EDI 837 X224A3 - Health Care Claim: Dental

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 Billing Provider is also the Rendering Provider for at least one of the claims in this transaction. 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 prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor 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. 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.

      4. 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 prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

         5. 0350 · REF · Billing Provider Secondary Identification · Max 1 · 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.

      5. 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 - 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.

         3. 1350 · DTP · Date - Appliance Placement · Max 1 · Optional

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

            Required when reporting the date orthodontic appliances were placed. 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 - Service Date · Max 1 · Optional

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

            Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. 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.

         5. 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.

         6. 1450 · DN1 · Orthodontic Total Months of Treatment · Max 1 · Optional

            To supply orthodontic information

            Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
            When reporting this segment, at least one of DN101, DN102 or DN104 must be present.

         7. 1500 · DN2 · Tooth Status · Max 35 · Optional

            To specify the status of individual teeth

            Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.

         8. 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.

         9. 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.

         10. 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).

         11. 1800 · REF · Predetermination Identification · Max 1 · Optional

             To specify identifying information

             Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
             Reference numbers at this position apply to the entire claim.

         12. 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.

         13. 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.

         14. 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.
             This segment must not be used to report the Predetermination of Benefits Identification Number.

         15. 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.
             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.
             This segment must not be used to report the Predetermination of Benefits Identification Number.
             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.

         16. 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.

         17. 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.

         18. 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.

         19. 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).

         20. 1900 · NTE · Claim Note · Max 5 · 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.
             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.;

         21. 2310 · HI · Health Care Diagnosis Code · Max 1 · Optional

             To supply information related to the delivery of health care

             Do not transmit the decimal point for ICD codes. The decimal point is implied.
             Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.

         22. 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.

         23. 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 the 2310A loop at the claim 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.

             2. 2550 · PRV · Referring 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. 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.

         24. 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 NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. 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 · Mandatory

                To specify the identifying characteristics of a provider

                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.

         25. 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.
                When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
                The purpose of this loop is to identify specifically where the service was rendered.
                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 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.

         26. 2310D Loop Optional Repeat 1

             1. 2500 · NM1 · Assistant Surgeon Name · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when the Rendering Provider provided these services in the role of the Assisting Surgeon. 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. 2550 · PRV · Assistant Surgeon Specialty Information · Max 1 · Mandatory

                To specify the identifying characteristics of a provider

                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.

             3. 2710 · REF · Assistant Surgeon 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 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.

         27. 2310E 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 or dentist. 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 when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop; OR Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider; OR Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider. If not required by this implementation guide, do not send.

         28. 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 · 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.

             5. 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.

             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 2 · 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. 3500 · 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 3 · Optional

                   To specify identifying information

                   Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the 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. 3550 · REF · Other Payer Prior Authorization Number · Max 1 · Optional

                   To specify identifying information

                   This segment must not be used to report the Predetermination of Benefits Identification Number.
                   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 Predetermination Identification · Max 1 · Optional

                   To specify identifying information

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

                10. 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

                    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

                    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 Supervising 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 Supervising Provider Secondary Identification · Max 3 · Mandatory

                    To specify identifying information

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

             13. 2330F 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.

             14. 2330G 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

                    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 Service Facility Location Secondary Identification · Max 3 · Mandatory

                    To specify identifying information

             15. 2330H Loop Optional Repeat 1

                 1. 3250 · NM1 · Other Payer Assistant Surgeon · 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 Assistant Surgeon Secondary Identifier · Max 3 · Mandatory

                    To specify identifying information

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

         29. 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. 3800 · SV3 · Dental Service · Max 1 · Mandatory

                To specify the service line item detail for dental work

             3. 3820 · TOO · Tooth Information · Max 32 · Optional

                To identify a tooth by number and, if applicable, one or more tooth surfaces

                Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
                Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.

             4. 4550 · DTP · Date - Service Date · Max 1 · Optional

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

                Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
                Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
                Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.

             5. 4550 · DTP · Date - Prior Placement · Max 1 · Optional

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

                Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.

             6. 4550 · DTP · Date - Appliance Placement · Max 1 · Optional

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

                Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;

             7. 4550 · DTP · Date - Replacement · Max 1 · Optional

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

                Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.

             8. 4550 · DTP · Date - Treatment Start · Max 1 · Optional

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

                Required when reporting initial impression or preparation for a crown or denture. OR Required when reporting initial endodontic treatment. OR Required when reporting the implant fixture placement. If not required by this implementation guide, do not send.
                When the Treatment Start Date is used, the Date of Service must not be used.

             9. 4550 · DTP · Date - Treatment Completion · Max 1 · Optional

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

                Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
                When the Treatment Completion Date is used, the Date of Service must not be used.

             10. 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.

             11. 4700 · REF · Service Predetermination Identification · Max 5 · Optional

                 To specify identifying information

                 Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
                 Reference numbers at this position apply to the current line item only.
                 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.

             12. 4700 · REF · Prior Authorization · Max 5 · Optional

                 To specify identifying information

                 This segment must not be used to report the Predetermination of Benefits Identification Number.
                 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.

             13. 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.

             14. 4700 · 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.

             15. 4700 · 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.

             16. 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.

             17. 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 (SV302) for this service line must include the amount reported in the Sales Tax Amount.

             18. 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).

             19. 4920 · HCP · Line 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.

             20. 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

                    Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present OR Required when each of the following conditions apply: - the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA) - this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider - the Assistant Surgeon loop (Loop ID-2420C) is not used. 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.

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

                    To specify the identifying characteristics of a provider

                 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.

             21. 2420B Loop Optional Repeat 1

                 1. 5000 · NM1 · Assistant Surgeon Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                    Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D. If not required by this implementation guide, do not send.;

                 2. 5050 · PRV · Assistant Surgeon Specialty Information · Max 1 · Optional

                    To specify the identifying characteristics of a provider

                    Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;

                 3. 5250 · REF · Assistant Surgeon 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 send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
                    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.

             22. 2420C 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 or dentist and the supervising physician or dentist 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 this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
                    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.

             23. 2420D 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.

                 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 20 · 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.

             24. 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

                    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.
                    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 not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
                    This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).

      6. 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

            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.
            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.

         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.

         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 - 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.

            3. 1350 · DTP · Date - Appliance Placement · Max 1 · Optional

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

               Required when reporting the date orthodontic appliances were placed. 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 - Service Date · Max 1 · Optional

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

               Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. 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.

            5. 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.

            6. 1450 · DN1 · Orthodontic Total Months of Treatment · Max 1 · Optional

               To supply orthodontic information

               Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
               When reporting this segment, at least one of DN101, DN102 or DN104 must be present.

            7. 1500 · DN2 · Tooth Status · Max 35 · Optional

               To specify the status of individual teeth

               Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.

            8. 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.

            9. 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.

            10. 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).

            11. 1800 · REF · Predetermination Identification · Max 1 · Optional

                To specify identifying information

                Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
                Reference numbers at this position apply to the entire claim.

            12. 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.

            13. 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.

            14. 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.
                This segment must not be used to report the Predetermination of Benefits Identification Number.

            15. 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.
                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.
                This segment must not be used to report the Predetermination of Benefits Identification Number.
                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.

            16. 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.

            17. 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.

            18. 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.

            19. 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).

            20. 1900 · NTE · Claim Note · Max 5 · 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.
                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.;

            21. 2310 · HI · Health Care Diagnosis Code · Max 1 · Optional

                To supply information related to the delivery of health care

                Do not transmit the decimal point for ICD codes. The decimal point is implied.
                Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.

            22. 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.

            23. 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 the 2310A loop at the claim 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.

                2. 2550 · PRV · Referring 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. 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.

            24. 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 NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. 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 · Mandatory

                   To specify the identifying characteristics of a provider

                   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.

            25. 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.
                   When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
                   The purpose of this loop is to identify specifically where the service was rendered.
                   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 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.

            26. 2310D Loop Optional Repeat 1

                1. 2500 · NM1 · Assistant Surgeon Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when the Rendering Provider provided these services in the role of the Assisting Surgeon. 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. 2550 · PRV · Assistant Surgeon Specialty Information · Max 1 · Mandatory

                   To specify the identifying characteristics of a provider

                   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.

                3. 2710 · REF · Assistant Surgeon 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 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.

            27. 2310E 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 or dentist. 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 when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop; OR Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider; OR Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider. If not required by this implementation guide, do not send.

            28. 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 · 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.

                5. 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.

                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 2 · 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. 3500 · 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 3 · Optional

                      To specify identifying information

                      Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the 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. 3550 · REF · Other Payer Prior Authorization Number · Max 1 · Optional

                      To specify identifying information

                      This segment must not be used to report the Predetermination of Benefits Identification Number.
                      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 Predetermination Identification · Max 1 · Optional

                      To specify identifying information

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

                   10. 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

                       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

                       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 Supervising 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 Supervising Provider Secondary Identification · Max 3 · Mandatory

                       To specify identifying information

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

                13. 2330F 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.

                14. 2330G 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

                       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 Service Facility Location Secondary Identification · Max 3 · Mandatory

                       To specify identifying information

                15. 2330H Loop Optional Repeat 1

                    1. 3250 · NM1 · Other Payer Assistant Surgeon · 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 Assistant Surgeon Secondary Identifier · Max 3 · Mandatory

                       To specify identifying information

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

            29. 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. 3800 · SV3 · Dental Service · Max 1 · Mandatory

                   To specify the service line item detail for dental work

                3. 3820 · TOO · Tooth Information · Max 32 · Optional

                   To identify a tooth by number and, if applicable, one or more tooth surfaces

                   Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
                   Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.

                4. 4550 · DTP · Date - Service Date · Max 1 · Optional

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

                   Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
                   Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
                   Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.

                5. 4550 · DTP · Date - Prior Placement · Max 1 · Optional

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

                   Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.

                6. 4550 · DTP · Date - Appliance Placement · Max 1 · Optional

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

                   Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;

                7. 4550 · DTP · Date - Replacement · Max 1 · Optional

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

                   Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.

                8. 4550 · DTP · Date - Treatment Start · Max 1 · Optional

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

                   Required when reporting initial impression or preparation for a crown or denture. OR Required when reporting initial endodontic treatment. OR Required when reporting the implant fixture placement. If not required by this implementation guide, do not send.
                   When the Treatment Start Date is used, the Date of Service must not be used.

                9. 4550 · DTP · Date - Treatment Completion · Max 1 · Optional

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

                   Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
                   When the Treatment Completion Date is used, the Date of Service must not be used.

                10. 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.

                11. 4700 · REF · Service Predetermination Identification · Max 5 · Optional

                    To specify identifying information

                    Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
                    Reference numbers at this position apply to the current line item only.
                    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.

                12. 4700 · REF · Prior Authorization · Max 5 · Optional

                    To specify identifying information

                    This segment must not be used to report the Predetermination of Benefits Identification Number.
                    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.

                13. 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.

                14. 4700 · 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.

                15. 4700 · 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.

                16. 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.

                17. 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 (SV302) for this service line must include the amount reported in the Sales Tax Amount.

                18. 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).

                19. 4920 · HCP · Line 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.

                20. 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

                       Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present OR Required when each of the following conditions apply: - the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA) - this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider - the Assistant Surgeon loop (Loop ID-2420C) is not used. 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.

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

                       To specify the identifying characteristics of a provider

                    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.

                21. 2420B Loop Optional Repeat 1

                    1. 5000 · NM1 · Assistant Surgeon Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D. If not required by this implementation guide, do not send.;

                    2. 5050 · PRV · Assistant Surgeon Specialty Information · Max 1 · Optional

                       To specify the identifying characteristics of a provider

                       Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;

                    3. 5250 · REF · Assistant Surgeon 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 send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
                       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.

                22. 2420C 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 or dentist and the supervising physician or dentist 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 this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
                       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.

                23. 2420D 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.

                    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 20 · 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.

                24. 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

                       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.
                       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 not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
                       This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).

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)