ADI Health care claim adjudication information

To provide adjudication information for all services in a health care claim.

Position

Element

Name

Type

Requirement

Min

Max

Repeat

010 E206 Object identification Composite (composite) Mandatory 3

010 · 7402 · Object identifier · String (AN) · Mandatory · 1 · 35 · -

Code specifying the unique identity of an object.

020 · 7405 · Object identification code qualifier · String (AN) · Conditional · 1 · 3 · -

Code qualifying the identification of an object.

1 Element marked for deletion for interactive use in D.01A and replaced by NME/E012. 2 Usage indicator will revert to (B) in D.01A.

030 · 4405 · Status description code · String (AN) · Conditional · 1 · 3 · -

Code specifying a status.

1 For transport status, use UN/ECE Recommendation 24.

020 E021 Service Composite (composite) Conditional 3

010 · 7135 · Product identifier · String (AN) · Mandatory · 1 · 35 · -

To identify a product.

020 · 1131 · Code list identification code · String (AN) · Conditional · 1 · 3 · -

Code identifying a code list.

030 · 9629 · Procedure modification code · String (AN) · Conditional · 1 · 3 · -

Code specifying the procedure modification.

040 · 9629 · Procedure modification code · String (AN) · Conditional · 1 · 3 · -

Code specifying the procedure modification.

050 · 9629 · Procedure modification code · String (AN) · Conditional · 1 · 3 · -

Code specifying the procedure modification.

060 · 9629 · Procedure modification code · String (AN) · Conditional · 1 · 3 · -

Code specifying the procedure modification.

030 · 1229 · Action request/notification description code · String (AN) · Conditional · 1 · 3 · 1

Code specifying the action to be taken or already taken.

040 E017 Monetary amount Composite (composite) Conditional 15

010 · 5025 · Monetary amount type code qualifier · String (AN) · Conditional · 1 · 3 · -

Code qualifying the type of monetary amount.

020 · 5004 · Monetary amount · Numeric (N) · Conditional · 1 · 35 · -

To specify a monetary amount.

030 · 6345 · Currency identification code · String (AN) · Conditional · 1 · 3 · -

Code specifying a monetary unit.

1 Use ISO 4217 three alpha code.

040 · 6343 · Currency type code qualifier · String (AN) · Conditional · 1 · 3 · -

Code qualifying the type of currency.

050 · 4405 · Status description code · String (AN) · Conditional · 1 · 3 · -

Code specifying a status.

1 For transport status, use UN/ECE Recommendation 24.

050 · 6060 · Quantity · String (AN) · Conditional · 1 · 35 · 3

Alphanumeric representation of a quantity.

060 E030 Adjustment information Composite (composite) Conditional 15

010 · 9619 · Adjustment category code · String (AN) · Mandatory · 1 · 3 · -

Code specifying the general category of adjustment.

020 · 4465 · Adjustment reason description code · String (AN) · Mandatory · 1 · 3 · -

Code specifying the adjustment reason.

030 · 5004 · Monetary amount · Numeric (N) · Conditional · 1 · 35 · -

To specify a monetary amount.

070 · 9620 · Policy limitation identifier · String (AN) · Conditional · 1 · 10 · 4

Code specifying a policy limitation.

080 · 5389 · Product group name code · String (AN) · Conditional · 1 · 25 · 1

Code specifying the name of a product group.

1 User or association defined code may be used in combination with 1131/3055.

090 E507 Date/time/period Composite (composite) Conditional 1

010 · 2005 · Date or time or period function code qualifier · String (AN) · Mandatory · 1 · 3 · -

Code qualifying the function of a date, time or period.

020 · 2380 · Date or time or period value · String (AN) · Conditional · 1 · 35 · -

The value of a date, a date and time, a time or of a period in a specified representation.

030 · 2379 · Date or time or period format code · String (AN) · Conditional · 1 · 3 · -

Code specifying the representation of a date, time or period.

100 · 9639 · Diagnosis category code · String (AN) · Conditional · 1 · 3 · 1

Code specifying a diagnosis category.

110 · 5482 · Percentage · Numeric (N) · Conditional · 1 · 10 · 1

To specify a percentage.