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 type of claim

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 Value · Type: String (AN) · Requirement: Conditional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of facility where services were performed; the first and second 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