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: 1

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: 18 · Repeat: 1

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: 1

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: 1

Code identifying the type of provider or claim

CLM-05 C023 Health Care Service Location Information Composite (composite) Optional 1

Position: 01 · Element: 1331 · Name: Facility Code Value · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 3 · Repeat: -

Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).

Position: 02 · Element: 1332 · Name: Facility Code Qualifier · Type: Identifier (ID) · Requirement: Mandatory · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of facility referenced

C023-02 qualifies C023-01.

Position: 03 · Element: 1325 · Name: Claim Frequency Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code specifying the Type of Bill Frequency Code. It is the last digit of Type of Bill in the UB manual, as defined by the National Uniform Billing Committee

Position: CLM-06 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.

Position: CLM-07 · Element: 1359 · Name: Provider Accept Assignment Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating whether the provider accepts assignment

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

Code indicating a Yes or No condition or response

CLM08 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-09 · Element: 1363 · Name: Release of Information Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

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

Position: CLM-10 · Element: 1351 · Name: Patient Signature Source Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

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

CLM-11 C024 Related Causes Information Composite (composite) Optional 1

Position: 01 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness, injury or an accident

Position: 02 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness, injury or an accident

Position: 03 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness, injury or an accident

Position: 04 · Element: 156 · Name: State or Province Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

Code specifying the Standard State/Province as defined by appropriate government agency

C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".

Position: 05 · Element: 26 · Name: Country Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying the country

Position: CLM-12 · Element: 1366 · Name: Special Program Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: 1

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

Position: CLM-13 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file; an "N" value indicates statement of nonavailability is not on file or not necessary.

Position: CLM-14 · Element: 1338 · Name: Level of Service Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 3 · Repeat: 1

Code specifying the level of service rendered

Position: CLM-15 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

CLM15 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-16 · Element: 1360 · Name: Provider Agreement Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

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

Position: CLM-17 · Element: 1029 · Name: Claim Status Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code identifying the status of an entire claim as assigned by the payer, claim review organization or repricing organization

Position: CLM-18 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

CLM18 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-19 · Element: 1383 · Name: Claim Submission Reason Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: 1

Code identifying reason for claim submission

Position: CLM-20 · Element: 1514 · Name: Delay Reason Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code indicating the reason why a request was delayed

Position: CLM-21 · Element: 1774 · Name: Claim Authorization Exception Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code identifying the reason for requesting an exception to standard processing of the claim