lists for a complete list.
12, 13, 14, 15, 16, 41, 42, 43, 47 The name of the subscriber's health plan. For example, Cigna or Blue Cross Blue Shield.
The subscriber's first name. This property is recommended when the subscriber is an individual. Some payers reject requests without the firstName property.
The subscriber's last name. This property is required if the subscriber is an individual.
The subscriber's middle name or initial.
The suffix of the subscriber's name, such as Jr. or Sr.
Identifies the subscriber's gender. Can be set to F - Female, M - Male, or U - Unknown. This property is required if the subscriber is an individual.
M, F, U The subscriber's date of birth. Expressed in format YYYYMMDD. This property is required if the subscriber is an individual.
The subscriber's health plan policy number. You should provide either this property OR the groupNumber, not both.
The subscriber's health plan group number. You should provide this property OR the policyNumber, not both.
The patient's address. Every claim must include this information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Only use this object for payer administrative contacts on property and casualty claims. Otherwise, you shoudn't include contact information here. If you include this object, you must supply at least one communication method (phone, fax, or email).
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
Information about the healthcare claim. Note that the objects and properties marked as required are required for all claims, while others are conditionally required, depending on type of claim and claim circumstances. For example, you must always provide the patient's diagnosis codes in the healthCareCodeInformation object, but you only need to provide the otherSubscriberInformation object in coordination of benefits scenarios. When you include a conditionally required object, you must provide all of its required properties.
A code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit Claims code lists for a complete list.
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ An identifier you assign to the claim. It can be up to 20 characters. We strongly recommend submitting a unique value for this property so that you can use it to correlate this claim with responses from the payer, such as the 835 Electronic Remittance Advice (ERA).
The total dollar amount charged for the services on this claim, expressed as a decimal. For example, 100.50. This is the total amount before any adjustments or payments. The amount must balance to the sum of the service line charges.
Code identifying the type of facility where the services were or may be performed. Visit Place of Service Codes for a complete list.
01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 65, 66, 71, 72, 81, 99 Code specifying the frequency of the claim. Can be set to 1 - Admit thru Discharge Claim, 7 - Replacement of Prior Claim, or 8 - Void/Cancel of Prior Claim. Visit the National Uniform Billing Committee for a complete code list and usage notes.
1, 7, 8 Indicates whether the provider's signature is on file. Can be set to N - No or Y - Yes.
N, Y A code indicating whether the patient or an authorized person has assigned benefits to the provider. Use W when the patient refuses to assign benefits. Can be set to N - No, Y - Yes, or W - Not Applicable (use when patient refuses to assign benefits).
N, W, Y Indicates whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to Y - Yes, or I - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues. Use I when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
I, Y Code indicating whether the provider accepts assignment. This refers to whether the provider accepts assignment and/or has a participation agreement with the destination payer. It does not indicate whether the patient has assigned benefits to the provider. Can be set to A - Assigned, B - Assignment Accepted on Clinical Lab Services Only, or C - Not Assigned. Choose A when the provider accepts assignment and/or has a participation agreement with the destination payer, OR the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under the participating provider benefits allowed under certain plans.
A, B, C Details about the patient's healthcare diagnosis. Do not submit the decimal for ICD codes; the decimal is implied. Use ABK as the type for the principal diagnosis code and ABF for any other diagnosis codes you include. One ABK code is required as the first object, and then you can submit up to 11 ABF codes as needed. If you need to submit more codes than this, you must create additional, separate claims.
Code indicating the specific industry code list. Can be set to ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or ABF - International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis.
BK, ABK, BF, ABF The diagnosis code. Do not submit the decimal point for ICD codes. The decimal point is implied. Also, do not submit IDC-10 header codes. Header codes exist to group related codes and are not valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.
Information about one or more services rendered to the patient. Each service line must be a unique procedure. Service lines can share the same dates of service if the patient received multiple services on the same day.
Deprecated; Stedi computes this value for you. This shape is deprecated.
The date the service was rendered (for services performed on a single day), expressed as YYYYMMDD. When you send this property with serviceDateEnd, it will be used as the start date for the date range in which the service was rendered.
The end date of the service period, expressed as YYYYMMDD. If you send this property, you must also send serviceDate.
A unique identifier for this service line within the claim. It appears in the 835 (ERA) response as lineItemControlNumber, allowing you to correlate ERAs to the specific service lines from the original claim. If you don't set this property, Stedi uses a random UUID. Stedi returns service line identifiers in the claimReference.serviceLines.lineItemControlNumber object of the synchronous API response.
Information about the service rendered.
Code identifying the specific industry code list used for the procedureCode. Visit Claims code lists for a complete list.
ER, HC, IV, WK The procedure code.
The total charge amount for the service, including the provider's base charge and any applicable tax or postage. It is acceptable to set this to 0 (zero).
Code identifying the unit of measurement. Can be set to MJ - Minutes or UN - Unit. Minutes is required for anesthesia services. Note that anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel.
MJ, UN The number of units of the service provided, formatted as a decimal.
Diagnosis code pointers in order of importance to this service line. These pointers are an index to the ICD-10 codes you included in the claimInformation.healthCareCodeInformation object array. The pointer values can be from 1 - 12 (integer numbers). You must set at least one pointer for the primary diagnosis. Then, you can add up to three additional pointers (up to four in total). Don't put ICD-10 codes here - they belong in claimInformation.healthCareCodeInformation.
A diagnosis code pointer for this service line.
A modifier code that clarifies or improves the reporting accuracy of the associated procedure code. If not required, do not send.
A free form description to clarify the procedure code and any procedure modifiers, as needed. Can be up to 80 characters.
1 - 80A code identifying the location where services were rendered. Visit Place of Service Codes for a complete list.
Code indicating whether the service was related to an emergency. Can be set to Y - Yes. An emergency is when the patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.
Y Code indicating whether there was EPSDT involvement in the service. Can be set to Y - Yes. EPSDT is a program that provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.
Y Code indicating whether the service was related to family planning. Can be set to Y - Yes.
Y Code indicating whether co-payment requirements were met. Can be set to O - Copay exempt.
0 Information about durable medical equipment. For example, the rental and purchase price information.
The length of medical treatment required.
The rental price for the equipment, expressed as a decimal. For example, 100.50.
The purchase price for the equipment, expressed as a decimal. For example, 100.50.
Code indicating the frequency at which the rental equipment is billed. Can be set to 1 - weekly, 4 - monthly, or 6 - daily.
1, 4, 6 Supporting documentation for the service line. Required when there is a paper attachment following this claim, when attachments are sent electronically, or when the provider needs to identify additional information that is being held at their office and is available upon request.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NM, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
AA, BM, EL, EM, FT, FX The control number assigned to the attachment.
Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN).
Code indicating the timing, transmission method, or format by which attachments will be sent. Required when the actual attachment is maintained by an attachment warehouse or similar vendor. Visit Claims code lists for a complete list. Use code NS when the paperwork is available on request at the provider's site, but is not being sent with the claim at this time.
AB, AD, AF, AG, NS Information about the ambulance service provided to the patient.
Code indicating the reason for ambulance transport. For example, A - Patient was transported to nearest facility for care of symptoms, complaints, or both. Visit Claims code lists for a complete list.
A, B, C, D, E The number of miles the ambulance traveled to transport the patient. Provide this value as a decimal, such as 20.5. Note that 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
The weight of the patient, in pounds, at the time of transport. Provide this value as a decimal, such as 150.5
The reason for the round trip ambulance service.
The reason for usage of a stretcher during ambulance service.
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line.
Code indicating the type of certification. Can be set to I - Initial, R - Renewal, or S - Revised.
I, R, S The length of time the DME equipment is needed.
Code indicating whether there is an ambulance certification.
N, Y 01, 04, 05, 06, 07, 08, 09, 12 Whether the rendering provider is a hospice employee. Required on all Medicare claims involving physician services to hospice patients. Set to true if the rendering provider is a hospice employee, and false if they are not.
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication.
Code indicating whether there is a certification. Can be set to N - No or Y - Yes.
Y, N Code indicating the condition of the certificate. Can be set to 38 - Certification signed by the physician is on file at the supplier's office or ZV - Replacement Item.
38, ZV A second code indicating the condition of the certificate. Can be set to 38 - Certification signed by the physician is on file at the supplier's office or ZV - Replacement Item.
38, ZV Identify specific dates related to the service rendered, formatted as YYYYMMDD.
Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written).
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line.
This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF).
This is the date of the latest visit or consultation.
Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported.
Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported.
Required when billing or reporting products that were shipped.
Required for claims involving spinal manipulation.
Required when this date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology.
The number of patients transported by the ambulance. Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services.
The number of units reported by an anesthesia provider to reflect additional complexity of services.
Required on Dialysis related service lines for ESRD, or required on on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier.
Code identifying the type of measurement. Can be set to OG - Original or TR - Test Results.
OG, TR Code identifying the specific measurement. Can be set to HT - Height, R1 - Hemoglobin, R2 - Hematocrit, R3 - Epoetin Starting Dosage, or R4 - Creatinine.
HT, R1, R2, R3, R4 The value of the measurement.
Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.
Code indicating the type of contract. Can be set to 01 - Diagnosis Related Group (DRG), 02 - Per Diem, 03 - Variable Per Diem, 04 - Flat, 05 - Capitated, 06 - Percent, or 09 - Other.
01, 02, 03, 04, 05, 06, 09 The total dollar amount of the contract, expressed as a decimal. For example, 100.50.
The allowance or charge percent, expressed as a decimal. For example, 0.80.
The contract code. This is an identifier for the contract.
Terms discount percentage, expressed as a decimal, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.
An additional identifier for the contract. Identifies the revision level of a particular format, program, technique or algorithm.
Additional identifiers for the service line.
Required when a repricing (pricing) organization needs to have an identifying number on the service line.
Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line.
The prior authorization number.
This must match the value in claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier.
Sales tax, formatted as a decimal. When you include this property, the total lineItemChargeAmount for this service line must include this sales tax value.
The amount of the postage, formatted as a decimal. When you include this property, the total lineItemChargeAmount for this service line must include this postage value.
Used to send additional data specifically requested by the payer. Not commonly used.
Additional information the provider feels is necessary to substantiate the medical treatment that cannot be provided in other claim properties. Don't use this property to describe non-specific procedure codes.
The provider's goals, rehabilitation potential, or discharge plans for the patient.
Required when the TPO/repricer needs to forward additional information to the payer. Providers shouldn't complete this property.
Specify information about services that were purchased. Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source OR when adjudication is known to be impacted by the acquisition cost of lenses.
This must be the same identifier you provided within claimInformation.serviceLines.purchasedServiceProvider.
The cost of the purchased service.
Repricing information to be completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code indicating the pricing or repricing methodology. Visit Claims code lists for a complete list.
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 The dollar amount, expressed as a decimal. For example, 100.50.
The dollar amount, expressed as a decimal.
The identifier of the organization that repriced the claim.
The pricing rate associated with per diem or flat rate repricing, expressed as a decimal.
The code indicating the type of repricing.
The dollar amount, expressed as a decimal.
Code indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.
T1, T2, T3, T4, T5, T6 Code indicating the policy compliance. Visit Claims code lists for a complete list.
1, 2, 3, 4, 5 Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit Claims code lists for a complete list.
1, 2, 3, 4, 5, 6 To report prescribed drugs and biologics.
Code indicating the source of the drug code or product number. Visit Claims code lists for a complete list.
EN, EO, HI, N4, ON, UK, UP The numeric value of the drug quantity.
Code identifying the unit of measurement. Can be set to F2 - International Unit, GR - Gram, ME - Milligram, ML - Milliliter, or UN - Unit.
F2, GR, ME, ML, UN Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. The link sequence number is a provider assigned number that is unique to this claim. It allows the receiver to piece together the components of the compound.
In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
Information about the provider who rendered the services. This can be a individual or a company (a laboratory or other facility). This is where you should enter the substitute provider's (locum tenens physician) information, if applicable.
Set to the provider matching the object name, with no spaces.
The National Provider Identifier (NPI) assigned to the provider.
The provider's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. If you provider this value, you cannot include the provider's employerId.
The provider's Employer Identification Number (EIN). The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The provider's commercial number.
The provider's location number.
The payer identification number.
The provider's Employer Identification Number (EIN). This field is the same as employerId. The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The National Association of Insurance Commissioners (NAIC) code.
The provider's state license number.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual. You should include either the lastName or organizationName property in this object.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name. You should include either the lastName or organizationName property in this object.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the provider who performed the purchased service. A purchased service provider performs a service on a contractual or reassignment basis for the billing provider. Examples of purchased services include processing a laboratory specimen and performing diagnostic testing services (excluding clinical laboratory testing) subject to Medicare's anti-markup rule. Note that a substitute provider (a locum tenens physician) is not considered a purchased service provider.
Set to PurchasedServiceProvider.
The National Provider Identifier (NPI) assigned to the provider.
The provider's state license number.
The provider's commercial number.
The payer identification number. This must match the value you provided in claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier.
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This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
10This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
This shape is deprecated.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
This shape is deprecated.
This shape is deprecated.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about where the services were rendered. When reporting ambulance services, you should use the ambulancePickUpLocation and ambulanceDropOffLocation properties instead.
The laboratory or facility name. When services were rendered in the patient's home, we recommend setting this to Residence or something similar.
The address of where services were rendered. If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered. Fo example, 'crossroad of State Road 34 and 45'.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The National Provider Identifier (NPI) assigned to the service facility. Only include this property when the service facility is not a component or subpart of the billing provider. Don't include when the service facility is the patient's home.
An identifier for the service facility. The qualifier can be set to OB - State License Number, LU - Location Number, or G2 - Provider Commercial Number.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The telephone extension, if applicable. Only submit the numeric extension. For example, don't include data that indicates an extension, such as 'ext.' or 'x-'.
Information about the provider who oversaw the rendering provider and the care reported in this service line. Include this object when the supervising provider is different than the one listed in the supervising object for the entire claim.
Set to the provider matching the object name, with no spaces.
The National Provider Identifier (NPI) assigned to the provider.
The provider's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. If you provider this value, you cannot include the provider's employerId.
The provider's Employer Identification Number (EIN). The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The provider's commercial number.
The provider's location number.
The payer identification number.
The provider's Employer Identification Number (EIN). This field is the same as employerId. The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The National Association of Insurance Commissioners (NAIC) code.
The provider's state license number.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual. You should include either the lastName or organizationName property in this object.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name. You should include either the lastName or organizationName property in this object.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the provider who requested the services or items reported in this service line.
Set to OrderingProvider.
The National Provider Identifier (NPI) assigned to the provider.
The provider's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators unless otherwise specified by the provider. If you include this value, you cannot include the provider's employerId.
The provider's Employer Identification Number (EIN). The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The provider's Employer Identification Number (EIN). This field is the same as employerId. The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot also include the provider's ssn.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number, formatted as AAABBBCCCC.
The email address.
The phone extension, if applicable.
An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the provider who directed the patient to the rendering provider for care. For example, a primary care provider may refer patients to a specialist. Include this object when the referring provider is different than the one listed in the referring object for the entire claim.
Set to the provider matching the object name, with no spaces.
The National Provider Identifier (NPI) assigned to the provider.
The provider's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. If you provider this value, you cannot include the provider's employerId.
The provider's Employer Identification Number (EIN). The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The provider's commercial number.
The provider's location number.
The payer identification number.
The provider's Employer Identification Number (EIN). This field is the same as employerId. The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn.
The National Association of Insurance Commissioners (NAIC) code.
The provider's state license number.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual. You should include either the lastName or organizationName property in this object.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name. You should include either the lastName or organizationName property in this object.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
The address where the ambulance picked up the patient. If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered. For example Exit near mile marker 123 on I-95.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The address where the ambulance dropped off the patient.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Includes service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers.
The payer ID for the payer responsible for reimbursement.
The amount paid for this service line, expressed as a decimal. Zero (0) is an acceptable value.
The procedure code.
Modifiers that convey special circumstances related to the performance of the service. You can include up to four modifiers in this array.
The meaning of the procedure code.
The number of paid units from the remittance advice. expressed as a decimal. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this property is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
The LX assigned number of the service line into which this service line is bundled. It's only used to bundle service lines.
Required when the payer made line level adjustments which caused the amount paid to differ from the amount originally charged. You can include up to five objects in this array.
Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other Adjustments, PI - Payor Initiated Reductions, or `PR - Patient Responsibility.
CO, CR, OA, PI, PR The date the other payer adjudicated or paid the claim, formatted as YYYYMMDD.
The amount of the service line that the patient is still responsible for, expressed as a decimal.
Code identifying the type of procedureCode. Visit Claims code lists for a complete list.
ER, HC, HP, IV, WK Use this object to attach standardized supplemental information to the claim when required by the payer. One example is payer documentation requirements for home health services.
Code indicating the type of form. Can be set to AS - Form Type Code or UT - Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms. Set this to AS when you plan to include a home health form in the formIdentifier property.
AS, UT A code from the industry code list you identified in formTypeCode.
Use to provide information in response to a coded questionnaire document.
Code indicating a yes or no condition response to the question. Can be set to N - No, W - Not Applicable, or Y - Yes.
N, W, Y A text response to the question.
Date expressed as YYYYMMDD.
Percent formatted as a decimal.
The agency claim number for this transaction. Used when services included in this claim are part of a property and casualty claim.
Code identifying an accompanying cause of an illness, injury or an accident. Can be set to AA - Auto Accident, EM - Employment, or OA - Other Accident. You can include up to two codes in this array.
AA, EM, OA A code identifying the state or province in which the automobile accident occurred. Use this code when relatedCausesCode is set to AA.
AA, EM, OA The country code where the accident occurred. Use when relatedCausesCode = AA and the accident occurred in a country other than US or Canada.
Code indicating the reason for the delay in claim submission. Visit Claims code lists for a complete list.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 The total amount in dollars the patient or their representatives have paid on this claim. For example, 20.50. This includes any co-payments, co-insurance, or other amounts already collected from the patient.
Used to send additional data specifically requested by the payer. Not commonly used.
Used to send additional data specifically requested by the payer. Not commonly used.
Repricing information to be completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code indicating the pricing or repricing methodology. Visit Claims code lists for a complete list.
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 The dollar amount, expressed as a decimal. For example, 100.50.
The dollar amount, expressed as a decimal.
The identifier of the organization that repriced the claim.
The pricing rate associated with per diem or flat rate repricing, expressed as a decimal.
The code indicating the type of repricing.
The dollar amount, expressed as a decimal.
Code indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.
T1, T2, T3, T4, T5, T6 Code indicating the policy compliance. Visit Claims code lists for a complete list.
1, 2, 3, 4, 5 Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit Claims code lists for a complete list.
1, 2, 3, 4, 5, 6 Required when the location for the service is different from the billing provider's address. The purpose of this object is to identify specifically where the service was rendered. This can be healthcare facilities, such as surgical centers or reference labs, OR the patient's address when services were rendered in their home. Don't use this object when reporting ambulance services - use ambulancePickupLocation and ambulanceDropoffLocation instead.
The laboratory or facility name. When services were rendered in the patient's home, we recommend setting this to Residence or something similar.
The address of where services were rendered. If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered. Fo example, 'crossroad of State Road 34 and 45'.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The National Provider Identifier (NPI) assigned to the service facility. Only include this property when the service facility is not a component or subpart of the billing provider. Don't include when the service facility is the patient's home.
An identifier for the service facility. The qualifier can be set to OB - State License Number, LU - Location Number, or G2 - Provider Commercial Number.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The telephone extension, if applicable. Only submit the numeric extension. For example, don't include data that indicates an extension, such as 'ext.' or 'x-'.
The patient's date of death, formatted as YYYYMMDD.
The patient's weight in pounds, such as 150. You should only set this property if the payer specifically requests it, such as for some Medicare DME claims. Otherwise, including this property can trigger claim edits.
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. Can be set to true - Signature generated by provider because the patient was not physically present for services. This means the signature was generated by an entity other than the patient according to State or Federal law. This property is required for claims submitted to Medicare.
Code indicating whether the patient is pregnant. Can be set to Y - Yes.
Y You must provide at least one date related to the claim. For example, the date on which the patient was admitted to the hospital. All dates are formatted as YYYYMMDD.
The date the patient began experiencing acute symptoms for the current illness or condition. Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service.
The date the patient first received treatment for the current illness or condition. Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy.
The date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Required when claims involve services for routine foot care and this date is known to impact the payer's adjudication process.
The date the patient first experienced acute symptoms for a chronic condition. Required when the patientConditionCode = A (Acute Condition) or M (Acute Manifestation of a Chronic Condition), the claim involves spinal manipulation, and the payer is Medicare.
The date of the accident related to this claim. Required when relatedCausesCode is set to AA - Auto Accident or OA - Other Accident. Also required when relatedCausesCode is set to EM - Employment and this claim is the result of an accident.
The date of the patient's last menstrual period. Required when the provider believes the services on this claim are related to the patient's pregnancy.
The date of the patient's last x-ray. Required when claim involves spinal manipulation and an x-ray was taken.
The date of the patient's hearing and vision prescription. Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim.
The start date of the patient's disability period. You can include this date without providing a disabilityEndDate if the patient is currently disabled and the end date is unknown. Used for claims involving disability where the provider judges that the patient was or will be unable to perform the duties normally associated with their work.
The end date of the patient's disability period. You can include this date without including a disabilityStartDate if the patient is no longer disabled and the start date is unknown. Used for claims involving disability where the provider judges that the patient was or will be unable to perform the duties normally associated with their work.
The date the patient last worked, related to disability claims. Required on claims where this information is necessary for adjudication, such as workers compensation claims.
The date the provider has authorized the patient to return to work. Required on claims where this information is necessary for adjudication, such as workers compensation claims.
The date the patient was admitted to the hospital. Required on ambulance claims when the patient was known to be admitted to the hospital. Also required on inpatient claims.
The date the patient was discharged from the hospital. Required for inpatient claims when the patient was discharged from the facility and the discharge date is known
The date the provider filing this claim assumed care from another provider during post-operative care. Required when providers share post-operative care (global surgery claims).
The date the provider filing this claim relinquished post-operative care to another provider. Required when providers share post-operative care (global surgery claims).
The date the repricing entity received the initial claim. Required when a repricer is passing the claim onto the payer.
Date the patient first consulted the provider for their condition by any means. This is not necessarily the same as the initial treatment date. Required for Property and Casualty claims when state mandated.
Additional information or documentation required for the claim.
Required when there is a paper attachment following this claim, when attachments are sent electronically with the claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NM, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
AA, BM, EL, EM, FT, FX The control number assigned to the attachment.
Required when an authorization number is assigned by the payer or UMO and the services on this claim were preauthorized. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information.
Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) and a referral is involved.
Required when the claimFrequencyCode indicates this claim is a replacement or void to a previously adjudicated claim.
Required for all CLIA certified facilities performing CLIA covered laboratory services. When this claim contains both in-house and outsourced laboratory services, use the CLIA Number for laboratory services performed by the billing or rendering provider. You can report outsourced laboratory services in the serviceLines object.
Required when the repricer believes this information is necessary. Providers should not complete this property.
Required when the repricer believes this information is necessary. Providers should not complete this property.
Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, you must split into separate claims.
The claim number assigned by clearinghouse, van, etc. Providers should not complete this property.
Required when mammography services are rendered by a certified mammography provider.
Required when the provider needs to identify the actual medical record of the patient for this episode of care.
Required when it is necessary to identify claims that are atypical in ways such as content, purpose, and/or payment. For example, claims made as the result of a demonstration or a clinical trial.
Required when the physician is billing Medicare for Care Plan Oversight (CPO). This is the number of the home health agency or hospice providing Medicare covered services to the patient.
Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim.
Code indicating the reason for the service authorization exception. Visit Claims code lists for a complete list.
1, 2, 3, 4, 5, 6, 7 Information about the ambulance service provided to the patient.
Code indicating the reason for ambulance transport. For example, A - Patient was transported to nearest facility for care of symptoms, complaints, or both. Visit Claims code lists for a complete list.
A, B, C, D, E The number of miles the ambulance traveled to transport the patient. Provide this value as a decimal, such as 20.5. Note that 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
The weight of the patient, in pounds, at the time of transport. Provide this value as a decimal, such as 150.5
The reason for the round trip ambulance service.
The reason for usage of a stretcher during ambulance service.
Information about a chiropractic service rendered to the patient. Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process.
A code indicating the nature of a patient's condition. Can be set to A - Acute Condition, C - Chronic Condition, ``D- Non-acute, E- Non-Life Threatening,F- Routine,G- Symptomatic, orM` - Acute Manifestation of a Chronic Condition.
A description of the patient's condition.
A, C, D, E, F, G, M Additional description of the patient's condition
Required when the claim involves ambulance transport services.
Code indicating whether there is an ambulance certification.
N, Y 01, 04, 05, 06, 07, 08, 09, 12 Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement.
Identifies the category to which the conditionCode applies. Can be set to E1 - Spectacle Lenses, E2 - Contact Lenses, or E3 - Spectacle Frames.
E1, E2, E3 Code indicating whether there is a certification. Can be set to N - No or Y - Yes.
N, Y Code indicating the reason for the vision services. Visit Claim code lists for a complete list.
L1, L2, L3, L4, L5 Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.
A code identifying the type of contract. Can be set to 01 - Diagnosis Related Group (DRG), 02 - Per Diem, 03 - Variable Per Diem, 04 - Flat, 05 - Capitated, 06 - Percent, or 09 - Other.
01, 02, 03, 04, 05, 06, 09 The total dollar amount of the contract, expressed as a decimal. For example, 100.50.
The allowance or charge percent, expressed as a decimal. For example, 0.80.
The contract code. This is a unique identifier for the contract.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.
An additional identifer for the contract. Identifies the revision level of a particular format, program, technique or algorithm.
Code indicating the Special Program under which the services rendered to the patient were performed. Used for Medicaid claims only. Can be set to 02 - Physically Handicapped Children's Program, 03 - Special Federal Funding, 05 - Disability, or 09 - Second Opinion or Surgery.
02, 03, 05, 09 Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.
Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim.
Code indicating whether an EPSDT referral was given to the patient. Can be set to N - No or Y - Yes.
N, Y Code indicating the patient's status. Set to AV when the patient refused the referral. Set to NU when you set certificationConditionCodeAppliesIndicator to N. Set to S2 when the patient is currently under treatment for the referred diagnostic or corrective health problem. Set to ST when either the patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals) or the patient is scheduled for another appointment with the screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
AV, NU, S2, ST The surgical code. Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code.
Required when condition information applies to the claim. You can include up to 24 codes in the array. Visit the National Uniform Claim Committee for a complete list of possible condition codes.
An array of condition codes.
Comments or special instructions related to the claim. Contains information required to substantiate the medical treatment that isn't provided elsewhere in the claim.
Additional information.
Certification narrative.
Information about goals, rehabilitation potential, or discharge plans.
Additional information about the diagnosis.
Notes from a third-party organization.
The address where the ambulance picked up the patient. If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered. For example Exit near mile marker 123 on I-95.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The address where the ambulance dropped off the patient.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Required when other payers are known to potentially be involved in paying on this claim. This object contains information about other health plans under which the patient has coverage. It's used for coordination of benefits scenarios.
Code identifying the insurance carrier's level of responsibility for a payment of a claim. Visit Claims code lists for a complete list. You may need to use other codes if the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial payer first as P and then bill the Medicare payer second as S.
A, B, C, D, E, F, G, H, P, S, T, U Code identifying the relationship to the person insured. Visit Claims code lists for a complete list.
01, 18, 19, 20, 21, 39, 40, 53, G8 The group or policy number.
The name of the health plan.
Code identifying the type of insurance policy within a specific insurance program. Visit Claims code lists for a complete list.
12, 13, 14, 15, 16, 41, 42, 43, 47 A code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit Claims code lists for a complete list.
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ Use this object to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, you must convert them to standard Claim Adjustment Reason Codes.
Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other Adjustments, PI - Payor Initiated Reductions, or `PR - Patient Responsibility.
CO, CR, OA, PI, PR Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.
The dollar amount of the adjustment, expressed as a decimal. For example, 100.50.
The units of service being adjusted.
The total amount in dollars the payer has paid on this claim. It is acceptable to set this to 0 (Zero). This is required when you include the payToPlan object, and you should set it to the amount the Medicaid agency actually paid.
Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in otherSubscriberInformation.otherPayerName. The amount must equal the total claim charge amount you reported in claimInformation.claimChargeAmount.
This is the remaining amount (as determined by the provider) to be paid after the other payer identified in the otherPayerName object has adjudicated the claim.
Code indicating whether whether or not the insured has authorized the plan to remit payment directly to the provider. Can be set to N - No, W - Not Applicable, or Y - Yes.
N, W, Y Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to I - Informed Consent to Release Medical Information or Y - Yes. Code I is required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Code Y is required when the provider has collected a signature OR when state or federal laws require a signature be collected.
I, Y Information about the provider who directed the patient to the rendering provider for care. For example, a primary care physician may refer patients to a specialist.
An identifier for the referring provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims. You can include up to three objects in this array.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the rendering provider.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
1, 2 An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims. You can include up to three objects in this array.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the service facility location.
A secondary identifier for the service facility location. The qualifier can be set to OB - State License Number, LU - Location Number, or G2 - Provider Commercial Number. You can include up to three objects in this array.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the supervising provider.
An identifier for the supervising provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number or G2` - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims. You can include up to three objects in this array.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Information about the billing provider.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
1, 2 An identifier for the billing provider. The qualifier can be set to LU - Location Number, or G2 - Provider Commercial Number. You can include up to two objects in this array.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. Can be set to true - Signature generated by provider because the patient was not physically present for services. This means the signature was generated by an entity other than the patient according to State or Federal law. This property is required for claims submitted to Medicare.
Claim-level data related to the adjudication of Medicare claims not related to an inpatient setting. Required when outpatient adjudication information is reported in the remittance advice or when you need to report remark codes.
The reimbursement percentage, expressed as a decimal.
The claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount, expressed as a decimal.
The remark code. Visit the X12 Remittance Advice Remark Codes for a complete list. You can include up to five codes in this array.
The End-Stage Renal Disease (ESRD) payment amount, expressed as a decimal.
The professional component amount billed but not payable, expressed as a decimal.
The person or entity who is the primary policyholder for the other payer's health plan.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
1, 2 The primary policyholder's last name or organizational name.
Code identifying the type of identifier. Can be set to II - Standard Unique Health Identifier for each individual in the United States or MI - Member Identification Number. The code MI should be the subscriber's identification number as assigned by the payer, such as their subscriber ID. You should also use MI in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). For IHS/CHS claims, you should also put the SSN in the otherInsuredAdditionalIdentifier property.)
II, MI The identifier you specified in otherInsuredIdentifierTypeCode.
The primary policyholder's first name, if they are an individual.
The primary policyholder's middle name or initial, if they are an individual.
The primary policyholder's name suffix, such as Jr. or III.
The other subscriber's address.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The primary policyholder's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.
Details about the other payer.
The payer's organization name.
Code designating the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
PI, XV The identifier specified in otherPayerIdentifierCode. When sending Line Adjudication Information for this payer, the identifier sent in lineAdjudicationInformation.otherPayerPrimaryIdentifier must match this value.
The payer's address.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The date the other payer adjudicated the claim. Required when this payer has previously adjudicated the claim and you aren’t including a value for LineAdjudicationInformation.adjudicationOrPaymentDate.
An additional identification number to identify the other payer. The qualifier can be set to 2U - Payer Identification Number, EI - Employer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners (NAIC) Code.
The code identifying the type of reference number.
The reference number.
The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the otherPayerName.otherPayerIdentifier property.
The authorization number assigned by this payer.
The referral number assigned by this payer.
The only valid value is true. Required when Required when the claim is being sent in the payer-to-payer COB model AND the destination payer is secondary to this payer AND this payer has re-adjudicated the claim.
The claim control number assigned by this payer.
Information about the billing provider. For tax identification, you must include either the provider's Social Security Number (SSN) or their Employer Identification Number (EIN), but not both.
Set to BillingProvider.
The billing provider's National Provider Identifier (NPI).
The billing provider's Social Security Number. Must be a string of exactly nine numbers with no separators. If you include this value, you cannot include the employerId.
The billing provider's Employer Identification Number. Typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer. If you include this value, you cannot include the ssn.
The billing provider's state license number.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the billing provider's type and/or area of specialty.
10The billing provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Contact information for the billing provider. You can include a maximum of two objects in this array.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
Not currently used.
Dependent who received the medical care associated with the claim. Note that if the dependent has their own member ID for the health plan, you should include the dependent's information in the subscriber object instead. To check whether a dependent has a member ID, submit an Eligibility Check to the payer. The payer returns the dependent's member ID in the dependents.memberId property in the response, if present.
The patient's first name.
The patient's last name.
Code indiciating the patient's gender. Can be set to F - Female, M - Male, or U - Unknown.
M, F, U The patient's date of birth, formatted as YYYYMMDD.
Identifies the relationship of the patient to the subscriber. Can be set to 01 - Spouse, 19 - Child, 20 - Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
01, 19, 20, 21, 39, 40, 53, G8 The patient's middle name or initial.
The patient's name suffix, such as Jr. or III.
The patient's Social Security Number. Only used for Property and Casualty claims. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.
The patient's identification number. Only used in Property and Casualty claims.
The patient's address. Every claim must include this information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Only use this object for payer administrative contacts on property and casualty claims. Otherwise, you shoudn't include contact information here. If you include this object, you must supply at least one communication method (phone, fax, or email).
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
Deprecated; please set all providers individually by type. For example, Referring.
This shape is deprecated.
Set to SupervisingProvider.
The National Provider Identifier (NPI) of the supervising provider. The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards.
The Social Security Number. Must be a string of nine numbers with no separators. If you include this value, you cannot include the provider's employerId.
Employer ID number is typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer. If you include this value, you cannot include the provider's ssn.
The commercial number of the supervising provider.
The location number of the supervising provider.
The state license number of the supervising provider.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The first name of the supervising provider.
The last name of the supervising provider.
The middle name or initial of the supervising provider.
The suffix of the supervising provider's name, such as Jr. or III.
The supervising provider's business name, when the provider is not an individual.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
Use when the address for payment is different than that of the billing provider for this claim.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.
The last name of the individual, or the business name of the pay-to-plan organization.
Code identifying the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
PI, XV The identifier you specified in primaryIdentifierTypeCode.
The address of the pay-to-plan organization.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The Employer Identification Number (EIN). This must be a string of exactly nine numbers with no separators.
9Code identifying the type of secondary identifier. Can be set to 2U - Payer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners. You should only set this to 2U when you set the primaryIdentifierTypeCode to XV.
2U, FY, NF The secondary identifier you specified in secondaryIdentifierTypeCode.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Whether you want to send a test or production claim. This property also allows you to filter claims in the Stedi app by production or test data. By default, this property is set to P for production data. Use T to designate a claim as test data.
Information about the provider who directed the patient to the rendering provider for care. For example, a primary care physician may refer patients to a specialist. Use when the referring provider applies to the entire claim, not just a specific service line.
Set to ReferringProvider.
The National Provider Identifier (NPI) assigned to the provider.
The provider's commercial number.
The provider's state license number.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
Information about the person or company (laboratory or other facility) who rendered the care. Use this object for all types of rendering providers including laboratories. When a substitute provider (locum tenens) was used, enter that provider's information here. Use when the provider applies to the entire claim, not just a specific service line.
Set to RenderingProvider.
The National Provider Identifier (NPI) assigned to the provider.
The provider's commercial number.
The provider's location number.
The provider's state license number.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual. You must include either the lastName or organizationName property in this object.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name, if the provider is an organization. You must include either the lastName or organizationName property in this object.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
Deprecated; please use claimInformation.serviceLines.orderingProvider instead.
This shape is deprecated.
10The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
The entity responsible for overseeing the rendering provider and the care reported in this claim. Applies when the rendering provider is supervised by a physician. Use when the provider applies to the entire claim, not just a specific service line.
Set to SupervisingProvider.
The National Provider Identifier (NPI) of the supervising provider. The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards.
The Social Security Number. Must be a string of nine numbers with no separators. If you include this value, you cannot include the provider's employerId.
Employer ID number is typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer. If you include this value, you cannot include the provider's ssn.
The commercial number of the supervising provider.
The location number of the supervising provider.
The state license number of the supervising provider.
Deprecated; do not use. This shape is deprecated.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.
10The first name of the supervising provider.
The last name of the supervising provider.
The middle name or initial of the supervising provider.
The suffix of the supervising provider's name, such as Jr. or III.
The supervising provider's business name, when the provider is not an individual.
The first line of the street address. This typically contains the building number and street name.
The city name.
The second line of the street address. This typically contains the apartment or suite number.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
You must include at least one communication method (phone, fax, or email) in this object.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The fax number.
The email address.
The phone extension, if applicable.
This is the payer's business name, like Cigna or Aetna.
Response
The status of the claim submission.
An identifier for the transaction.
An ID for the payer you identified in the original claim. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.
Information about the claim.
An identifier Stedi assigns to the claim.
Stedi's ID for the entity that submitted the claim.
A tracking number that Stedi assigns to the claim.
The patientControlNumber from the original request, if supplied. This is a unique identifier that you assign to the claim so you can track the claim and correlate it with responses from the payer.
A timestamp for Stedi's response to the claim submission.
The type of claim, currently not used.
The ID of the payer. This is the same as the tradingPartnerServiceId.
The X12 EDI version Stedi used to generate the claim for the payer. This is always 5010.
A tracking number Stedi assigns to the claim. This is the same as the correlationId.
Contains a unique identifier for each service line, listed in the order the service lines were included in the claim. You can use these identifiers to correlate payer responses to specific service lines.
A unique identifier for the service line, matching the value provided for the claimInformation.serviceLines.providerControlNumber property in the claim submission. If you didn't provide a value for providerControlNumber, this property contains a randomly generated a UUID for the service line.
A list of errors. Currently not used.
The field related to the error.
The value for the data causing the error.
The error code.
The description of the error code.
Recommended followup actions to correct the error.
Where the error is located in the original request.
A 200 response indicates that Stedi successfully generated the X12 EDI claim format required by the payer. It does not indicate whether the payer has accepted the claim - the payer will respond later with a 277CA containing this information. Learn more about 277CAs. A 400 response indicates one or more problems with the claim data in the request. Examples include missing required fields, invalid values, or incorrect data types. The response includes a message describing the problem.
200 OK, 400 BAD_REQUEST Metadata from Stedi about the request.
The submitter ID assigned to this request.
The sender ID assigned to this request.
The biller ID assigned to this request.
The file execution ID, a unique identifier assigned to the processed file within the Stedi platform.
Indicates where this request can be found for support.
Currently not used.
Currently not used.
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