EDI 837 X222A2 - Health Care Claim: Professional

Functional Group HC

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

What is an EDI 837?

An EDI 837 Healthcare Claim communicates a patient's healthcare claim, sent from healthcare agencies to insurance providers. It contains information about the patient (SBR segment), the provider (PRV segment), services provided and the cost of the treatment (CLM segment). It must be HIPAA 5010 compliant.

How is an EDI 837 used?

For example, when Person A receives an x-ray, Hospital B will issue an EDI 837 Healthcare Claim to Medical Insurance Provider C. Insurance Provider C will respond to the EDI 837 Healthcare Claim an EDI 835 Health Care Claim Payment/Advice to provide payment or further details.

Heading

1. 0050 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 0100 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

   To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

   The second example denotes the case where the entire transaction set contains ENCOUNTERS.

3. 1000A Loop Mandatory Repeat 1

   1. 0200 · NM1 · Submitter Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

      The submitter is the entity responsible for the creation and formatting of this transaction.

   2. 0450 · PER · Submitter EDI Contact Information · Max 2 · Mandatory

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

      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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
      The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
      There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.

4. 1000B Loop Mandatory Repeat 1

   1. 0200 · NM1 · Receiver Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

Detail

1. 2000A Loop Mandatory Repeat >1

   1. 0010 · HL · Billing Provider Hierarchical Level · Max 1 · Mandatory

      To identify dependencies among and the content of hierarchically related groups of data segments

   2. 0030 · PRV · Billing Provider Specialty 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. 0100 · CUR · Foreign Currency Information · Max 1 · Optional

      To specify the currency (dollars, pounds, francs, etc.) used in a transaction

      Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.
      It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.

   4. 2010AA Loop Mandatory Repeat 1

      1. 0150 · NM1 · Billing Provider Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
         Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
         The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
         The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
         When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.

      2. 0250 · N3 · Billing Provider Address · Max 1 · Mandatory

         To specify the location of the named party

         The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.

      3. 0300 · N4 · Billing Provider City, State, ZIP Code · Max 1 · Mandatory

         To specify the geographic place of the named party

      4. 0350 · REF · Billing Provider Tax Identification · Max 1 · Mandatory

         To specify identifying information

         This is the tax identification number (TIN) of the entity to be paid for the submitted services.

      5. 0350 · REF · Billing Provider UPIN/License Information · Max 2 · Optional

         To specify identifying information

         Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
         Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification.

      6. 0400 · PER · Billing Provider Contact Information · Max 2 · Optional

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

         Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
         There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.

   5. 2010AB Loop Optional Repeat 1

      1. 0150 · NM1 · Pay-to Address Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
         The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.

      2. 0250 · N3 · Pay-to Address - ADDRESS · Max 1 · Mandatory

         To specify the location of the named party

      3. 0300 · N4 · Pay-To Address City, State, ZIP Code · Max 1 · Mandatory

         To specify the geographic place of the named party

   6. 2010AC Loop Optional Repeat 1

      1. 0150 · NM1 · Pay-To Plan Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Required when willing trading partners agree to use this implementation for their subrogation payment requests.
         This loop may only be used when BHT06 = 31.

      2. 0250 · N3 · Pay-to Plan Address · Max 1 · Mandatory

         To specify the location of the named party

      3. 0300 · N4 · Pay-To Plan City, State, ZIP Code · Max 1 · Mandatory

         To specify the geographic place of the named party

      4. 0350 · REF · Pay-to Plan Secondary Identification · Max 1 · Optional

         To specify identifying information

         Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

      5. 0350 · REF · Pay-To Plan Tax Identification Number · Max 1 · Mandatory

         To specify identifying information

   7. 2000B Loop Mandatory Repeat >1

      1. 0010 · HL · Subscriber Hierarchical Level · Max 1 · Mandatory

         To identify dependencies among and the content of hierarchically related groups of data segments

         If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used.
         If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are required.

      2. 0050 · SBR · Subscriber Information · Max 1 · Mandatory

         To record information specific to the primary insured and the insurance carrier for that insured

      3. 0070 · PAT · Patient Information · Max 1 · Optional

         To supply patient information

         Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send.

      4. 2010BA Loop Mandatory Repeat 1

         1. 0150 · NM1 · Subscriber Name · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

            In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.

         2. 0250 · N3 · Subscriber Address · Max 1 · Optional

            To specify the location of the named party

            Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.

         3. 0300 · N4 · Subscriber City, State, ZIP Code · Max 1 · Optional

            To specify the geographic place of the named party

            Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.

         4. 0320 · DMG · Subscriber Demographic Information · Max 1 · Optional

            To supply demographic information

            Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.

         5. 0350 · REF · Subscriber Secondary Identification · Max 1 · Optional

            To specify identifying information

            Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

         6. 0350 · REF · Property and Casualty Claim Number · Max 1 · Optional

            To specify identifying information

            Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
            This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
            This segment is not a HIPAA requirement as of this writing.

         7. 0400 · PER · Property and Casualty Subscriber Contact Information · Max 1 · Optional

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

            Required for Property and Casualty claims when this information is deemed necessary by the submitter. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

      5. 2010BB Loop Mandatory Repeat 1

         1. 0150 · NM1 · Payer Name · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

            This is the destination payer.
            For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.

         2. 0250 · N3 · Payer Address · Max 1 · Optional

            To specify the location of the named party

            Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

         3. 0300 · N4 · Payer City, State, ZIP Code · Max 1 · Optional

            To specify the geographic place of the named party

            Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

         4. 0350 · REF · Payer Secondary Identification · Max 3 · Optional

            To specify identifying information

            Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

         5. 0350 · REF · Billing Provider Secondary Identification · Max 2 · Optional

            To specify identifying information

            Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

      6. 2300 Loop Optional Repeat 100

         1. 1300 · CLM · Claim Information · Max 1 · Mandatory

            To specify basic data about the claim

            The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
            For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.

         2. 1350 · DTP · Date - Onset of Current Illness or Symptom · Max 1 · Optional

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

            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. If not required by this implementation guide, do not send.
            This date is the onset of acute symptoms for the current illness or condition.

         3. 1350 · DTP · Date - Initial Treatment Date · Max 1 · Optional

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

            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. If not required by this implementation guide, do not send.
            Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

         4. 1350 · DTP · Date - Last Seen Date · Max 1 · Optional

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

            Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.
            This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
            Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

         5. 1350 · DTP · Date - Acute Manifestation · Max 1 · Optional

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

            Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send.

         6. 1350 · DTP · Date - Accident · Max 1 · Optional

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

            Required when CLM11-1 or CLM11-2 has a value of `AA' or `OA'. OR Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident. If not required by this implementation guide, do not send.

         7. 1350 · DTP · Date - Last Menstrual Period · Max 1 · Optional

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

            Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send.

         8. 1350 · DTP · Date - Last X-ray Date · Max 1 · Optional

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

            Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send.
            Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

         9. 1350 · DTP · Date - Hearing and Vision Prescription Date · Max 1 · Optional

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

            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. If not required by this implementation guide, do not send.

         10. 1350 · DTP · Date - Disability Dates · Max 1 · Optional

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

             Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send.

         11. 1350 · DTP · Date - Last Worked · Max 1 · Optional

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

             Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.

         12. 1350 · DTP · Date - Authorized Return to Work · Max 1 · Optional

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

             Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.

         13. 1350 · DTP · Date - Admission · Max 1 · Optional

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

             Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send.

         14. 1350 · DTP · Date - Discharge · Max 1 · Optional

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

             Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send.

         15. 1350 · DTP · Date - Assumed and Relinquished Care Dates · Max 2 · Optional

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

             Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send.
             Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".

         16. 1350 · DTP · Date - Property and Casualty Date of First Contact · Max 1 · Optional

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

             Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send.
             This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.

         17. 1350 · DTP · Date - Repricer Received Date · Max 1 · Optional

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

             Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.

         18. 1550 · PWK · Claim Supplemental Information · Max 10 · Optional

             To identify the type or transmission or both of paperwork or supporting information

             Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send.

         19. 1600 · CN1 · Contract Information · Max 1 · Optional

             To specify basic data about the contract or contract line item

             The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
             Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.

         20. 1750 · AMT · Patient Amount Paid · Max 1 · Optional

             To indicate the total monetary amount

             Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
             Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).

         21. 1800 · REF · Service Authorization Exception Code · Max 1 · Optional

             To specify identifying information

             Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.

         22. 1800 · REF · Mandatory Medicare (Section 4081) Crossover Indicator · Max 1 · Optional

             To specify identifying information

             Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send.

         23. 1800 · REF · Mammography Certification Number · Max 1 · Optional

             To specify identifying information

             Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send.

         24. 1800 · REF · Referral Number · Max 1 · Optional

             To specify identifying information

             Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send.
             Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.

         25. 1800 · REF · Prior Authorization · Max 1 · Optional

             To specify identifying information

             Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. 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. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
             Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
             Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send.

         26. 1800 · REF · Payer Claim Control Number · Max 1 · Optional

             To specify identifying information

             Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
             This information is specific to the destination payer reported in Loop ID-2010BB.

         27. 1800 · REF · Clinical Laboratory Improvement Amendment (CLIA) Number · Max 1 · Optional

             To specify identifying information

             Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send.
             If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
             In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.

         28. 1800 · REF · Repriced Claim Number · Max 1 · Optional

             To specify identifying information

             Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
             This information is specific to the destination payer reported in Loop ID-2010BB.

         29. 1800 · REF · Adjusted Repriced Claim Number · Max 1 · Optional

             To specify identifying information

             Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
             This information is specific to the destination payer reported in Loop ID-2010BB.

         30. 1800 · REF · Investigational Device Exemption Number · Max 1 · Optional

             To specify identifying information

             Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.

         31. 1800 · REF · Claim Identifier For Transmission Intermediaries · Max 1 · Optional

             To specify identifying information

             Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. 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, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.

         32. 1800 · REF · Medical Record Number · Max 1 · Optional

             To specify identifying information

             Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.

         33. 1800 · REF · Demonstration Project Identifier · Max 1 · Optional

             To specify identifying information

             Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.

         34. 1800 · REF · Care Plan Oversight · Max 1 · Optional

             To specify identifying information

             Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send.
             This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI.

         35. 1850 · K3 · File Information · Max 10 · Optional

             To transmit a fixed-format record or matrix contents

             Required when ALL of the following conditions are met: - A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; - The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement - X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send.
             At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
             Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
             X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

         36. 1900 · NTE · Claim Note · Max 1 · Optional

             To transmit information in a free-form format, if necessary, for comment or special instruction

             Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send.
             Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300.
             The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;

         37. 1950 · CR1 · Ambulance Transport Information · Max 1 · Optional

             To supply information related to the ambulance service rendered to a patient

             Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send.
             The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101.

         38. 2000 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

             To supply information related to the chiropractic service rendered to a patient

             Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.

         39. 2200 · CRC · Ambulance Certification · Max 3 · Optional

             To supply information on conditions

             Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send.
             The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01.
             Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07.

         40. 2200 · CRC · Patient Condition Information: Vision · Max 3 · Optional

             To supply information on conditions

             Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send.

         41. 2200 · CRC · Homebound Indicator · Max 1 · Optional

             To supply information on conditions

             Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send.

         42. 2200 · CRC · EPSDT Referral · Max 1 · Optional

             To supply information on conditions

             Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.

         43. 2310 · HI · Health Care Diagnosis Code · Max 1 · Mandatory

             To supply information related to the delivery of health care

             Do not transmit the decimal point for ICD codes. The decimal point is implied.

         44. 2310 · HI · Anesthesia Related Procedure · Max 1 · Optional

             To supply information related to the delivery of health care

             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. If not required by this implementation guide, do not send.

         45. 2310 · HI · Condition Information · Max 2 · Optional

             To supply information related to the delivery of health care

             Required when condition information applies to the claim. If not required by this implementation guide, do not send.

         46. 2410 · HCP · Claim Pricing/Repricing Information · Max 1 · Optional

             To specify pricing or repricing information about a health care claim or line item

             Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
             This information is specific to the destination payer reported in Loop ID-2010BB.
             For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

         47. 2310A Loop Optional Repeat 2

             1. 2500 · NM1 · Referring Provider Name · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when this claim involves a referral. If not required by this implementation guide, do not send.
                When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
                When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
                Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

             2. 2710 · REF · Referring Provider Secondary Identification · Max 3 · Optional

                To specify identifying information

                The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
                Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

         48. 2310B Loop Optional Repeat 1

             1. 2500 · NM1 · Rendering Provider Name · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send.
                Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
                Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

             2. 2550 · PRV · Rendering Provider Specialty Information · Max 1 · Optional

                To specify the identifying characteristics of a provider

                Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
                The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.

             3. 2710 · REF · Rendering Provider Secondary Identification · Max 4 · Optional

                To specify identifying information

                The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
                Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

         49. 2310C Loop Optional Repeat 1

             1. 2500 · NM1 · Service Facility Location Name · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send.
                When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
                The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location.
                Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

             2. 2650 · N3 · Service Facility Location Address · Max 1 · Mandatory

                To specify the location of the named party

                If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

             3. 2700 · N4 · Service Facility Location City, State, ZIP Code · Max 1 · Mandatory

                To specify the geographic place of the named party

             4. 2710 · REF · Service Facility Location Secondary Identification · Max 3 · Optional

                To specify identifying information

                Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

             5. 2750 · PER · Service Facility Contact Information · Max 1 · Optional

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

                Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

         50. 2310D Loop Optional Repeat 1

             1. 2500 · NM1 · Supervising Provider Name · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send.
                Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

             2. 2710 · REF · Supervising Provider Secondary Identification · Max 4 · Optional

                To specify identifying information

                Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send.

         51. 2310E Loop Optional Repeat 1

             1. 2500 · NM1 · Ambulance Pick-up Location · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
                Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

             2. 2650 · N3 · Ambulance Pick-up Location Address · Max 1 · Mandatory

                To specify the location of the named party

                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, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

             3. 2700 · N4 · Ambulance Pick-up Location City, State, ZIP Code · Max 1 · Mandatory

                To specify the geographic place of the named party

         52. 2310F Loop Optional Repeat 1

             1. 2500 · NM1 · Ambulance Drop-off Location · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
                Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

             2. 2650 · N3 · Ambulance Drop-off Location Address · Max 1 · Mandatory

                To specify the location of the named party

             3. 2700 · N4 · Ambulance Drop-off Location City, State, ZIP Code · Max 1 · Mandatory

                To specify the geographic place of the named party

         53. 2320 Loop Optional Repeat 10

             1. 2900 · SBR · Other Subscriber Information · Max 1 · Mandatory

                To record information specific to the primary insured and the insurance carrier for that insured

                Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
                All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
                See Crosswalking COB Data Elements section for more information on handling COB in the 837.

             2. 2950 · CAS · Claim Level Adjustments · Max 5 · Optional

                To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

                Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
                Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
                Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
                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, the paper values must be converted to standard Claim Adjustment Reason Codes.;
                A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

             3. 3000 · AMT · Coordination of Benefits (COB) Payer Paid Amount · Max 1 · Optional

                To indicate the total monetary amount

                Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.;

             4. 3000 · AMT · Coordination of Benefits (COB) Total Non-Covered Amount · Max 1 · Optional

                To indicate the total monetary amount

                Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
                When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.

             5. 3000 · AMT · Remaining Patient Liability · Max 1 · Optional

                To indicate the total monetary amount

                Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send.
                In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
                This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
                This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.

             6. 3100 · OI · Other Insurance Coverage Information · Max 1 · Mandatory

                To specify information associated with other health insurance coverage

                All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.

             7. 3200 · MOA · Outpatient Adjudication Information · Max 1 · Optional

                To convey 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 Required when it is necessary to report remark codes. If not required by this implementation guide, do not send.

             8. 2330A Loop Mandatory Repeat 1

                1. 3250 · NM1 · Other Subscriber Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
                   If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
                   See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                2. 3320 · N3 · Other Subscriber Address · Max 1 · Optional

                   To specify the location of the named party

                   Required when the information is available. If not required by this implementation guide, do not send.

                3. 3400 · N4 · Other Subscriber City, State, ZIP Code · Max 1 · Optional

                   To specify the geographic place of the named party

                   Required when the information is available. If not required by this implementation guide, do not send.

                4. 3550 · REF · Other Subscriber Secondary Identification · Max 1 · Optional

                   To specify identifying information

                   Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

             9. 2330B Loop Mandatory Repeat 1

                1. 3250 · NM1 · Other Payer Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                2. 3320 · N3 · Other Payer Address · Max 1 · Optional

                   To specify the location of the named party

                   Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

                3. 3400 · N4 · Other Payer City, State, ZIP Code · Max 1 · Optional

                   To specify the geographic place of the named party

                   Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

                4. 3450 · DTP · Claim Check or Remittance Date · Max 1 · Optional

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

                   Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;

                5. 3550 · REF · Other Payer Secondary Identifier · Max 2 · Optional

                   To specify identifying information

                   Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

                6. 3550 · REF · Other Payer Prior Authorization Number · Max 1 · Optional

                   To specify identifying information

                   Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send.

                7. 3550 · REF · Other Payer Referral Number · Max 1 · Optional

                   To specify identifying information

                   Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send.

                8. 3550 · REF · Other Payer Claim Adjustment Indicator · Max 1 · Optional

                   To specify identifying information

                   Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send.

                9. 3550 · REF · Other Payer Claim Control Number · Max 1 · Optional

                   To specify identifying information

                   Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send.

             10. 2330C Loop Optional Repeat 2

                 1. 3250 · NM1 · Other Payer Referring Provider · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                    Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                 2. 3550 · REF · Other Payer Referring Provider Secondary Identification · Max 3 · Mandatory

                    To specify identifying information

                    Non-destination (COB) payer's provider identification number(s).
                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.

             11. 2330D Loop Optional Repeat 1

                 1. 3250 · NM1 · Other Payer Rendering Provider · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                    Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                 2. 3550 · REF · Other Payer Rendering Provider Secondary Identification · Max 3 · Mandatory

                    To specify identifying information

                    Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.

             12. 2330E Loop Optional Repeat 1

                 1. 3250 · NM1 · Other Payer Service Facility Location · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                    Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                 2. 3550 · REF · Other Payer Service Facility Location Secondary Identification · Max 3 · Mandatory

                    To specify identifying information

             13. 2330F Loop Optional Repeat 1

                 1. 3250 · NM1 · Other Payer Supervising Provider · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                    Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                 2. 3550 · REF · Other Payer Supervising Provider Secondary Identification · Max 3 · Mandatory

                    To specify identifying information

             14. 2330G Loop Optional Repeat 1

                 1. 3250 · NM1 · Other Payer Billing Provider · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.
                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                 2. 3550 · REF · Other Payer Billing Provider Secondary Identification · Max 2 · Mandatory

                    To specify identifying information

                    See Crosswalking COB Data Elements section for more information on handling COB in the 837.

         54. 2400 Loop Mandatory Repeat 50

             1. 3650 · LX · Service Line Number · Max 1 · Mandatory

                To reference a line number in a transaction set

                The LX functions as a line counter.
                The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
                LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.

             2. 3700 · SV1 · Professional Service · Max 1 · Mandatory

                To specify the service line item detail for a health care professional

             3. 4000 · SV5 · Durable Medical Equipment Service · Max 1 · Optional

                To specify the claim service detail for durable medical equipment

                Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send.

             4. 4200 · PWK · Line Supplemental Information · Max 10 · Optional

                To identify the type or transmission or both of paperwork or supporting information

                Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send.

             5. 4200 · PWK · Durable Medical Equipment Certificate of Medical Necessity Indicator · Max 1 · Optional

                To identify the type or transmission or both of paperwork or supporting information

                Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.;

             6. 4250 · CR1 · Ambulance Transport Information · Max 1 · Optional

                To supply information related to the ambulance service rendered to a patient

                Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

             7. 4350 · CR3 · Durable Medical Equipment Certification · Max 1 · Optional

                To supply information regarding a physician's certification for durable medical equipment

                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. If not required by this implementation guide, do not send.

             8. 4500 · CRC · Ambulance Certification · Max 3 · Optional

                To supply information on conditions

                The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

             9. 4500 · CRC · Hospice Employee Indicator · Max 1 · Optional

                To supply information on conditions

                Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send.
                The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                The example shows the method used to indicate whether the rendering provider is an employee of the hospice.

             10. 4500 · CRC · Condition Indicator/Durable Medical Equipment · Max 1 · Optional

                 To supply information on conditions

                 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. If not required by this implementation guide, do not send.
                 The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                 The first example shows a case where an item billed was not a replacement item.

             11. 4550 · DTP · Date - Service Date · Max 1 · Mandatory

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

                 In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.

             12. 4550 · DTP · Date - Prescription Date · Max 1 · Optional

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

                 Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send.

             13. 4550 · DTP · DATE - Certification Revision/Recertification Date · Max 1 · Optional

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

                 Required when CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send.

             14. 4550 · DTP · Date - Begin Therapy Date · Max 1 · Optional

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

                 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. If not required by this implementation guide, do not send.

             15. 4550 · DTP · Date - Last Certification Date · Max 1 · Optional

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

                 Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
                 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).

             16. 4550 · DTP · Date - Last Seen Date · Max 1 · Optional

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

                 Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.;

             17. 4550 · DTP · Date - Test Date · Max 2 · Optional

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

                 Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send.

             18. 4550 · DTP · Date - Shipped Date · Max 1 · Optional

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

                 Required when billing or reporting shipped products. If not required by this implementation guide, do not send.

             19. 4550 · DTP · Date - Last X-ray Date · Max 1 · Optional

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

                 Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

             20. 4550 · DTP · Date - Initial Treatment Date · Max 1 · Optional

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

                 Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send.

             21. 4600 · QTY · Ambulance Patient Count · Max 1 · Optional

                 To specify quantity information

                 Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
                 The QTY02 is the only place to report the number of patients when there are multiple patients transported.

             22. 4600 · QTY · Obstetric Anesthesia Additional Units · Max 1 · Optional

                 To specify quantity information

                 Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send.

             23. 4620 · MEA · Test Result · Max 5 · Optional

                 To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)

                 Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send.

             24. 4650 · CN1 · Contract Information · Max 1 · Optional

                 To specify basic data about the contract or contract line item

                 The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
                 Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.

             25. 4700 · REF · Repriced Line Item Reference Number · Max 1 · Optional

                 To specify identifying information

                 Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.

             26. 4700 · REF · Adjusted Repriced Line Item Reference Number · Max 1 · Optional

                 To specify identifying information

                 Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.

             27. 4700 · REF · Prior Authorization · Max 5 · Optional

                 To specify identifying information

                 Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.
                 When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.

             28. 4700 · REF · Line Item Control Number · Max 1 · Optional

                 To specify identifying information

                 Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
                 The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
                 Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.

             29. 4700 · REF · Mammography Certification Number · Max 1 · Optional

                 To specify identifying information

                 Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send.

             30. 4700 · REF · Clinical Laboratory Improvement Amendment (CLIA) Number · Max 1 · Optional

                 To specify identifying information

                 Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.;

             31. 4700 · REF · Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification · Max 1 · Optional

                 To specify identifying information

                 Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send.

             32. 4700 · REF · Immunization Batch Number · Max 1 · Optional

                 To specify identifying information

                 Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send.

             33. 4700 · REF · Referral Number · Max 5 · Optional

                 To specify identifying information

                 Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send.
                 When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.

             34. 4750 · AMT · Sales Tax Amount · Max 1 · Optional

                 To indicate the total monetary amount

                 Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
                 When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount.

             35. 4750 · AMT · Postage Claimed Amount · Max 1 · Optional

                 To indicate the total monetary amount

                 Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send.
                 When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount.

             36. 4800 · K3 · File Information · Max 10 · Optional

                 To transmit a fixed-format record or matrix contents

                 Required when ALL of the following conditions are met: - A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; - The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement - X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send.
                 At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
                 Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
                 X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

             37. 4850 · NTE · Line Note · Max 1 · Optional

                 To transmit information in a free-form format, if necessary, for comment or special instruction

                 Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send.
                 Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description.

             38. 4850 · NTE · Third Party Organization Notes · Max 1 · Optional

                 To transmit information in a free-form format, if necessary, for comment or special instruction

                 Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.

             39. 4880 · PS1 · Purchased Service Information · Max 1 · Optional

                 To specify the information about services that are 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 Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send.

             40. 4920 · HCP · Line Pricing/Repricing Information · Max 1 · Optional

                 To specify pricing or repricing information about a health care claim or line item

                 This information is specific to the destination payer reported in Loop ID-2010BB.
                 For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
                 Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.

             41. 2410 Loop Optional Repeat 1

                 1. 4930 · LIN · Drug Identification · Max 1 · Mandatory

                    To specify basic item identification data

                    Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send.
                    Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.

                 2. 4940 · CTP · Drug Quantity · Max 1 · Mandatory

                    To specify pricing information

                 3. 4950 · REF · Prescription or Compound Drug Association Number · Max 1 · Optional

                    To specify identifying information

                    Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send.
                    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.
                    For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.

             42. 2420A Loop Optional Repeat 1

                 1. 5000 · NM1 · Rendering Provider Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
                    Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, do not send.;

                 2. 5050 · PRV · Rendering Provider Specialty Information · Max 1 · Optional

                    To specify the identifying characteristics of a provider

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

                 3. 5250 · REF · Rendering Provider Secondary Identification · Max 20 · Optional

                    To specify identifying information

                    Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

             43. 2420B Loop Optional Repeat 1

                 1. 5000 · NM1 · Purchased Service Provider Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send.
                    Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations.

                 2. 5250 · REF · Purchased Service Provider Secondary Identification · Max 20 · Optional

                    To specify identifying information

                    Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

             44. 2420C Loop Optional Repeat 1

                 1. 5000 · NM1 · Service Facility Location Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
                    Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
                    The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.;

                 2. 5140 · N3 · Service Facility Location Address · Max 1 · Mandatory

                    To specify the location of the named party

                    If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                 3. 5200 · N4 · Service Facility Location City, State, ZIP Code · Max 1 · Mandatory

                    To specify the geographic place of the named party

                 4. 5250 · REF · Service Facility Location Secondary Identification · Max 3 · Optional

                    To specify identifying information

                    When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
                    Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send.

             45. 2420D Loop Optional Repeat 1

                 1. 5000 · NM1 · Supervising Provider Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.

                 2. 5250 · REF · Supervising Provider Secondary Identification · Max 20 · Optional

                    To specify identifying information

                    Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

             46. 2420E Loop Optional Repeat 1

                 1. 5000 · NM1 · Ordering Provider Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send.

                 2. 5140 · N3 · Ordering Provider Address · Max 1 · Optional

                    To specify the location of the named party

                    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. If not required by this implementation guide, do not send.

                 3. 5200 · N4 · Ordering Provider City, State, ZIP Code · Max 1 · Optional

                    To specify the geographic place of the named party

                    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. If not required by this implementation guide, do not send.

                 4. 5250 · REF · Ordering Provider Secondary Identification · Max 20 · Optional

                    To specify identifying information

                    Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

                 5. 5300 · PER · Ordering Provider Contact Information · Max 1 · Optional

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

                    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. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

             47. 2420F Loop Optional Repeat 2

                 1. 5000 · NM1 · Referring Provider Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
                    When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
                    Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                 2. 5250 · REF · Referring Provider Secondary Identification · Max 20 · Optional

                    To specify identifying information

                    Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

             48. 2420G Loop Optional Repeat 1

                 1. 5000 · NM1 · Ambulance Pick-up Location · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.;

                 2. 5140 · N3 · Ambulance Pick-up Location Address · Max 1 · Mandatory

                    To specify the location of the named party

                    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, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                 3. 5200 · N4 · Ambulance Pick-up Location City, State, ZIP Code · Max 1 · Mandatory

                    To specify the geographic place of the named party

             49. 2420H Loop Optional Repeat 1

                 1. 5000 · NM1 · Ambulance Drop-off Location · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send.

                 2. 5140 · N3 · Ambulance Drop-off Location Address · Max 1 · Mandatory

                    To specify the location of the named party

                    If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                 3. 5200 · N4 · Ambulance Drop-off Location City, State, ZIP Code · Max 1 · Mandatory

                    To specify the geographic place of the named party

             50. 2430 Loop Optional Repeat 15

                 1. 5400 · SVD · Line Adjudication Information · Max 1 · Mandatory

                    To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

                    Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
                    To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.

                 2. 5450 · CAS · Line Adjustment · Max 5 · Optional

                    To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

                    Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
                    A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

                 3. 5500 · DTP · Line Check or Remittance Date · Max 1 · Mandatory

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

                 4. 5505 · AMT · Remaining Patient Liability · Max 1 · Optional

                    To indicate the total monetary amount

                    In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
                    This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
                    Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
                    This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.

             51. 2440 Loop Optional Repeat >1

                 1. 5510 · LQ · Form Identification Code · Max 1 · Mandatory

                    To identify standard industry codes

                    Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send.
                    Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used.
                    An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services.

                 2. 5520 · FRM · Supporting Documentation · Max 99 · Mandatory

                    To specify information in response to a codified questionnaire document

                    The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQ*UT*08.02~).

      7. 2000C Loop Optional Repeat >1

         1. 0010 · HL · Patient Hierarchical Level · Max 1 · Mandatory

            To identify dependencies among and the content of hierarchically related groups of data segments

            Required when the patient is a dependent of the subscriber identified in Loop ID-2000B and cannot be uniquely identified to the payer using the subscriber's identifier in the Subscriber Level. If not required by this implementation guide, do not send.
            There are no HLs subordinate to the Patient HL.
            If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Identification Number, then the patient is considered the subscriber and is to be identified in the Subscriber Level.

         2. 0070 · PAT · Patient Information · Max 1 · Mandatory

            To supply patient information

         3. 2010CA Loop Mandatory Repeat 1

            1. 0150 · NM1 · Patient Name · Max 1 · Mandatory

               To supply the full name of an individual or organizational entity

            2. 0250 · N3 · Patient Address · Max 1 · Mandatory

               To specify the location of the named party

            3. 0300 · N4 · Patient City, State, ZIP Code · Max 1 · Mandatory

               To specify the geographic place of the named party

            4. 0320 · DMG · Patient Demographic Information · Max 1 · Mandatory

               To supply demographic information

            5. 0350 · REF · Property and Casualty Claim Number · Max 1 · Optional

               To specify identifying information

               Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
               This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
               This segment is not a HIPAA requirement as of this writing.

            6. 0350 · REF · Property and Casualty Patient Identifier · Max 1 · Optional

               To specify identifying information

               Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.

            7. 0400 · PER · Property and Casualty Patient Contact Information · Max 1 · Optional

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

               Required for Property and Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID-2010BA and this information is deemed necessary by the submitter. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

         4. 2300 Loop Mandatory Repeat 100

            1. 1300 · CLM · Claim Information · Max 1 · Mandatory

               To specify basic data about the claim

               The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
               For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.

            2. 1350 · DTP · Date - Onset of Current Illness or Symptom · Max 1 · Optional

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

               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. If not required by this implementation guide, do not send.
               This date is the onset of acute symptoms for the current illness or condition.

            3. 1350 · DTP · Date - Initial Treatment Date · Max 1 · Optional

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

               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. If not required by this implementation guide, do not send.
               Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

            4. 1350 · DTP · Date - Last Seen Date · Max 1 · Optional

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

               Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.
               This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
               Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

            5. 1350 · DTP · Date - Acute Manifestation · Max 1 · Optional

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

               Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send.

            6. 1350 · DTP · Date - Accident · Max 1 · Optional

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

               Required when CLM11-1 or CLM11-2 has a value of `AA' or `OA'. OR Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident. If not required by this implementation guide, do not send.

            7. 1350 · DTP · Date - Last Menstrual Period · Max 1 · Optional

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

               Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send.

            8. 1350 · DTP · Date - Last X-ray Date · Max 1 · Optional

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

               Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send.
               Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

            9. 1350 · DTP · Date - Hearing and Vision Prescription Date · Max 1 · Optional

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

               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. If not required by this implementation guide, do not send.

            10. 1350 · DTP · Date - Disability Dates · Max 1 · Optional

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

                Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send.

            11. 1350 · DTP · Date - Last Worked · Max 1 · Optional

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

                Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.

            12. 1350 · DTP · Date - Authorized Return to Work · Max 1 · Optional

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

                Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.

            13. 1350 · DTP · Date - Admission · Max 1 · Optional

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

                Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send.

            14. 1350 · DTP · Date - Discharge · Max 1 · Optional

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

                Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send.

            15. 1350 · DTP · Date - Assumed and Relinquished Care Dates · Max 2 · Optional

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

                Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send.
                Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".

            16. 1350 · DTP · Date - Property and Casualty Date of First Contact · Max 1 · Optional

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

                Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send.
                This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.

            17. 1350 · DTP · Date - Repricer Received Date · Max 1 · Optional

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

                Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.

            18. 1550 · PWK · Claim Supplemental Information · Max 10 · Optional

                To identify the type or transmission or both of paperwork or supporting information

                Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send.

            19. 1600 · CN1 · Contract Information · Max 1 · Optional

                To specify basic data about the contract or contract line item

                The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
                Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.

            20. 1750 · AMT · Patient Amount Paid · Max 1 · Optional

                To indicate the total monetary amount

                Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
                Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).

            21. 1800 · REF · Service Authorization Exception Code · Max 1 · Optional

                To specify identifying information

                Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.

            22. 1800 · REF · Mandatory Medicare (Section 4081) Crossover Indicator · Max 1 · Optional

                To specify identifying information

                Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send.

            23. 1800 · REF · Mammography Certification Number · Max 1 · Optional

                To specify identifying information

                Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send.

            24. 1800 · REF · Referral Number · Max 1 · Optional

                To specify identifying information

                Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send.
                Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.

            25. 1800 · REF · Prior Authorization · Max 1 · Optional

                To specify identifying information

                Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. 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. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
                Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
                Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send.

            26. 1800 · REF · Payer Claim Control Number · Max 1 · Optional

                To specify identifying information

                Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
                This information is specific to the destination payer reported in Loop ID-2010BB.

            27. 1800 · REF · Clinical Laboratory Improvement Amendment (CLIA) Number · Max 1 · Optional

                To specify identifying information

                Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send.
                If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
                In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.

            28. 1800 · REF · Repriced Claim Number · Max 1 · Optional

                To specify identifying information

                Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
                This information is specific to the destination payer reported in Loop ID-2010BB.

            29. 1800 · REF · Adjusted Repriced Claim Number · Max 1 · Optional

                To specify identifying information

                Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
                This information is specific to the destination payer reported in Loop ID-2010BB.

            30. 1800 · REF · Investigational Device Exemption Number · Max 1 · Optional

                To specify identifying information

                Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.

            31. 1800 · REF · Claim Identifier For Transmission Intermediaries · Max 1 · Optional

                To specify identifying information

                Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. 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, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.

            32. 1800 · REF · Medical Record Number · Max 1 · Optional

                To specify identifying information

                Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.

            33. 1800 · REF · Demonstration Project Identifier · Max 1 · Optional

                To specify identifying information

                Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.

            34. 1800 · REF · Care Plan Oversight · Max 1 · Optional

                To specify identifying information

                Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send.
                This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI.

            35. 1850 · K3 · File Information · Max 10 · Optional

                To transmit a fixed-format record or matrix contents

                Required when ALL of the following conditions are met: - A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; - The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement - X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send.
                At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
                Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
                X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

            36. 1900 · NTE · Claim Note · Max 1 · Optional

                To transmit information in a free-form format, if necessary, for comment or special instruction

                Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send.
                Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300.
                The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;

            37. 1950 · CR1 · Ambulance Transport Information · Max 1 · Optional

                To supply information related to the ambulance service rendered to a patient

                Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send.
                The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101.

            38. 2000 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                To supply information related to the chiropractic service rendered to a patient

                Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.

            39. 2200 · CRC · Ambulance Certification · Max 3 · Optional

                To supply information on conditions

                Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send.
                The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01.
                Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07.

            40. 2200 · CRC · Patient Condition Information: Vision · Max 3 · Optional

                To supply information on conditions

                Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send.

            41. 2200 · CRC · Homebound Indicator · Max 1 · Optional

                To supply information on conditions

                Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send.

            42. 2200 · CRC · EPSDT Referral · Max 1 · Optional

                To supply information on conditions

                Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.

            43. 2310 · HI · Health Care Diagnosis Code · Max 1 · Mandatory

                To supply information related to the delivery of health care

                Do not transmit the decimal point for ICD codes. The decimal point is implied.

            44. 2310 · HI · Anesthesia Related Procedure · Max 1 · Optional

                To supply information related to the delivery of health care

                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. If not required by this implementation guide, do not send.

            45. 2310 · HI · Condition Information · Max 2 · Optional

                To supply information related to the delivery of health care

                Required when condition information applies to the claim. If not required by this implementation guide, do not send.

            46. 2410 · HCP · Claim Pricing/Repricing Information · Max 1 · Optional

                To specify pricing or repricing information about a health care claim or line item

                Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
                This information is specific to the destination payer reported in Loop ID-2010BB.
                For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

            47. 2310A Loop Optional Repeat 2

                1. 2500 · NM1 · Referring Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when this claim involves a referral. If not required by this implementation guide, do not send.
                   When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
                   When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
                   Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

                2. 2710 · REF · Referring Provider Secondary Identification · Max 3 · Optional

                   To specify identifying information

                   The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
                   Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

            48. 2310B Loop Optional Repeat 1

                1. 2500 · NM1 · Rendering Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send.
                   Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
                   Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

                2. 2550 · PRV · Rendering Provider Specialty Information · Max 1 · Optional

                   To specify the identifying characteristics of a provider

                   Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
                   The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.

                3. 2710 · REF · Rendering Provider Secondary Identification · Max 4 · Optional

                   To specify identifying information

                   The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
                   Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

            49. 2310C Loop Optional Repeat 1

                1. 2500 · NM1 · Service Facility Location Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send.
                   When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
                   The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location.
                   Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

                2. 2650 · N3 · Service Facility Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                   If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                3. 2700 · N4 · Service Facility Location City, State, ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

                4. 2710 · REF · Service Facility Location Secondary Identification · Max 3 · Optional

                   To specify identifying information

                   Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

                5. 2750 · PER · Service Facility Contact Information · Max 1 · Optional

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

                   Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

            50. 2310D Loop Optional Repeat 1

                1. 2500 · NM1 · Supervising Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send.
                   Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

                2. 2710 · REF · Supervising Provider Secondary Identification · Max 4 · Optional

                   To specify identifying information

                   Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send.

            51. 2310E Loop Optional Repeat 1

                1. 2500 · NM1 · Ambulance Pick-up Location · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
                   Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

                2. 2650 · N3 · Ambulance Pick-up Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                   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, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                3. 2700 · N4 · Ambulance Pick-up Location City, State, ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

            52. 2310F Loop Optional Repeat 1

                1. 2500 · NM1 · Ambulance Drop-off Location · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
                   Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

                2. 2650 · N3 · Ambulance Drop-off Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                3. 2700 · N4 · Ambulance Drop-off Location City, State, ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

            53. 2320 Loop Optional Repeat 10

                1. 2900 · SBR · Other Subscriber Information · Max 1 · Mandatory

                   To record information specific to the primary insured and the insurance carrier for that insured

                   Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
                   All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
                   See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                2. 2950 · CAS · Claim Level Adjustments · Max 5 · Optional

                   To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

                   Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
                   Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
                   Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
                   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, the paper values must be converted to standard Claim Adjustment Reason Codes.;
                   A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

                3. 3000 · AMT · Coordination of Benefits (COB) Payer Paid Amount · Max 1 · Optional

                   To indicate the total monetary amount

                   Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.;

                4. 3000 · AMT · Coordination of Benefits (COB) Total Non-Covered Amount · Max 1 · Optional

                   To indicate the total monetary amount

                   Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
                   When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.

                5. 3000 · AMT · Remaining Patient Liability · Max 1 · Optional

                   To indicate the total monetary amount

                   Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send.
                   In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
                   This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
                   This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.

                6. 3100 · OI · Other Insurance Coverage Information · Max 1 · Mandatory

                   To specify information associated with other health insurance coverage

                   All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.

                7. 3200 · MOA · Outpatient Adjudication Information · Max 1 · Optional

                   To convey 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 Required when it is necessary to report remark codes. If not required by this implementation guide, do not send.

                8. 2330A Loop Mandatory Repeat 1

                   1. 3250 · NM1 · Other Subscriber Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
                      If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
                      See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                   2. 3320 · N3 · Other Subscriber Address · Max 1 · Optional

                      To specify the location of the named party

                      Required when the information is available. If not required by this implementation guide, do not send.

                   3. 3400 · N4 · Other Subscriber City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when the information is available. If not required by this implementation guide, do not send.

                   4. 3550 · REF · Other Subscriber Secondary Identification · Max 1 · Optional

                      To specify identifying information

                      Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

                9. 2330B Loop Mandatory Repeat 1

                   1. 3250 · NM1 · Other Payer Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                   2. 3320 · N3 · Other Payer Address · Max 1 · Optional

                      To specify the location of the named party

                      Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

                   3. 3400 · N4 · Other Payer City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

                   4. 3450 · DTP · Claim Check or Remittance Date · Max 1 · Optional

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

                      Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;

                   5. 3550 · REF · Other Payer Secondary Identifier · Max 2 · Optional

                      To specify identifying information

                      Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

                   6. 3550 · REF · Other Payer Prior Authorization Number · Max 1 · Optional

                      To specify identifying information

                      Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send.

                   7. 3550 · REF · Other Payer Referral Number · Max 1 · Optional

                      To specify identifying information

                      Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send.

                   8. 3550 · REF · Other Payer Claim Adjustment Indicator · Max 1 · Optional

                      To specify identifying information

                      Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send.

                   9. 3550 · REF · Other Payer Claim Control Number · Max 1 · Optional

                      To specify identifying information

                      Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send.

                10. 2330C Loop Optional Repeat 2

                    1. 3250 · NM1 · Other Payer Referring Provider · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                       Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                    2. 3550 · REF · Other Payer Referring Provider Secondary Identification · Max 3 · Mandatory

                       To specify identifying information

                       Non-destination (COB) payer's provider identification number(s).
                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                11. 2330D Loop Optional Repeat 1

                    1. 3250 · NM1 · Other Payer Rendering Provider · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                       Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                    2. 3550 · REF · Other Payer Rendering Provider Secondary Identification · Max 3 · Mandatory

                       To specify identifying information

                       Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                12. 2330E Loop Optional Repeat 1

                    1. 3250 · NM1 · Other Payer Service Facility Location · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                       Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                    2. 3550 · REF · Other Payer Service Facility Location Secondary Identification · Max 3 · Mandatory

                       To specify identifying information

                13. 2330F Loop Optional Repeat 1

                    1. 3250 · NM1 · Other Payer Supervising Provider · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.
                       Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

                    2. 3550 · REF · Other Payer Supervising Provider Secondary Identification · Max 3 · Mandatory

                       To specify identifying information

                14. 2330G Loop Optional Repeat 1

                    1. 3250 · NM1 · Other Payer Billing Provider · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.
                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.

                    2. 3550 · REF · Other Payer Billing Provider Secondary Identification · Max 2 · Mandatory

                       To specify identifying information

                       See Crosswalking COB Data Elements section for more information on handling COB in the 837.

            54. 2400 Loop Mandatory Repeat 50

                1. 3650 · LX · Service Line Number · Max 1 · Mandatory

                   To reference a line number in a transaction set

                   The LX functions as a line counter.
                   The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
                   LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.

                2. 3700 · SV1 · Professional Service · Max 1 · Mandatory

                   To specify the service line item detail for a health care professional

                3. 4000 · SV5 · Durable Medical Equipment Service · Max 1 · Optional

                   To specify the claim service detail for durable medical equipment

                   Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send.

                4. 4200 · PWK · Line Supplemental Information · Max 10 · Optional

                   To identify the type or transmission or both of paperwork or supporting information

                   Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send.

                5. 4200 · PWK · Durable Medical Equipment Certificate of Medical Necessity Indicator · Max 1 · Optional

                   To identify the type or transmission or both of paperwork or supporting information

                   Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.;

                6. 4250 · CR1 · Ambulance Transport Information · Max 1 · Optional

                   To supply information related to the ambulance service rendered to a patient

                   Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

                7. 4350 · CR3 · Durable Medical Equipment Certification · Max 1 · Optional

                   To supply information regarding a physician's certification for durable medical equipment

                   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. If not required by this implementation guide, do not send.

                8. 4500 · CRC · Ambulance Certification · Max 3 · Optional

                   To supply information on conditions

                   The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                   Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

                9. 4500 · CRC · Hospice Employee Indicator · Max 1 · Optional

                   To supply information on conditions

                   Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send.
                   The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                   The example shows the method used to indicate whether the rendering provider is an employee of the hospice.

                10. 4500 · CRC · Condition Indicator/Durable Medical Equipment · Max 1 · Optional

                    To supply information on conditions

                    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. If not required by this implementation guide, do not send.
                    The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                    The first example shows a case where an item billed was not a replacement item.

                11. 4550 · DTP · Date - Service Date · Max 1 · Mandatory

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

                    In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.

                12. 4550 · DTP · Date - Prescription Date · Max 1 · Optional

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

                    Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send.

                13. 4550 · DTP · DATE - Certification Revision/Recertification Date · Max 1 · Optional

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

                    Required when CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send.

                14. 4550 · DTP · Date - Begin Therapy Date · Max 1 · Optional

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

                    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. If not required by this implementation guide, do not send.

                15. 4550 · DTP · Date - Last Certification Date · Max 1 · Optional

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

                    Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
                    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).

                16. 4550 · DTP · Date - Last Seen Date · Max 1 · Optional

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

                    Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.;

                17. 4550 · DTP · Date - Test Date · Max 2 · Optional

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

                    Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send.

                18. 4550 · DTP · Date - Shipped Date · Max 1 · Optional

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

                    Required when billing or reporting shipped products. If not required by this implementation guide, do not send.

                19. 4550 · DTP · Date - Last X-ray Date · Max 1 · Optional

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

                    Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

                20. 4550 · DTP · Date - Initial Treatment Date · Max 1 · Optional

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

                    Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send.

                21. 4600 · QTY · Ambulance Patient Count · Max 1 · Optional

                    To specify quantity information

                    Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
                    The QTY02 is the only place to report the number of patients when there are multiple patients transported.

                22. 4600 · QTY · Obstetric Anesthesia Additional Units · Max 1 · Optional

                    To specify quantity information

                    Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send.

                23. 4620 · MEA · Test Result · Max 5 · Optional

                    To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)

                    Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send.

                24. 4650 · CN1 · Contract Information · Max 1 · Optional

                    To specify basic data about the contract or contract line item

                    The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
                    Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.

                25. 4700 · REF · Repriced Line Item Reference Number · Max 1 · Optional

                    To specify identifying information

                    Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.

                26. 4700 · REF · Adjusted Repriced Line Item Reference Number · Max 1 · Optional

                    To specify identifying information

                    Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.

                27. 4700 · REF · Prior Authorization · Max 5 · Optional

                    To specify identifying information

                    Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.

                28. 4700 · REF · Line Item Control Number · Max 1 · Optional

                    To specify identifying information

                    Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
                    The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
                    Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.

                29. 4700 · REF · Mammography Certification Number · Max 1 · Optional

                    To specify identifying information

                    Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send.

                30. 4700 · REF · Clinical Laboratory Improvement Amendment (CLIA) Number · Max 1 · Optional

                    To specify identifying information

                    Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.;

                31. 4700 · REF · Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification · Max 1 · Optional

                    To specify identifying information

                    Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send.

                32. 4700 · REF · Immunization Batch Number · Max 1 · Optional

                    To specify identifying information

                    Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send.

                33. 4700 · REF · Referral Number · Max 5 · Optional

                    To specify identifying information

                    Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send.
                    When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.

                34. 4750 · AMT · Sales Tax Amount · Max 1 · Optional

                    To indicate the total monetary amount

                    Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
                    When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount.

                35. 4750 · AMT · Postage Claimed Amount · Max 1 · Optional

                    To indicate the total monetary amount

                    Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send.
                    When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount.

                36. 4800 · K3 · File Information · Max 10 · Optional

                    To transmit a fixed-format record or matrix contents

                    Required when ALL of the following conditions are met: - A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; - The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement - X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send.
                    At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
                    Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
                    X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

                37. 4850 · NTE · Line Note · Max 1 · Optional

                    To transmit information in a free-form format, if necessary, for comment or special instruction

                    Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send.
                    Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description.

                38. 4850 · NTE · Third Party Organization Notes · Max 1 · Optional

                    To transmit information in a free-form format, if necessary, for comment or special instruction

                    Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.

                39. 4880 · PS1 · Purchased Service Information · Max 1 · Optional

                    To specify the information about services that are 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 Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send.

                40. 4920 · HCP · Line Pricing/Repricing Information · Max 1 · Optional

                    To specify pricing or repricing information about a health care claim or line item

                    This information is specific to the destination payer reported in Loop ID-2010BB.
                    For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
                    Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.

                41. 2410 Loop Optional Repeat 1

                    1. 4930 · LIN · Drug Identification · Max 1 · Mandatory

                       To specify basic item identification data

                       Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send.
                       Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.

                    2. 4940 · CTP · Drug Quantity · Max 1 · Mandatory

                       To specify pricing information

                    3. 4950 · REF · Prescription or Compound Drug Association Number · Max 1 · Optional

                       To specify identifying information

                       Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send.
                       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.
                       For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.

                42. 2420A Loop Optional Repeat 1

                    1. 5000 · NM1 · Rendering Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
                       Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, do not send.;

                    2. 5050 · PRV · Rendering Provider Specialty Information · Max 1 · Optional

                       To specify the identifying characteristics of a provider

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

                    3. 5250 · REF · Rendering Provider Secondary Identification · Max 20 · Optional

                       To specify identifying information

                       Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                       When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

                43. 2420B Loop Optional Repeat 1

                    1. 5000 · NM1 · Purchased Service Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send.
                       Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations.

                    2. 5250 · REF · Purchased Service Provider Secondary Identification · Max 20 · Optional

                       To specify identifying information

                       Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                       When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

                44. 2420C Loop Optional Repeat 1

                    1. 5000 · NM1 · Service Facility Location Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
                       Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
                       The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.;

                    2. 5140 · N3 · Service Facility Location Address · Max 1 · Mandatory

                       To specify the location of the named party

                       If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                    3. 5200 · N4 · Service Facility Location City, State, ZIP Code · Max 1 · Mandatory

                       To specify the geographic place of the named party

                    4. 5250 · REF · Service Facility Location Secondary Identification · Max 3 · Optional

                       To specify identifying information

                       When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
                       Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send.

                45. 2420D Loop Optional Repeat 1

                    1. 5000 · NM1 · Supervising Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.

                    2. 5250 · REF · Supervising Provider Secondary Identification · Max 20 · Optional

                       To specify identifying information

                       Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                       When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

                46. 2420E Loop Optional Repeat 1

                    1. 5000 · NM1 · Ordering Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send.

                    2. 5140 · N3 · Ordering Provider Address · Max 1 · Optional

                       To specify the location of the named party

                       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. If not required by this implementation guide, do not send.

                    3. 5200 · N4 · Ordering Provider City, State, ZIP Code · Max 1 · Optional

                       To specify the geographic place of the named party

                       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. If not required by this implementation guide, do not send.

                    4. 5250 · REF · Ordering Provider Secondary Identification · Max 20 · Optional

                       To specify identifying information

                       Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                       When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

                    5. 5300 · PER · Ordering Provider Contact Information · Max 1 · Optional

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

                       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. 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

                47. 2420F Loop Optional Repeat 2

                    1. 5000 · NM1 · Referring Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
                       When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
                       Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                    2. 5250 · REF · Referring Provider Secondary Identification · Max 20 · Optional

                       To specify identifying information

                       Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
                       When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

                48. 2420G Loop Optional Repeat 1

                    1. 5000 · NM1 · Ambulance Pick-up Location · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.;

                    2. 5140 · N3 · Ambulance Pick-up Location Address · Max 1 · Mandatory

                       To specify the location of the named party

                       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, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                    3. 5200 · N4 · Ambulance Pick-up Location City, State, ZIP Code · Max 1 · Mandatory

                       To specify the geographic place of the named party

                49. 2420H Loop Optional Repeat 1

                    1. 5000 · NM1 · Ambulance Drop-off Location · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send.

                    2. 5140 · N3 · Ambulance Drop-off Location Address · Max 1 · Mandatory

                       To specify the location of the named party

                       If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

                    3. 5200 · N4 · Ambulance Drop-off Location City, State, ZIP Code · Max 1 · Mandatory

                       To specify the geographic place of the named party

                50. 2430 Loop Optional Repeat 15

                    1. 5400 · SVD · Line Adjudication Information · Max 1 · Mandatory

                       To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

                       Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
                       To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.

                    2. 5450 · CAS · Line Adjustment · Max 5 · Optional

                       To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

                       Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
                       A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

                    3. 5500 · DTP · Line Check or Remittance Date · Max 1 · Mandatory

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

                    4. 5505 · AMT · Remaining Patient Liability · Max 1 · Optional

                       To indicate the total monetary amount

                       In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
                       This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
                       Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
                       This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.

                51. 2440 Loop Optional Repeat >1

                    1. 5510 · LQ · Form Identification Code · Max 1 · Mandatory

                       To identify standard industry codes

                       Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send.
                       Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used.
                       An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services.

                    2. 5520 · FRM · Supporting Documentation · Max 99 · Mandatory

                       To specify information in response to a codified questionnaire document

                       The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQ*UT*08.02~).

2. 5550 · SE · 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)