ITC Institutional claim

To provide specific claim information for services performed while admitted to an institution.

Position

Element

Name

Type

Requirement

Min

Max

Repeat

010 E027 Invoice type Composite (composite) Mandatory 1

010 · 9631 · Invoice type code · String (AN) · Mandatory · 1 · 3 · -

Code specifying the type of invoice.

020 · 2013 · Frequency code · String (AN) · Conditional · 1 · 3 · -

Code specifying the rate of recurrence.

020 · 6060 · Quantity · String (AN) · Mandatory · 1 · 35 · 4

Alphanumeric representation of a quantity.

030 E026 Admission Composite (composite) Mandatory 1

010 · 9445 · Admission type description code · String (AN) · Conditional · 1 · 3 · -

Code specifying the type of admission.

020 · 9627 · Admission source code · String (AN) · Conditional · 1 · 3 · -

Code specifying the source of admission.

040 · 9447 · Discharge type description code · String (AN) · Mandatory · 1 · 3 · 1

Code specifying the type of discharge.

050 E025 Basis of service information Composite (composite) Conditional 9

010 · 9641 · Service basis code qualifier · String (AN) · Mandatory · 1 · 3 · -

Code qualifying the basis on which a service is performed.

020 · 7135 · Product identifier · String (AN) · Mandatory · 1 · 35 · -

To identify a product.

030 · 1131 · Code list identification code · String (AN) · Conditional · 1 · 17 · -

Code identifying a user or association maintained code list.

1 The codes for this data element are provided by the code list responsible agency defined in data element 3055.

040 · 2380 · Date or time or period text · String (AN) · Conditional · 1 · 35 · -

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

050 · 2379 · Date or time or period format code · String (AN) · Conditional · 1 · 3 · -

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

060 · 5004 · Monetary amount · Numeric (N) · Conditional · 1 · 35 · -

To specify a monetary amount.