EDI 837 X300A1 - Post-adjudicated Claims Data Reporting: 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

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 available in the payer's system. If not required by this implementation guide, do not send.
      If, for whatever reason, the data is not stored within the payer's system, do not use.

   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

         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.
         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 information provided in this segment is intended to be representative of the information as known to the payer's system.

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

         To specify the location of the named party

         The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

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

         To specify the geographic place of the named party

         The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

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

         To specify identifying information

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

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

         To specify identifying information

         Required when available in the payer's system. If not required by this implementation guide, do not send.
         If, for whatever reason, the data is not stored within the payer's system, do not use.

      6. 0350 · REF · Billing Provider Secondary Identification · Max 1 · Optional

         To specify identifying information

         Required when available in the payer's system. If not required by this implementation guide, do not send.
         If, for whatever reason, the data is not stored within the payer's system, do not use.

   5. 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

         When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.

      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.
            When submitting to an All Payer Claims Database or Health Benefit Exchange, this is the Subscriber as defined within the payers enrollment files. When submitting Medicare or Medicaid encounters, the patient is always the subscriber.

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

            To specify the location of the named party

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

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

            To specify the geographic place of the named party

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

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

            To supply demographic information

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

         5. 0350 · REF · Subscriber Social Security Number · Max 1 · Optional

            To specify identifying information

            Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
            Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

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

            To specify identifying information

            Required when available in the payer's system. If not required by this implementation guide, do not send.
            If, for whatever reason, the data is not stored within the payer's system, do not use.

      4. 2010BB Loop Mandatory Repeat 1

         1. 0150 · NM1 · Data Receiver · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

      5. 2000C Loop Optional Repeat >1

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

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

            Required when the data receiver is a reporting entity, such as an APCD or Health Insurance Exchange, AND the patient is not the subscriber.
            The information reported in this loop describes the patient as known by the payer's system.
            When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.
            There are no HLs subordinate to the Patient HL.

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

            To supply patient information

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

         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

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

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

               To specify the location of the named party

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

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

               To specify the geographic place of the named party

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

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

               To supply demographic information

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

            5. 0350 · REF · Patient Social Security Number · Max 1 · Optional

               To specify identifying information

               Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
               Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

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

               To specify identifying information

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

         4. 2300 Loop Mandatory Repeat 100

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

               To specify basic data about the claim

               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 patient 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 patient. 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, Loop ID-2000C and Loop ID-2010CA are not sent.

            2. 1350 · DTP · Date - Accident · Max 1 · Optional

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

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

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

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

               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.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            4. 1350 · DTP · Date - Service Date · Max 1 · Optional

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

               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.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            5. 1450 · DN1 · Orthodontic Total Months of Treatment · Max 1 · Optional

               To supply orthodontic information

               When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            6. 1500 · DN2 · Tooth Status · Max 35 · Optional

               To specify the status of individual teeth

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            7. 1600 · CN1 · Contract Information · Max 1 · Optional

               To specify basic data about the contract or contract line item

               Required when this information is necessary to satisfy contract requirements. If not required by this implementation guide, do not send.

            8. 1750 · AMT · Patient Amount Paid · Max 1 · Optional

               To indicate the total monetary amount

               Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            9. 1800 · REF · Referral Number · Max 1 · Optional

               To specify identifying information

               Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            10. 1800 · REF · Prior Authorization · Max 1 · Optional

                To specify identifying information

                Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            11. 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.
                The data conveyed in this segment is not related to the provider submission to the payer. This segment is used only when the payer is submitting this transaction to the Data Receiver through an intermediary that assigns their own unique claim number.

            12. 1850 · K3 · File Information · Max 10 · Optional

                To transmit a fixed-format record or matrix contents

                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).
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            13. 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 available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            14. 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

                   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.
                   When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

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

                   To specify the identifying characteristics of a provider

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                3. 2710 · REF · Referring Provider Secondary Identification · Max 2 · 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 when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            15. 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

                   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.
                   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.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

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

                   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.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                3. 2710 · REF · Rendering 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 when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            16. 2310C Loop Mandatory Repeat 1

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

                   To supply the full name of an individual or organizational entity

                   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.
                   This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

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

                   To specify the location of the named party

                   This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

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

                   To specify the geographic place of the named party

                   This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

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

                   To specify identifying information

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            17. 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

                   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.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                2. 2550 · PRV · Assistant Surgeon Specialty Information · Max 1 · Optional

                   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.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                3. 2710 · REF · Assistant Surgeon Secondary Identification · Max 3 · Optional

                   To specify identifying information

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            18. 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

                   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.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

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

                   To specify identifying information

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            19. 2320 Loop Mandatory 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

                   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.;
                   Loop ID 2320 and its suboordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by both the submitting payer and other payers who have previously adjudicated the claim. This loop is not to be provided for payers who have not adjudicated the claim. For example, the provider submitted claim includes payer information that is subsequent to the payer submitting this transaction. SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer. When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider. When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.

                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 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.
                   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).
                   When the payer identified is not the submitting payer, codes and associated amounts must be reported as submitted by the provider. When the payer identified is the submitting payer, codes and amounts must be reported the same as if creating the 835 to send to the provider.

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

                   To indicate the total monetary amount

                4. 3000 · AMT · Remaining Patient Liability · Max 1 · Optional

                   To indicate the total monetary amount

                   In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                5. 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 SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider. OR Required when SBR06 = 1; and this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

                6. 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

                      When SBR06 = 1, the information in this segment represents the Subscriber as submitted by the provider for the payer identified in Loop ID 2330B. When SBR06 = 6, the information in this segment represents the Subscriber as known by the submitting payer.

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

                      To specify the location of the named party

                      Required when available in the payer's system. If not required by this implementation guide, do not send.
                      If, for whatever reason, the data is not stored within the payer's system, do not use.

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

                      To specify the geographic place of the named party

                      Required when available in the payer's system. If not required by this implementation guide, do not send.
                      If, for whatever reason, the data is not stored within the payer's system, do not use.

                   4. 3550 · REF · Other Subscriber Social Security Number · Max 2 · Optional

                      To specify identifying information

                      Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
                      Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

                7. 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

                   2. 3500 · DTP · Claim Check or Remittance Date · Max 1 · Mandatory

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

                   3. 3550 · REF · Other Payer Secondary Identifier · Max 3 · Optional

                      To specify identifying information

                      Required when available in the payer's system. If not required by this implementation guide, do not send.

                   4. 3550 · REF · Other Payer Claim Adjustment Indicator · Max 1 · Optional

                      To specify identifying information

                      Required when SBR06 = 6; and this claim is a void or adjustment of a previously adjudicated claim. If not required by this implementation guide, do not send.

                   5. 3550 · REF · Other Payer Claim Control Number · Max 1 · Optional

                      To specify identifying information

                      If, for whatever reason, the data is not stored within the payer's system, do not use.
                      Required when SBR06 = 6. OR Required when available in the payer's system. If not required by this implementation guide, do not send.

                   6. 3550 · REF · Other Payer Adjusted Claim Control Number · Max 1 · Optional

                      To specify identifying information

                      If, for whatever reason, the data is not stored within the payer's system, do not use.
                      Required when SBR06 = 6 and the submitting payer has adjusted this claim. OR Required when available in the payer's system. If not required by this implementation guide, do not send.

                8. 2330C Loop Optional Repeat 1

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

                      To supply the full name of an individual or organizational entity

                      When SBR06 = 1, the information in this segment represents the Patient as submitted by the provider for the payer identified in Loop ID 2330B. When SBR06 = 6, the information in this segment represents the Patient as known by the submitting payer.
                      Required when the entity reported in Loop ID 2330A (Other Payer Subscriber) is not the patient.

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

                      To specify the location of the named party

                      If, for whatever reason, the data is not stored within the payer's system, do not use.
                      Required when available in the payer's system. If not required by this implementation guide, do not send.

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

                      To specify the geographic place of the named party

                      Required when available in the payer's system. If not required by this implementation guide, do not send.
                      If, for whatever reason, the data is not stored within the payer's system, do not use.

                   4. 3550 · REF · Other Patient Secondary Identification · Max 3 · Optional

                      To specify identifying information

                      Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
                      Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

            20. 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 1.4.2.4 for more information on bundling and section 1.4.2.6 for more information on 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 available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

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

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

                   Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                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 available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                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 available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

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

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

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

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

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

                   When the Treatment Start Date is used, the Date of Service must not be used.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

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

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

                   When the Treatment Completion Date is used, the Date of Service must not be used.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                10. 4650 · CN1 · Contract Information · Max 1 · Optional

                    To specify basic data about the contract or contract line item

                    Required when this information is necessary to satisfy contract requirements. If not required by this implementation guide, do not send.

                11. 4700 · REF · Prior Authorization · Max 5 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                12. 4700 · REF · Referral Number · Max 5 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                13. 4800 · K3 · File Information · Max 10 · Optional

                    To transmit a fixed-format record or matrix contents

                    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).
                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                14. 2420A Loop Optional Repeat 1

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

                       To supply the full name of an individual or organizational entity

                       Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

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

                       To specify the identifying characteristics of a provider

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

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

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                15. 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 available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

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

                       To specify the identifying characteristics of a provider

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    3. 5250 · REF · Assistant Surgeon Secondary Identification · Max 3 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                16. 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 available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    2. 5250 · REF · Supervising Provider Secondary Identification · Max 3 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                17. 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

                       Loop ID 2430 conveys information demonstrating how this line was adjudicated by both the submitting payer and other payers who have previously adjudicated the line. Loop 2430 and the related 2320 loop are linked using the value reported in Loop 2320 SBR01 and Loop 2430 SVD01. Loop 2320 SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer. When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider. When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.
                       Required when 2320 SBR06 = 6 and an 835 sent to the provider would have included service line detail. OR Required when the related Loop ID 2320 SBR06 = 1; and the data was present on the provider submitted claim. If not required by this implementation guide, do not send.

                    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

                       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).
                       Required when the payer identified in this Line Adjudication Information Loop ID-2430 made line level adjustments which caused the dollar amount paid for the service line (SVD02) to differ from the amount originally charged for this service. If not required by this implementation guide, do not send.

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

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

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

                       To indicate the total monetary amount

                       In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.

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)