Claims code lists
You may need to reference the following code lists when submitting claims through Stedi clearinghouse. Note that this page doesn’t contain every code list in the professional and institutional claim specifications; it only contains code lists that are too long to represent clearly within the API reference documentation.
Ambulance Certification Condition Codes
Used in the Professional Claims claimInformation.ambulanceCertification.conditionCodes
property.
01
- Patient was admitted to a hospital04
- Patient was moved by stretcher05
- Patient was unconscious or in shock06
- Patient was transported in an emergency situation07
- Patient had to be physically restrained08
- Patient had visible hemorrhaging09
- Ambulance service was medically necessary12
- Patient is confined to a bed or chair; use to indicate that the patient was bedridden during transport
Ambulance Transport Reason Codes
Used in the Professional Claims claimInformation.ambulanceTransportInformation.ambulanceTransportReasonCode
property.
A
- Patient was transported to nearest facility for care of symptoms, complaints, or bothB
- Patient was transported for the benefit of a preferred physicianC
- Patient was transported for the nearness of family membersD
- Patient was transported for the care of a specialist or for availability of specialized equipmentE
- Patient Transferred to Rehabilitation Facility
Attachment Report Type Codes
Used in the Professional Claims claimInformation.serviceLines.serviceLineSupplementalInformation.attachmentReportTypeCode
property.
Used in the Institutional Claims claimInformation.claimSupplementalInformation.reportInformation.attachmentReportTypeCode
property.
03
- Report Justifying Treatment Beyond Utilization Guidelines04
- Drugs Administered05
- Treatment Diagnosis06
- Initial Assessment07
- Functional Goals08
- Plan of Treatment09
- Progress Report10
- Continued Treatment11
- Chemical Analysis13
- Certified Test Report15
- Justification for Admission21
- Recovery PlanA3
- Allergies/Sensitivities DocumentA4
- Autopsy ReportAM
- Ambulance CertificationAS
- Admission SummaryB2
- PrescriptionB3
- Physician OrderB4
- Referral FormBR
- Benchmark Testing ResultsBS
- BaselineBT
- Blanket Test ResultsCB
- Chiropractic JustificationCK
- Consent Form(s)CT
- CertificationD2
- Drug Profile DocumentDA
- Dental ModelsDB
- Durable Medical Equipment PrescriptionDG
- Diagnostic ReportDJ
- Discharge Monitoring ReportDS
- Discharge SummaryEB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)HC
- Health CertificateHR
- Health Clinic RecordsI5
- Immunization RecordIR
- State School Immunization RecordsLA
- Laboratory ResultsM1
- Medical Record AttachmentMT
- ModelsNN
- Nursing NotesOB
- Operative NoteOC
- Oxygen Content Averaging ReportOD
- Orders and Treatments DocumentOE
- Objective Physical Examination (including vital signs) DocumentOX
- Oxygen Therapy CertificationOZ
- Support Data for ClaimP4
- Pathology ReportP5
- Patient Medical History DocumentPE
- Parenteral or Enteral CertificationPN
- Physical Therapy NotesPO
- Prosthetics or Orthotic CertificationPQ
- Paramedical ResultsPY
- Physician’s ReportPZ
- Physical Therapy CertificationRB
- Radiology FilmsRR
- Radiology ReportsRT
- Report of Tests and Analysis ReportRX
- Renewable Oxygen Content Averaging ReportSG
- Symptoms DocumentV5
- Death NotificationXP
- Photographs
Attachment Transmission Codes
Used in the Professional Claims claimInformation.serviceLines.durableMedicalEquipmentCertificateOfMedicalNecessity.attachmentTransmissionCode
property.
AB
- Previously Submitted to PayerAD
- Certification Included in this ClaimAF
- Narrative Segment Included in this ClaimAG
- No Documentation is RequiredNS
- Not Specified; Paperwork is available on request at the provider’s site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
Claim Filing Indicator Codes
Used in the Professional Claims claimInformation.claimFilingCode
and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode
properties.
Used in the Institutional Claims claimInformation.claimFilingCode
and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode
properties.
11
- Other Non-Federal Programs12
- Preferred Provider Organization (PPO)13
- Point of Service (POS)14
- Exclusive Provider Organization (EPO)15
- Indemnity Insurance16
- Health Maintenance Organization (HMO) Medicare Risk17
- Dental Maintenance OrganizationAM
- Automobile MedicalBL
- Blue Cross/Blue ShieldCH
- ChampusCI
- Commercial Insurance Co.DS
- DisabilityFI
- Federal Employees ProgramHM
- Health Maintenance OrganizationLM
- Liability MedicalMA
- Medicare Part AMB
- Medicare Part BMC
- MedicaidOF
- Other Federal Program; Use when submitting Medicare Part D claimsTV
- Title VVA
- Veterans Affairs PlanWC
- Workers’ Compensation Health ClaimZZ
- Mutually Defined; Use when Type of Insurance is not known
Claim Pricing (Institutional Claims)
For properties in the Institutional Claims claimInformation.claimPricingInformation
object.
Exception Codes
Used in the Institutional Claims claimInformation.claimPricingInformation.exceptionCode
property.
1
- Non-Network Professional Provider in Network Hospital2
- Emergency Care3
- Services or Specialist not in Network4
- Out-of-Service Area5
- State Mandates6
- Other
Policy Compliance Codes
Used in the Institutional Claims claimInformation.claimPricingInformation.policyComplianceCode
property.
1
- Procedure Followed (Compliance)2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)4
- Not Followed Other (Non-Compliance Other)5
- Emergency Admit to Non-Network Hospital
Pricing Methodology Codes
Used in the Institutional Claims claimInformation.claimPricingInformation.pricingMethodologyCode
property.
00
- Zero Pricing (Not Covered Under Contract)01
- Priced as Billed at 100%02
- Priced at the Standard Fee Schedule03
- Priced at a Contractual Percentage04
- Bundled Pricing05
- Peer Review Pricing06
- Per Diem Pricing07
- Flat Rate Pricing08
- Combination Pricing09
- Maternity Pricing10
- Other Pricing11
- Lower of Cost12
- Ratio of Cost13
- Cost Reimbursed14
- Adjustment Pricing
Product or Service ID Qualifier Codes
Used in the Institutional Claims claimInformation.claimPricingInformation.productOrServiceIDQualifier
property.
ER
- Jurisdiction Specific Procedure and Supply Codes; Not allowed for use under HIPAA. You can only use this code if a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes; Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported under HC.HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate CodeIV
- Home Infusion EDI Coalition (HIEC) Product/Service Code; Not allowed for use under HIPAA. You can only use this qualifier if a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.WK
- Advanced Billing Concepts (ABC) Codes; Approved by the Secretary of HHS as a pilot project allowed under HIPAA law. Only parties registered in the pilot project and their trading partners can use this qualifier in transactions covered by HIPAA. Otherwise, you can only use this code if a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA OR for claims not covered by HIPAA.
Reject Reason Codes
Used in the Institutional Claims claimInformation.claimPricingInformation.rejectReasonCode
property.
T1
- Cannot Identify Provider as TPO (Third Party Organization) ParticipantT2
- Cannot Identify Payer as TPO (Third Party Organization) ParticipantT3
- Cannot Identify Insured as TPO (Third Party Organization) ParticipantT4
- Payer Name or Identifier MissingT5
- Certification Information MissingT6
- Claim does not contain enough information for re-pricing
Composite Medical Procedure - Product or Service ID Qualifier Codes
Used in the Professional Claims claimInformation.serviceLines.lineAdjudicationInformation.serviceIdQualifier
and claimInformation.serviceLines.professionalService.procedureIdentifier
properties.
ER
- Jurisdiction Specific Procedure and Supply Codes; Not allowed for use under HIPAA. You can only use this code if a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes; Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported under HC.IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code; Not allowed for use under HIPAA. You can only use this qualifier if a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.WK
- Advanced Billing Concepts (ABC) Codes; Approved by the Secretary of HHS as a pilot project allowed under HIPAA law. Only parties registered in the pilot project and their trading partners can use this qualifier in transactions covered by HIPAA. Otherwise, you can only use this code if a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA OR for claims not covered by HIPAA.
Delay Reason Codes
Used in the Professional Claims claimInformation.delayReasonCode
property.
Used in the Institutional Claims claimInformation.delayReasonCode
property.
1
- Proof of Eligibility Unknown or Unavailable2
- Litigation3
- Authorization Delays4
- Delay in Certifying Provider5
- Delay in Supplying Billing Forms6
- Delay in Delivery of Custom-made Appliances7
- Third Party Processing Delay8
- Delay in Eligibility Determination9
- Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules10
- Administration Delay in the Prior Approval Process11
- Other15
- Natural Disaster
Drug Identification Product or Service ID Qualifier Codes
Used in the Professional Claims claimInformation.serviceLines.drugIdentification.serviceIdQualifier
property.
EN
- EAN/UCC - 13EO
- EAN/UCC - 8HI
- HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data MessageN4
- National Drug Code in 5-4-2 FormatON
- Customer Order NumberUK
- GTIN 14-digit Data StructureUP
- UCC - 12
Individual Relationship Codes
Used in the Professional Claims claimInformation.otherSubscriberInformation.individualRelationshipCode
property.
Used in the claimInformation.otherSubscriberInformation.individualRelationshipCode
property.
01
- Spouse18
- Self19
- Child20
- Employee21
- Unknown39
- Organ Donor40
- Cadaver Donor53
- Life PartnerG8
- Other Relationship
Insurance Type Codes
Used in the Professional Claims subscriber.insuranceTypeCode
and claimInformation.otherSubscriberInformation.insuranceTypeCode
properties.
12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan14
- Medicare Secondary, No-fault Insurance including Auto is Primary15
- Medicare Secondary Worker’s Compensation16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency41
- Medicare Secondary Black Lung42
- Medicare Secondary Veteran’s Administration43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)47
- Medicare Secondary, Other Liability Insurance is Primary
Payment Responsibility Sequence Number Codes
Used in the Professional Claims subscriber.paymentResponsibilityLevelCode
and claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode
properties.
Used in the Insititutional Claims claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode
property.
A
- Payer Responsibility FourB
- Payer Responsibility FiveC
- Payer Responsibility SixD
- Payer Responsibility SevenE
- Payer Responsibility EightF
- Payer Responsibility NineG
- Payer Responsibility TenH
- Payer Responsibility ElevenP
- PrimaryS
- SecondaryT
- TertiaryU
- Unknown; This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.
Service Authorization Exception Codes
Used in the Professional Claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode
property.
Used in the Institutional Claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode
property.
1
- Immediate/Urgent Care2
- Services Rendered in a Retroactive Period3
- Emergency Care4
- Client has Temporary Medicaid5
- Request from County for Second Opinion to Determine if Recipient Can Work6
- Request for Override Pending7
- Special Handling
Service Line Repricing (Professional Claims)
For properties in the Professional Claims claimInformation.serviceLines.linePricingRepricingInformation
object.
Exception Codes
Used in the Professional Claims claimInformation.serviceLines.linePricingRepricingInformation.exceptionCode
property.
1
- Non-Network Professional Provider in Network Hospital2
- Emergency Care3
- Services or Specialist not in Network4
- Out-of-Service Area5
- State Mandates6
- Other
Policy Compliance Codes
Used in the Professional Claims claimInformation.serviceLines.linePricingRepricingInformation.policyComplianceCode
property.
1
- Procedure Followed (Compliance)2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)4
- Not Followed Other (Non-Compliance Other)5
- Emergency Admit to Non-Network Hospital
Pricing Methodology Codes
Used in the Professional Claims claimInformation.serviceLines.linePricingRepricingInformation.pricingMethodologyCode
property.
00
- Zero Pricing (Not Covered Under Contract)01
- Priced as Billed at 100%02
- Priced at the Standard Fee Schedule03
- Priced at a Contractual Percentage04
- Bundled Pricing05
- Peer Review Pricing07
- Flat Rate Pricing08
- Combination Pricing09
- Maternity Pricing10
- Other Pricing11
- Lower of Cost12
- Ratio of Cost13
- Cost Reimbursed14
- Adjustment Pricing
Reject Reason Codes
Used in the Professional Claims claimInformation.serviceLines.linePricingRepricingInformation.rejectReasonCode
property.
T1
- Cannot Identify Provider as TPO (Third Party Organization) ParticipantT2
- Cannot Identify Payer as TPO (Third Party Organization) ParticipantT3
- Cannot Identify Insured as TPO (Third Party Organization) ParticipantT4
- Payer Name or Identifier MissingT5
- Certification Information MissingT6
- Claim does not contain enough information for re-pricing
Vision Condition Codes
Used in the Professional Claims claimInformation.patientConditionInformationVision.conditionCodes
property.
L1
- General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change MetL2
- Replacement Due to Loss or TheftL3
- Replacement Due to Breakage or DamageL4
- Replacement Due to Patient PreferenceL5
- Replacement Due to Medical Reason
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