EDI 275 X210 - Patient Information

Functional Group PI

X12N Insurance Subcommittee

j4

Heading

1. 0100 · ST · 275 Transaction Header · Max 1 · Mandatory

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

2. 0200 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set

3. 1000A Loop Mandatory Repeat 1

   1. 0500 · NM1 · Payer Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

   2. 0900 · PER · Payer Contact Information · Max 1 · Optional

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

      Required when the value in BGN01 is 11 and the Payer Response Contact Information (PER Segment) was reported in the 2210D loop of the 277 transaction. If not required by this implementation guide, do not send.
      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The telephone extension, when applicable, should be included in the next sequential communication number data element.

4. 1000B Loop Mandatory Repeat 1

   1. 0500 · NM1 · Submitter Information · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

5. 1000C Loop Mandatory Repeat 1

   1. 0500 · NM1 · Provider Name Information · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

      In the solicited 275 model, the information from the 2100C NM1 segment of the 277 must be returned in this segment.
      In the unsolicited 275 model, the billing provider information must be sent in this segment.

   2. 0800 · PRV · Provider Taxonomy Information · Max 1 · Optional

      To specify the identifying characteristics of a provider

      Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.

   3. 1000 · REF · Provider Secondary Identification · Max 1 · Optional

      To specify identifying information

      Required when the provider is not covered under the NPI mandate. If not required by this implementation guide, do not send.

   4. 1100C Loop Mandatory Repeat 1

      1. 1100 · NX1 · Provider Identification · Max 1 · Mandatory

         To define the attributes of a property or an entity

         The provider address information in this loop applies to the provider information listed in the 1000C loop.

      2. 1200 · N3 · Provider Address · Max 1 · Mandatory

         To specify the location of the named party

      3. 1300 · N4 · Provider City, State, ZIP Code · Max 1 · Mandatory

         To specify the geographic place of the named party

6. 1000D Loop Mandatory Repeat 1

   1. 0500 · NM1 · Patient Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

   2. 1000 · REF · Patient Control Number · Max 1 · Mandatory

      To specify identifying information

      When the value in BGN01 of the 275 is 02, the Patient Control Number must be the same number as reported in CLM01 of the 2300 loop in the 837. When the value in BGN01 is 11, the Patient Control Number must be the same number as reported in REF02 of the 2200D loop in the 277.

   3. 1000 · REF · Institutional Type Of Bill · Max 1 · Optional

      To specify identifying information

      Required when the Institutional Type of Bill from the submitted claim is available in the payer's system and is included in the 2200D REF segment of the 277. If not required by this implementation guide, do not send.

   4. 1000 · REF · Medical Record Identification Number · Max 1 · Optional

      To specify identifying information

      Required when the Medical Record Identification Number is submitted on the original claim. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

   5. 1000 · REF · Claim Identification Number for Clearinghouses and Other Transmission Intermediaries · Max 1 · Optional

      To specify identifying information

      Required when this claim identification number is sent in the 2200D REF segment of the 277. If not required by this implementation guide, do not send.
      Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, trading partners are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.

   6. 1050 · DTP · Claim Service Date · Max 1 · Optional

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

      Required when the information submitted or requested applies to the entire claim. If not required by this implementation guide, may be provided at the sender's discretion but can not be required by the receiver.

Detail

1. 2000A Loop Mandatory Repeat >1

   1. 0100 · LX · Assigned Number · Max 1 · Mandatory

      To reference a line number in a transaction set

      Within the LX, LX01 is the sequence number of the segments that follow. The LX01 sequence number must start at 1 and increment by 1.
      The LX segment can be repeated to respond to multiple questions on an individual claim. The 275 transaction structure only allows the submitter to send one claim in each 275. A separate Transaction Set Header/Trailer (ST/SE) must be sent for each claim.

   2. 0150 · TRN · Payer Claim Control Number/Provider Attachment Control Number · Max 1 · Mandatory

      To uniquely identify a transaction to an application

      Payer Claim Control Number is the value from the TRN segment loop 2200D of the 277 when in response to a solicited request.
      The TRN02 value must be the same in each iteration of the 2000A loop when the value in TRN02 is the Payer claim control number.
      For the unsolicited 275, the Attachment Control Number is the value from PWK06 loop 2300 of the 837. This is the main matching criteria and must be unique on a per attachment basis.

   3. 0175 · STC · Status Information · Max 1 · Optional

      To report the status, required action, and paid information of a claim or service line

      Required when the value in BGN01 is 11 (Response). If not required by this implementation guide, do not send.

   4. 0500 · REF · Service Line Item Identification · Max 1 · Optional

      To specify identifying information

      Required when the additional information is associated with the service line or revenue line information. If not required by this implementation guide, do not send.
      If this segment is used, then there will be a REF segment that contains the Procedure Code or Revenue Code.

   5. 0500 · REF · Procedure or Revenue Code · Max 1 · Optional

      To specify identifying information

      This segment will convey service line or revenue code information that is associated with the additional information. This matches the value in the 837 SV101-2, SV201-2, or SV301-2 or the 277 SVC01-2 or SVC04.
      Required when the additional information is associated with the service line or revenue line information. If not required by this implementation guide, do not send.

   6. 0500 · REF · Procedure Code Modifier · Max 1 · Optional

      To specify identifying information

      Required when the procedure code submitted on the original claim include modifiers. If not required by this implementation guide, do not send.
      The procedure code modifiers should be reported in the same order as on the original claim.

   7. 2100A Loop Optional Repeat 1

      1. 0600 · DTP · Service Line Date of Service · Max 1 · Mandatory

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

         Required when the date of service is not reported at the claim level. If not required by this implementation guide, do not send.

   8. 2100B Loop Mandatory Repeat 1

      1. 0600 · DTP · Additional Information Submission Date · Max 1 · Mandatory

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

      2. 0700 · CAT · Category of Patient Information Service · Max 1 · Mandatory

         To specify categories of patient information service

      3. 2110B Loop Mandatory Repeat 1

         1. 0900 · EFI · Electronic Format Identification · Max 1 · Mandatory

            To provide basic information about the electronic format of the interchange data

         2. 1000 · BIN · Binary Data Segment · Max 1 · Mandatory

            To transfer binary data in a single data segment and allow identification of the end of the data segment through a count; there is no identification of the internal structure of the binary data in this segment

            This segment is used to attach the data referenced in the CAT02 element.

2. 1100 · SE · 275 Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)