CLM Health Claim

To specify basic data about the claim

Position: CLM-01 · Element: 1028 · Name: Claim Submitter's Identifier · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 38 · Repeat: -

Identifier used to track a claim from creation by the health care provider through payment.

Position: CLM-02 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 15 · Repeat: -

Monetary amount.

CLM02 is the total amount of all submitted charges of service segments for this claim.

Position: CLM-03 · Element: 1032 · Name: Claim Filing Indicator Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of health insurance or program.

Position: CLM-04 · Element: 1343 · Name: Non-Institutional Claim Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of provider or claim

Position: CLM-05 · Element: 1332 · Name: Facility Code Qualifier · Type: Identifier (ID) · Requirement: Conditional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of facility referenced

P0506: If either CLM-05 or CLM-06 is present, then the other is required

Position: CLM-06 · Element: 1331 · Name: Facility Code · Type: Identifier (ID) · Requirement: Conditional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of facility where services were performed; the first position of the uniform bill type or place of service from health care financing administration claim form or place of treatment from the dental claim form

Position: CLM-07 · Element: 1325 · Name: Claim Frequency Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

Position: CLM-08 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating a Yes or No condition or response.

CLM08 is provider signature on file indicator. A ``Y'' value indicates the provider signature is on file. A ``N'' value indicates the provider signature is not on file.

Position: CLM-09 · Element: 1359 · Name: Provider Accept Assignment Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating whether the provider accepts assignment

Position: CLM-10 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating a Yes or No condition or response.

CLM10 is assignment of benefits indicator. A ``Y'' value indicates insured or authorized person authorizes benefits to be assigned to the provider. An ``N'' value indicates benefits have not been assigned to the provider.

Position: CLM-11 · Element: 1363 · Name: Release of Information Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations in order to adjudicate the claim

Position: CLM-12 · Element: 1351 · Name: Patient Signature Source Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

Position: CLM-13 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness or an accident

Position: CLM-14 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness or an accident

Position: CLM-15 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness or an accident

Position: CLM-16 · Element: 156 · Name: State or Province Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

Code (Standard State/Province) as defined by appropriate government agency.

CLM16 and CLM17 apply only to auto accidents when CLM13, CLM14, or CLM15 is equal to AA.

Position: CLM-17 · Element: 26 · Name: Country Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying the country.

Position: CLM-18 · Element: 1366 · Name: Special Program Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code indicating the Special Program under which the services rendered to the patient were performed

Position: CLM-19 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating a Yes or No condition or response.

CLM19 is CHAMPUS non-availability indicator. A ``Y'' value indicates a statement of non-availability is on file. An ``N'' value indicates statement of non-availability is not on file or not necessary.

Position: CLM-20 · Element: 1338 · Name: Level of Service Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 3 · Repeat: -

Code specifying the level of service rendered

Position: CLM-21 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating a Yes or No condition or response.

CLM21 is charges itemized by service indicator. A ``Y'' value indicates charges are itemized by service. An ``N'' value indicates charges are summarized by service.

Position: CLM-22 · Element: 1360 · Name: Provider Agreement Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating the type of agreement under which the provider is submitting this claim

Position: CLM-23 · Element: 1029 · Name: Claim Status Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

Code identifying the status of an entire claim as assigned by the payor.

Position: CLM-24 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating a Yes or No condition or response.

CLM24 is explanation of benefit (EOB) indicator. A ``Y'' value indicates that a paper EOB is requested. An ``N'' value indicates that no paper EOB is requested.

Position: CLM-25 · Element: 1383 · Name: Claim Submission Reason Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

Code identifying reason for claim submission