837 Health Care Claim: Institutional: Companion Guide · 837 Health Care Claim: Institutional: Companion Guide HIPAA/V4010X096A1/837: 837 Health Care Claim: Institutional Version:

837 Health Care Claim:Institutional: Companion

GuideHIPAA/V4010X096A1/837: 837 Health Care Claim: Institutional

Version: 1.1 Final

Author: Kelli Gonczeruk & Cindy

Brown

Company: Blue Shield of California Publication: 12/7/2010 Modified: 12/7/2010 Current: 12/7/2010

12/1/2010 Health Care Claim: Institutional - 837

837I_CG.ecs i For internal use only

Table of Contents

837 Health Care Claim: Institutional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>ISA Interchange Control Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>GS Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>ST Transaction Set Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>BHT Beginning of Hierarchical Transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Transmission Type Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>1000A Loop Submitter Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Submitter Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PER Submitter EDI Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>1000B Loop Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2000A Loop Billing/Pay-To Provider Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HL Billing/Pay-To Provider Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PRV Billing/Pay-To Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CUR Foreign Currency Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010AA Loop Billing Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Billing Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Billing Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Billing Provider City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Billing Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Credit/Debit Card Billing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PER Billing Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010AB Loop Pay-To Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Pay-To Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Pay-To Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Pay-To Provider City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Pay-To Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2000B Loop Subscriber Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HL Subscriber Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SBR Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010BA Loop Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Subscriber City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DMG Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Subscriber Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Property and Casualty Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010BB Loop Credit/Debit Card Account Holder Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Credit/Debit Card Account Holder Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

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837I_CG.ecs ii For internal use only

REF Credit/Debit Card Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010BC Loop Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Payer Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Payer City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Payer Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010BD Loop Responsible Party Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Responsible Party Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Responsible Party Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Responsible Party City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2300 Loop Claim information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CLM Claim information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Discharge Hour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Statement Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Admission Date/Hour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CL1 Institutional Claim Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PWK Claim Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CN1 Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Payer Estimated Amount Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Patient Estimated Amount Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Patient Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Credit/Debit Card Maximum Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Adjusted Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries . <PH>REF Document Identification Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Original Reference Number (ICN/DCN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Investigational Device Exemption Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Service Authorization Exception Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Peer Review Organization (PRO) Approval Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Medical Record Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Demonstration Project Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>K3 File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NTE Claim Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NTE Billing Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CR6 Home Health Care Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CRC Home Health Functional Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CRC Home Health Activities Permitted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CRC Home Health Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information . . . . . . . . . . . <PH>HI Diagnosis Related Group (DRG) Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Other Diagnosis Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

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837I_CG.ecs iii For internal use only

HI Principal Procedure Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Other Procedure Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Occurrence Span Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Occurrence Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Value Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Condition Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Treatment Code Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>QTY Claim Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HCP Claim Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2305 Loop Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CR7 Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HSD Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310A Loop Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PRV Attending Physician Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Attending Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310B Loop Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Operating Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310C Loop Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310E Loop Service Facility Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Service Facility Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Service Facility Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Service Facility City/State/Zip Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Service Facility Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2320 Loop Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SBR Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CAS Claim Level Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Payer Prior Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Allowed Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Submitted Charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Diagnostic Related Group (DRG) Outlier Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Medicare Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Medicare Paid Amount - 100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Medicare Paid Amount - 80% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Non-covered Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Denied Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DMG Other Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>OI Other Insurance Coverage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

158. . 167. . 169. . 181. . 192. . 205. . 214. . 223. . 229. . 231. . 236. . 237. . 238. . 241. . 242. . 244. . 245. . 247. . 248. . 250. . 252. . 253. . 256. . 258. . 259. . 261. . 262. . 264. . 266. . 268. . 273. . 278. . 279. . 280. . 281. . 282. . 283. . 284. . 285. . 286. . 287. . 288. . 289. .


837I_CG.ecs iv For internal use only

MIA Medicare Inpatient Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>MOA Medicare Outpatient Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330A Loop Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Other Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Other Subscriber City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Subscriber Secondary Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330B Loop Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Other Payer Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Other Payer City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Claim Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Secondary Identification and Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330C Loop Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Patient Identification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330D Loop Other Payer Attending Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Attending Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Attending Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330E Loop Other Payer Operating Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Operating Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Operating Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330F Loop Other Payer Other Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Other Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Other Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330H Loop Other Payer Service Facility Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Service Facility Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Service Facility Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2400 Loop Service Line Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>LX Service Line Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SV2 Institutional Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PWK Line Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Service Line Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Assessment Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Service Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Facility Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HCP Line Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2410 Loop Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>LIN Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CTP Drug Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Prescription Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2420A Loop Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

290. . 292. . 297. . 300. . 301. . 303. . 304. . 306. . 307. . 308. . 310. . 311. . 313. . 314. . 316. . 317. . 318. . 320. . 321. . 322. . 323. . 324. . 325. . 326. . 327. . 328. . 329. . 330. . 331. . 332. . 333. . 334. . 335. . 340. . 343. . 345. . 346. . 347. . 348. . 353. . 354. . 356. . 358. .


837I_CG.ecs v For internal use only

NM1 Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Attending Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2420B Loop Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Operating Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2420C Loop Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2430 Loop Service Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SVD Service Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CAS Service Line Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Service Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2000C Loop Patient Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HL Patient Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PAT Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2010CA Loop Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Patient Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Patient City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DMG Patient Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Patient Secondary Identification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Property and Casualty Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2300 Loop Claim information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CLM Claim information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Discharge Hour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Statement Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Admission Date/Hour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CL1 Institutional Claim Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PWK Claim Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CN1 Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Payer Estimated Amount Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Patient Estimated Amount Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Patient Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Credit/Debit Card Maximum Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Adjusted Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries . <PH>REF Document Identification Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Original Reference Number (ICN/DCN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Investigational Device Exemption Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Service Authorization Exception Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Peer Review Organization (PRO) Approval Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

359. . 360. . 362. . 364. . 365. . 367. . 369. . 370. . 372. . 374. . 375. . 379. . 384. . 385. . 386. . 388. . 391. . 392. . 394. . 395. . 397. . 398. . 399. . 400. . 402. . 407. . 408. . 409. . 410. . 411. . 414. . 416. . 417. . 418. . 419. . 420. . 421. . 422. . 423. . 424. . 426. . 427. . 428. .


837I_CG.ecs vi For internal use only

REF Medical Record Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Demonstration Project Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>K3 File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NTE Claim Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NTE Billing Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CR6 Home Health Care Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CRC Home Health Functional Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CRC Home Health Activities Permitted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CRC Home Health Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information . . . . . . . . . . . <PH>HI Diagnosis Related Group (DRG) Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Other Diagnosis Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Principal Procedure Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Other Procedure Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Occurrence Span Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Occurrence Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Value Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Condition Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HI Treatment Code Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>QTY Claim Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HCP Claim Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2305 Loop Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CR7 Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HSD Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310A Loop Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PRV Attending Physician Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Attending Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310B Loop Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Operating Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310C Loop Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2310E Loop Service Facility Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Service Facility Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Service Facility Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Service Facility City/State/Zip Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Service Facility Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2320 Loop Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SBR Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CAS Claim Level Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Payer Prior Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

429. . 431. . 432. . 433. . 435. . 437. . 438. . 444. . 450. . 456. . 461. . 463. . 464. . 473. . 475. . 487. . 498. . 511. . 520. . 529. . 535. . 537. . 542. . 543. . 544. . 547. . 548. . 551. . 552. . 554. . 555. . 557. . 559. . 560. . 563. . 565. . 566. . 568. . 569. . 571. . 573. . 575. . 580. .


837I_CG.ecs vii For internal use only

AMT Coordination of Benefits (COB) Total Allowed Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Submitted Charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Diagnostic Related Group (DRG) Outlier Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Medicare Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Medicare Paid Amount - 100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Medicare Paid Amount - 80% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Non-covered Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Coordination of Benefits (COB) Total Denied Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DMG Other Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>OI Other Insurance Coverage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>MIA Medicare Inpatient Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>MOA Medicare Outpatient Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330A Loop Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Other Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Other Subscriber City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Subscriber Secondary Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330B Loop Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N3 Other Payer Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>N4 Other Payer City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Claim Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Secondary Identification and Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330C Loop Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Patient Identification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330D Loop Other Payer Attending Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Attending Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Attending Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330E Loop Other Payer Operating Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Operating Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Operating Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330F Loop Other Payer Other Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Other Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Other Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2330H Loop Other Payer Service Facility Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Payer Service Facility Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Payer Service Facility Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2400 Loop Service Line Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>LX Service Line Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

585. . 586. . 587. . 588. . 589. . 590. . 591. . 592. . 593. . 594. . 595. . 596. . 597. . 599. . 604. . 607. . 608. . 610. . 611. . 613. . 614. . 615. . 617. . 618. . 620. . 621. . 623. . 624. . 625. . 627. . 628. . 629. . 630. . 631. . 632. . 633. . 634. . 635. . 636. . 637. . 638. . 639. . 640. .


837I_CG.ecs viii For internal use only

SV2 Institutional Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>PWK Line Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Service Line Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Assessment Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Service Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>AMT Facility Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>HCP Line Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2410 Loop Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>LIN Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CTP Drug Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Prescription Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2420A Loop Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Attending Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Attending Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2420B Loop Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Operating Physician Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Operating Physician Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2420C Loop Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>NM1 Other Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>REF Other Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>2430 Loop Service Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SVD Service Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>CAS Service Line Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>DTP Service Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>SE Transaction Set Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>GE Functional Group Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>IEA Interchange Control Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>

641. . 642. . 648. . 651. . 653. . 654. . 655. . 656. . 661. . 662. . 665. . 667. . 668. . 669. . 671. . 673. . 674. . 676. . 678. . 679. . 681. . 683. . 684. . 688. . 693. . 694. . 695. . 696


837I_CG.ecs 1 For internal use only

837 Health Care Claim: InstitutionalFunctional Group=HC

Purpose: This Draft Standard for Trial Use contains the format and establishes the data contents of the Health CareClaim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. Thistransaction set can be used to submit health care claim billing information, encounter information, or both, fromproviders of health care services to payers, either directly or via intermediary billers and claims clearinghouses. Itcan also be used to transmit health care claims and billing payment information between payers with differentpayment responsibilities where coordination of benefits is required or between payers and regulatory agencies tomonitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industrysegment.For purposes of this standard, providers of health care products or services may include entities such asphysicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providingmedical information to meet regulatory requirements. The payer refers to a third party entity that pays claims oradministers the insurance product or benefit or both. For example, a payer may be an insurance company, healthmaintenance 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 partyadministrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatoryagency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or aspecific health care/insurance industry segment.

Not Defined:Pos Id Segment Name Req Max Use Repeat Notes Usage

ISA Interchange ControlHeader

M 1 Required

GS Functional Group Header M 1 Required

Heading:Pos Id Segment Name Req Max Use Repeat Notes Usage005 ST Transaction Set Header M 1 Required010 BHT Beginning of Hierarchical

TransactionM 1 Required

015 REF Transmission TypeIdentification

O 1 Required

LOOP ID - 1000A 1 N1/020L LOOP ID - 1000A 1 N1/020L

020 NM1 Submitter Name O 1 N1/020 Required045 PER Submitter EDI Contact

InformationO 2 Required

LOOP ID - 1000B 1 N1/020L LOOP ID - 1000B 1 N1/020L

020 NM1 Receiver Name O 1 N1/020 Required

Detail:Pos Id Segment Name Req Max Use Repeat Notes Usage

LOOP ID - 2000A >1 LOOP ID - 2000A >1

001 HL Billing/Pay-To ProviderHierarchical Level

M 1 Required

003 PRV Billing/Pay-To ProviderSpecialty Information

O 1 Situational

010 CUR Foreign CurrencyInformation

O 1 Situational

LOOP ID - 2010AA 1 N2/015L LOOP ID - 2010AA 1 N2/015L

015 NM1 Billing Provider Name O 1 N2/015 Required


Pos Id Segment Name Req Max Use Repeat Notes Usage


025 N3 Billing Provider Address O 1 Required030 N4 Billing Provider

City/State/ZIP CodeO 1 Required

035 REF Billing Provider SecondaryIdentification

O 8 Situational

035 REF Credit/Debit Card BillingInformation

O 8 Situational

040 PER Billing Provider ContactInformation

O 2 Situational

LOOP ID - 2010AB 1 N2/015L LOOP ID - 2010AB 1 N2/015L

015 NM1 Pay-To Provider Name O 1 N2/015 Situational025 N3 Pay-To Provider Address O 1 Required030 N4 Pay-To Provider


035 REF Pay-To ProviderSecondary Identification

O 5 Situational

LOOP ID - 2000B >1 LOOP ID - 2000B >1

001 HL Subscriber HierarchicalLevel

M 1 Required

005 SBR Subscriber Information O 1 Required LOOP ID - 2010BA 1 N2/015L LOOP ID - 2010BA 1 N2/015L

015 NM1 Subscriber Name O 1 N2/015 Required025 N3 Subscriber Address O 1 Situational030 N4 Subscriber City/State/ZIP

CodeO 1 Situational

032 DMG Subscriber DemographicInformation

O 1 Situational

035 REF Subscriber SecondaryIdentification

O 4 Situational

035 REF Property and CasualtyClaim Number

O 1 Situational

LOOP ID - 2010BB 1 N2/015L LOOP ID - 2010BB 1 N2/015L

015 NM1 Credit/Debit Card AccountHolder Name

O 1 N2/015 Situational

035 REF Credit/Debit CardInformation

O 2 Situational

LOOP ID - 2010BC 1 N2/015L LOOP ID - 2010BC 1 N2/015L

015 NM1 Payer Name O 1 N2/015 Required025 N3 Payer Address O 1 Situational030 N4 Payer City/State/ZIP Code O 1 Situational035 REF Payer Secondary

IdentificationO 3 Situational

LOOP ID - 2010BD 1 N2/015L LOOP ID - 2010BD 1 N2/015L

015 NM1 Responsible Party Name O 1 N2/015 Situational025 N3 Responsible Party Address O 1 Required030 N4 Responsible Party





LOOP ID - 2300 100LOOP ID - 2300 100130 CLM Claim information O 1 Required135 DTP Discharge Hour O 1 Situational135 DTP Statement Dates O 1 Required135 DTP Admission Date/Hour O 1 Situational140 CL1 Institutional Claim Code O 1 Situational155 PWK Claim Supplemental

InformationO 10 Situational

160 CN1 Contract Information O 1 Situational175 AMT Payer Estimated Amount

DueO 1 Situational

175 AMT Patient Estimated AmountDue

O 1 Situational

175 AMT Patient Paid Amount O 1 Situational175 AMT Credit/Debit Card

Maximum AmountO 1 Situational

180 REF Adjusted Repriced ClaimNumber

O 1 Situational

180 REF Repriced Claim Number O 1 Situational180 REF Claim Identification

Number ForClearinghouses and OtherTransmissionIntermediaries

O 1 Situational

180 REF Document IdentificationCode

O 2 Situational

180 REF Original ReferenceNumber (ICN/DCN)

O 1 Situational

180 REF Investigational DeviceExemption Number

O 1 Situational

180 REF Service AuthorizationException Code

O 1 Situational

180 REF Peer Review Organization(PRO) Approval Number

O 1 Situational

180 REF Prior Authorization orReferral Number

O 2 Situational

180 REF Medical Record Number O 1 Situational180 REF Demonstration Project

IdentifierO 1 Situational

185 K3 File Information O 10 Situational190 NTE Claim Note O 10 Situational190 NTE Billing Note O 1 Situational216 CR6 Home Health Care


220 CRC Home Health FunctionalLimitations

O 3 Situational

220 CRC Home Health ActivitiesPermitted

O 3 Situational

220 CRC Home Health MentalStatus

O 2 Situational

231 HI Principal, Admitting,E-Code and Patient

O 1 Situational




Reason For VisitDiagnosis Information

231 HI Diagnosis Related Group(DRG) Information

O 1 Situational

231 HI Other DiagnosisInformation

O 2 Situational

231 HI Principal ProcedureInformation

O 1 Situational

231 HI Other ProcedureInformation

O 2 Situational

231 HI Occurrence SpanInformation

O 2 Situational

231 HI Occurrence Information O 2 Situational231 HI Value Information O 2 Situational231 HI Condition Information O 2 Situational231 HI Treatment Code


240 QTY Claim Quantity O 4 Situational241 HCP Claim Pricing/Repricing


LOOP ID - 2305 6 LOOP ID - 2305 6

242 CR7 Home Health Care PlanInformation

O 1 Situational

243 HSD Health Care ServicesDelivery

O 12 Situational


250 NM1 Attending Physician Name O 1 N2/250 Situational255 PRV Attending Physician

Specialty InformationO 1 Situational

271 REF Attending PhysicianSecondary Identification

O 5 Situational


250 NM1 Operating Physician Name O 1 N2/250 Situational271 REF Operating Physician

Secondary IdentificationO 5 Situational

LOOP ID - 2310C 1 N2/250L LOOP ID - 2310C 1 N2/250L

250 NM1 Other Provider Name O 1 N2/250 Situational271 REF Other Provider Secondary


LOOP ID - 2310E 1 N2/250L LOOP ID - 2310E 1 N2/250L

250 NM1 Service Facility Name O 1 N2/250 Situational265 N3 Service Facility Address O 1 Required270 N4 Service Facility

City/State/Zip CodeO 1 Required

271 REF Service Facility SecondaryIdentification

O 5 Situational

LOOP ID - 2320 10 N2/290L LOOP ID - 2320 10 N2/290L

290 SBR Other SubscriberInformation





295 CAS Claim Level Adjustment O 5 Situational300 AMT Payer Prior Payment O 1 Situational300 AMT Coordination of Benefits

(COB) Total AllowedAmount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total SubmittedCharges

O 1 Situational

300 AMT Diagnostic Related Group(DRG) Outlier Amount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total Medicare PaidAmount

O 1 Situational

300 AMT Medicare Paid Amount -100%

O 1 Situational


O 1 Situational

300 AMT Coordination of Benefits(COB) Medicare A TrustFund Paid Amount

O 1 Situational

300 AMT Coordination of Benefits(COB) Medicare B TrustFund Paid Amount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total Non-coveredAmount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total DeniedAmount

O 1 Situational

305 DMG Other SubscriberDemographic Information

O 1 Situational

310 OI Other Insurance CoverageInformation

O 1 Required

315 MIA Medicare InpatientAdjudication Information

O 1 Situational

320 MOA Medicare OutpatientAdjudication Information

O 1 Situational


325 NM1 Other Subscriber Name O 1 N2/325 Required332 N3 Other Subscriber Address O 1 Situational340 N4 Other Subscriber

City/State/ZIP CodeO 1 Situational

355 REF Other SubscriberSecondary Information

O 3 Situational


325 NM1 Other Payer Name O 1 N2/325 Required332 N3 Other Payer Address O 1 Situational340 N4 Other Payer City/State/ZIP

CodeO 1 Situational

350 DTP Claim Adjudication Date O 1 Situational355 REF Other Payer Secondary

Identification and O 2 Situational




Reference Number355 REF Other Payer Prior

Authorization or ReferralNumber

O 1 Situational


325 NM1 Other Payer PatientInformation


355 REF Other Payer PatientIdentification Number

O 3 Situational

LOOP ID - 2330D 1 N2/325L LOOP ID - 2330D 1 N2/325L

325 NM1 Other Payer AttendingProvider


355 REF Other Payer AttendingProvider Identification

O 3 Required


325 NM1 Other Payer OperatingProvider


355 REF Other Payer OperatingProvider Identification

O 3 Required

LOOP ID - 2330F 1 N2/325L LOOP ID - 2330F 1 N2/325L

325 NM1 Other Payer OtherProvider


355 REF Other Payer OtherProvider Identification

O 3 Required

LOOP ID - 2330H 1 N2/325L LOOP ID - 2330H 1 N2/325L

325 NM1 Other Payer ServiceFacility Provider


355 REF Other Payer ServiceFacility ProviderIdentification

O 3 Required


365 LX Service Line Number O 1 N2/365 Required375 SV2 Institutional Service Line O 1 Required420 PWK Line Supplemental


455 DTP Service Line Date O 1 Situational455 DTP Assessment Date O 1 Situational475 AMT Service Tax Amount O 1 Situational475 AMT Facility Tax Amount O 1 Situational492 HCP Line Pricing/Repricing



494 LIN Drug Identification O 1 N2/494 Situational495 CTP Drug Pricing O 1 Situational496 REF Prescription Number O 1 Situational


500 NM1 Attending Physician Name O 1 N2/500 Situational





O 1 Situational








540 SVD Service Line AdjudicationInformation


545 CAS Service Line Adjustment O 99 Situational550 DTP Service Adjudication Date O 1 Situational

LOOP ID - 2000C >1 LOOP ID - 2000C >1

001 HL Patient Hierarchical Level O 1 Situational007 PAT Patient Information O 1 Required

LOOP ID - 2010CA 1 N2/015L LOOP ID - 2010CA 1 N2/015L

015 NM1 Patient Name O 1 N2/015 Required025 N3 Patient Address O 1 Required030 N4 Patient City/State/ZIP

CodeO 1 Required

032 DMG Patient DemographicInformation

O 1 Required

035 REF Patient SecondaryIdentification Number

O 5 Situational

035 REF Property and CasualtyClaim Number

O 1 Situational

LOOP ID - 2300 100 LOOP ID - 2300 100

130 CLM Claim information O 1 Required135 DTP Discharge Hour O 1 Situational135 DTP Statement Dates O 1 Required135 DTP Admission Date/Hour O 1 Situational140 CL1 Institutional Claim Code O 1 Situational155 PWK Claim Supplemental


160 CN1 Contract Information O 1 Situational175 AMT Payer Estimated Amount

DueO 1 Situational

175 AMT Patient Estimated AmountDue

O 1 Situational

175 AMT Patient Paid Amount O 1 Situational175 AMT Credit/Debit Card

Maximum AmountO 1 Situational

180 REF Adjusted Repriced ClaimNumber

O 1 Situational




180 REF Repriced Claim Number O 1 Situational180 REF Claim Identification

Number ForClearinghouses and OtherTransmissionIntermediaries

O 1 Situational

180 REF Document IdentificationCode

O 2 Situational

180 REF Original ReferenceNumber (ICN/DCN)

O 1 Situational

180 REF Investigational DeviceExemption Number

O 1 Situational

180 REF Service AuthorizationException Code

O 1 Situational

180 REF Peer Review Organization(PRO) Approval Number

O 1 Situational

180 REF Prior Authorization orReferral Number

O 2 Situational

180 REF Medical Record Number O 1 Situational180 REF Demonstration Project

IdentifierO 1 Situational

185 K3 File Information O 10 Situational190 NTE Claim Note O 10 Situational190 NTE Billing Note O 1 Situational216 CR6 Home Health Care


220 CRC Home Health FunctionalLimitations

O 3 Situational

220 CRC Home Health ActivitiesPermitted

O 3 Situational

220 CRC Home Health MentalStatus

O 2 Situational

231 HI Principal, Admitting,E-Code and PatientReason For VisitDiagnosis Information

O 1 Situational

231 HI Diagnosis Related Group(DRG) Information

O 1 Situational

231 HI Other DiagnosisInformation

O 2 Situational

231 HI Principal ProcedureInformation

O 1 Situational

231 HI Other ProcedureInformation

O 2 Situational

231 HI Occurrence SpanInformation

O 2 Situational

231 HI Occurrence Information O 2 Situational231 HI Value Information O 2 Situational231 HI Condition Information O 2 Situational231 HI Treatment Code


240 QTY Claim Quantity O 4 Situational241 HCP Claim Pricing/Repricing O 1 Situational




Information LOOP ID - 2305 6 LOOP ID - 2305 6

242 CR7 Home Health Care PlanInformation

O 1 Situational

243 HSD Health Care ServicesDelivery

O 12 Situational


250 NM1 Attending Physician Name O 1 N2/250 Situational255 PRV Attending Physician

Specialty InformationO 1 Situational


O 5 Situational








250 NM1 Service Facility Name O 1 N2/250 Situational265 N3 Service Facility Address O 1 Required270 N4 Service Facility

City/State/Zip CodeO 1 Required

271 REF Service Facility SecondaryIdentification

O 5 Situational


290 SBR Other SubscriberInformation


295 CAS Claim Level Adjustment O 5 Situational300 AMT Payer Prior Payment O 1 Situational300 AMT Coordination of Benefits

(COB) Total AllowedAmount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total SubmittedCharges

O 1 Situational

300 AMT Diagnostic Related Group(DRG) Outlier Amount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total Medicare PaidAmount

O 1 Situational


O 1 Situational


O 1 Situational

300 AMT Coordination of Benefits(COB) Medicare A Trust

O 1 Situational




Fund Paid Amount300 AMT Coordination of Benefits

(COB) Medicare B TrustFund Paid Amount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total Non-coveredAmount

O 1 Situational

300 AMT Coordination of Benefits(COB) Total DeniedAmount

O 1 Situational

305 DMG Other SubscriberDemographic Information

O 1 Situational

310 OI Other Insurance CoverageInformation

O 1 Required

315 MIA Medicare InpatientAdjudication Information

O 1 Situational

320 MOA Medicare OutpatientAdjudication Information

O 1 Situational


325 NM1 Other Subscriber Name O 1 N2/325 Required332 N3 Other Subscriber Address O 1 Situational340 N4 Other Subscriber

City/State/ZIP CodeO 1 Situational

355 REF Other SubscriberSecondary Information

O 3 Situational


325 NM1 Other Payer Name O 1 N2/325 Required332 N3 Other Payer Address O 1 Situational340 N4 Other Payer City/State/ZIP

CodeO 1 Situational

350 DTP Claim Adjudication Date O 1 Situational355 REF Other Payer Secondary

Identification andReference Number

O 2 Situational

355 REF Other Payer PriorAuthorization or ReferralNumber

O 1 Situational


325 NM1 Other Payer PatientInformation


355 REF Other Payer PatientIdentification Number

O 3 Situational

LOOP ID - 2330D 1 N2/325L LOOP ID - 2330D 1 N2/325L

325 NM1 Other Payer AttendingProvider


355 REF Other Payer AttendingProvider Identification

O 3 Required


325 NM1 Other Payer OperatingProvider





355 REF Other Payer OperatingProvider Identification

O 3 Required

LOOP ID - 2330F 1 N2/325L LOOP ID - 2330F 1 N2/325L

325 NM1 Other Payer OtherProvider


355 REF Other Payer OtherProvider Identification

O 3 Required

LOOP ID - 2330H 1 N2/325L LOOP ID - 2330H 1 N2/325L

325 NM1 Other Payer ServiceFacility Provider


355 REF Other Payer ServiceFacility ProviderIdentification

O 3 Required


365 LX Service Line Number O 1 N2/365 Required375 SV2 Institutional Service Line O 1 Required420 PWK Line Supplemental


455 DTP Service Line Date O 1 Situational455 DTP Assessment Date O 1 Situational475 AMT Service Tax Amount O 1 Situational475 AMT Facility Tax Amount O 1 Situational492 HCP Line Pricing/Repricing



494 LIN Drug Identification O 1 N2/494 Situational495 CTP Drug Pricing O 1 Situational496 REF Prescription Number O 1 Situational


500 NM1 Attending Physician Name O 1 N2/500 Situational525 REF Attending Physician









540 SVD Service Line AdjudicationInformation


545 CAS Service Line Adjustment O 99 Situational550 DTP Service Adjudication Date O 1 Situational555 SE Transaction Set Trailer M 1 Required



Not Defined:Pos Id Segment Name Req Max Use Repeat Notes Usage

GE Functional Group Trailer M 1 RequiredIEA Interchange Control Trailer M 1 Required

Notes: 1/020L Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data

in any way, then they add an occurrence to the loop as a form of identification. The added loopoccurrence must be the last occurrence of the loop.

1/020 Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add datain any way, then they add an occurrence to the loop as a form of identification. The added loopoccurrence must be the last occurrence of the loop.

1/020L Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add datain any way, then they add an occurrence to the loop as a form of identification. The added loopoccurrence must be the last occurrence of the loop.

1/020 Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add datain any way, then they add an occurrence to the loop as a form of identification. The added loopoccurrence must be the last occurrence of the loop.

2/015L Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, theseentities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, orclaimant.

2/015 Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, theseentities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, orclaimant.











2/250L Loop 2310 contains information about the rendering, referring, or attending provider.



2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/290L Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,

Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.2/290 Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,

Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.2/325L Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop

2320.2/325 Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop

2320.2/325L Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop












2320.2/365L Loop 2400 contains Service Line information.2/365 Loop 2400 contains Service Line information.2/494L Loop 2410 contains compound drug components, quantities and prices.2/494 Loop 2410 contains compound drug components, quantities and prices.2/500L Loop 2420 contains information about the rendering, referring, or attending provider on a service line

level. These segments override the information in the claim - level segments if the entity identifier codes ineach NM1 segment are the same.

2/500 Loop 2420 contains information about the rendering, referring, or attending provider on a service linelevel. These segments override the information in the claim - level segments if the entity identifier codes ineach NM1 segment are the same.

2/500L Loop 2420 contains information about the rendering, referring, or attending provider on a service linelevel. These segments override the information in the claim - level segments if the entity identifier codes ineach NM1 segment are the same.

2/500 Loop 2420 contains information about the rendering, referring, or attending provider on a service line






2/540L SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in theNM109 position 325 for the payer.

2/540 SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in theNM109 position 325 for the payer.



2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/250L Loop 2310 contains information about the rendering, referring, or attending provider.2/250 Loop 2310 contains information about the rendering, referring, or attending provider.2/290L Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,

Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.2/290 Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,

Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.2/325L Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop












2320.



2/325L Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop2320.

2/325 Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop2320.

2/365L Loop 2400 contains Service Line information.2/365 Loop 2400 contains Service Line information.2/494L Loop 2410 contains compound drug components, quantities and prices.2/494 Loop 2410 contains compound drug components, quantities and prices.2/500L Loop 2420 contains information about the rendering, referring, or attending provider on a service line







2/540L SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in theNM109 position 325 for the payer.

2/540 SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in theNM109 position 325 for the payer.



ISA Interchange Control Header Pos: Max: 1Not Defined - Mandatory

Loop: N/A Elements: 16

User Option (Usage): RequiredPurpose: To start and identify an interchange of zero or more functional groups and interchange-related controlsegments

Element Summary: Ref Id Element Name Req Type Min/Max UsageISA01 I01 Authorization Information Qualifier M ID 2/2 Required

Description: Code to identify the type of information in the Authorization Information

CodeList Summary (Total Codes: 7, Included: 2)Code Name00 No Authorization Information Present (No Meaningful Information in I02)

ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OFADDITIONAL IDENTIFICATION.ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OFADDITIONAL IDENTIFICATION.

03 Additional Data Identification

ISA02 I02 Authorization Information M AN 10/10 Required

Description: Information used for additional identification or authorization of theinterchange sender or the data in the interchange; the type of information is set by theAuthorization Information Qualifier (I01)

ISA03 I03 Security Information Qualifier M ID 2/2 Required

Description: Code to identify the type of information in the Security Information

CodeList Summary (Total Codes: 2, Included: 2)Code Name00 No Security Information Present (No Meaningful Information in I04)

ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OFPASSWORD DATA.ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OFPASSWORD DATA.

01 Password

ISA04 I04 Security Information M AN 10/10 Required

Description: This is used for identifying the security information about the interchangesender or the data in the interchange; the type of information is set by the SecurityInformation Qualifier (I03)

ISA05 I05 Interchange ID Qualifier M ID 2/2 Required

Description: Qualifier to designate the system/method of code structure used to designatethe sender or receiver ID element being qualifiedThis ID qualifies the Sender in ISA06.This ID qualifies the Sender in ISA06.

CodeList Summary (Total Codes: 38, Included: 9)Code Name01 Duns (Dun & Bradstreet)14 Duns Plus Suffix20 Health Industry Number (HIN)

CODE SOURCE:CODE SOURCE:


Code Name


121: Health Industry Identification Number121: Health Industry Identification Number27 Carrier Identification Number as assigned by Health Care Financing Administration

(HCFA)28 Fiscal Intermediary Identification Number as assigned by Health Care Financing

Administration (HCFA)29 Medicare Provider and Supplier Identification Number as assigned by Health Care

Financing Administration (HCFA)30 U.S. Federal Tax Identification Number33 National Association of Insurance Commissioners Company Code (NAIC)ZZ Mutually Defined

ISA06 I06 Interchange Sender ID M AN 15/15 Required

Description: Identification code published by the sender for other parties to use as thereceiver ID to route data to them; the sender always codes this value in the sender IDelement

ISA07 I05 Interchange ID Qualifier M ID 2/2 Required

Description: Qualifier to designate the system/method of code structure used to designatethe sender or receiver ID element being qualifiedThis ID qualifies the Receiver in ISA08.This ID qualifies the Receiver in ISA08.

CodeList Summary (Total Codes: 38, Included: 9)Code Name01 Duns (Dun & Bradstreet)14 Duns Plus Suffix20 Health Industry Number (HIN)

CODE SOURCE:CODE SOURCE:121: Health Industry Identification Number121: Health Industry Identification Number

27 Carrier Identification Number as assigned by Health Care Financing Administration(HCFA)

28 Fiscal Intermediary Identification Number as assigned by Health Care FinancingAdministration (HCFA)

29 Medicare Provider and Supplier Identification Number as assigned by Health CareFinancing Administration (HCFA)

30 U.S. Federal Tax Identification Number33 National Association of Insurance Commissioners Company Code (NAIC)ZZ Mutually Defined

ISA08 I07 Interchange Receiver ID M AN 15/15 Required

Description: Identification code published by the receiver of the data; When sending, it isused by the sender as their sending ID, thus other parties sending to them will use this as areceiving ID to route data to them

ISA09 I08 Interchange Date M DT 6/6 Required

Description: Date of the interchangeThe date format is YYMMDD.The date format is YYMMDD.

ISA10 I09 Interchange Time M TM 4/4 Required

Description: Time of the interchangeThe time format is HHMM.The time format is HHMM.


Ref Id Element Name Req Type Min/Max Usage


ISA11 I10 Interchange Control StandardsIdentifier

M ID 1/1 Required

Description: Code to identify the agency responsible for the control standard used by themessage that is enclosed by the interchange header and trailer

CodeList Summary (Total Codes: 1, Included: 1)Code NameU U.S. EDI Community of ASC X12, TDCC, and UCS

ISA12 I11 Interchange Control Version Number M ID 5/5 Required

Description: Code specifying the version number of the interchange control segments

CodeList Summary (Total Codes: 14, Included: 1)Code Name00401 Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures

Review Board through October 1997

ISA13 I12 Interchange Control Number M N0 9/9 Required

Description: A control number assigned by the interchange senderThe Interchange Control Number, ISA13, must be identical to the associated InterchangeTrailer IEA02.The Interchange Control Number, ISA13, must be identical to the associated InterchangeTrailer IEA02.

ISA14 I13 Acknowledgment Requested M ID 1/1 Required

Description: Code sent by the sender to request an interchange acknowledgment (TA1)See Section A.1.5.1 for interchange acknowledgment information.See Section A.1.5.1 for interchange acknowledgment information.

CodeList Summary (Total Codes: 2, Included: 2)Code Name0 No Acknowledgment Requested1 Interchange Acknowledgment Requested

ISA15 I14 Usage Indicator M ID 1/1 Required

Description: Code to indicate whether data enclosed by this interchange envelope is test,production or information

CodeList Summary (Total Codes: 3, Included: 2)Code NameP Production DataT Test Data

ISA16 I15 Component Element Separator M 1/1 Required

Description: Type is not applicable; the component element separator is a delimiter andnot a data element; this field provides the delimiter used to separate component dataelements within a composite data structure; this value must be different than the dataelement separator and the segment terminator

Notes:Notes:The ISA is a fixed record length segment and all positions within each of the data elements must be filled. Thefirst element separator defines the element separator to be used through the entire interchange. The segmentterminator used after the ISA defines the segment terminator to be used throughout the entire interchange.Spaces in the example are represented by '.' for clarity.

The ISA is a fixed record length segment and all positions within each of the data elements must be filled. Thefirst element separator defines the element separator to be used through the entire interchange. The segmentterminator used after the ISA defines the segment terminator to be used throughout the entire interchange.Spaces in the example are represented by '.' for clarity.



Example:Example:ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*RECEIVERS.ID...*930602*1253*U*00401*000000905*1*T*:~ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*RECEIVERS.ID...*930602*1253*U*00401*000000905*1*T*:~



GS Functional Group Header Pos: Max: 1Not Defined - Mandatory


User Option (Usage): RequiredPurpose: To indicate the beginning of a functional group and to provide control information

Element Summary: Ref Id Element Name Req Type Min/Max UsageGS01 479 Functional Identifier Code M ID 2/2 Required

Description: Code identifying a group of application related transaction sets

CodeList Summary (Total Codes: 240, Included: 1)Code NameHC Health Care Claim (837)

GS02 142 Application Sender's Code M AN 2/15 Required

Description: Code identifying party sending transmission; codes agreed to by tradingpartnersUse this code to identify the unit sending the information.Use this code to identify the unit sending the information.

GS03 124 Application Receiver's Code M AN 2/15 Required

Description: Code identifying party receiving transmission; codes agreed to by tradingpartnersUse this code to identify the unit receiving the information.Use this code to identify the unit receiving the information.

GS04 373 Date M DT 8/8 Required

Description: Date expressed as CCYYMMDDUse this date for the functional group creation date.Use this date for the functional group creation date.

GS05 337 Time M TM 4/8 Required

Description: Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, orHHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integerseconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D= tenths (0-9) and DD = hundredths (00-99)Use this time for the creation time. The recommended format is HHMM.Use this time for the creation time. The recommended format is HHMM.

GS06 28 Group Control Number M N0 1/9 Required

Description: Assigned number originated and maintained by the sender

GS07 455 Responsible Agency Code M ID 1/2 Required

Description: Code identifying the issuer of the standard; this code is used in conjunctionwith Data Element 480

CodeList Summary (Total Codes: 2, Included: 1)Code NameX Accredited Standards Committee X12

GS08 480 Version / Release / Industry IdentifierCode

M AN 1/12 Required

Description: Code indicating the version, release, subrelease, and industry identifier of the




EDI standard being used, including the GS and GE segments; if code in DE455 in GSsegment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are therelease and subrelease, level of the version; and positions 7-12 are the industry or tradeassociation identifiers (optionally assigned by user); if code in DE455 in GS segment is T,then other formats are allowed

CodeList Summary (Total Codes: 48, Included: 1)Code Name004010X096A1

Draft Standards Approved for Publication by ASC X12 Procedures ReviewBoard through October 1997, as published in this implementation guide.

Semantics: 1. GS04 is the group date.2. GS05 is the group time.3. The data interchange control number GS06 in this header must be identical to the same data element in the

associated functional group trailer, GE02.

Comments: 1. A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of

similar transaction sets enclosed by a functional group header and a functional group trailer.

Example:Example:GS*HC*SENDER CODE*RECEIVER CODE*19940331*0802*1*X*004010X097~GS*HC*SENDER CODE*RECEIVER CODE*19940331*0802*1*X*004010X097~



ST Transaction Set Header Pos: 005 Max: 1Heading - Mandatory


User Option (Usage): RequiredPurpose: To indicate the start of a transaction set and to assign a control number

Element Summary: Ref Id Element Name Req Type Min/Max UsageST01 143 Transaction Set Identifier Code M ID 3/3 Required

Description: Code uniquely identifying a Transaction Set

CodeList Summary (Total Codes: 298, Included: 1)Code Name837 Health Care Claim

REQUIREDREQUIRED

ST02 329 Transaction Set Control Number M AN 4/9 Required

Description: Identifying control number that must be unique within the transaction setfunctional group assigned by the originator for a transaction setThe Transaction Set Control Number in ST02 and SE02 must be identical. This uniquenumber also aids in error resolution research. Submitters could be sending transactionsusing the number 0001 in this element and increment from there. The number must beunique within a specific functional group (GS-GE) andinterchange (ISA-IEA), but canrepeat in other groups and interchanges.

The Transaction Set Control Number in ST02 and SE02 must be identical. This uniquenumber also aids in error resolution research. Submitters could be sending transactionsusing the number 0001 in this element and increment from there. The number must beunique within a specific functional group (GS-GE) andinterchange (ISA-IEA), but canrepeat in other groups and interchanges.

Semantics: 1. The transaction set identifier (ST01) used by the translation routines of the interchange partners to select the

appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).

Example:Example:ST*837*987654~ST*837*987654~



BHT Beginning of HierarchicalTransaction

Pos: 010 Max: 1Heading - Mandatory


User Option (Usage): RequiredPurpose: To define the business hierarchical structure of the transaction set and identify the business applicationpurpose and reference data, i.e., number, date, and time

Element Summary: Ref Id Element Name Req Type Min/Max UsageBHT01 1005 Hierarchical Structure Code M ID 4/4 Required

Description: Code indicating the hierarchical application structure of a transaction set thatutilizes the HL segment to define the structure of the transaction set

CodeList Summary (Total Codes: 61, Included: 1)Code Name0019 Information Source, Subscriber, Dependent

BHT02 353 Transaction Set Purpose Code M ID 2/2 Required

Description: Code identifying purpose of transaction setBHT02 is intended to convey the electronic transmission status of the 837 batch containedin this ST-SE envelope. The terms “original” and “reissue” refer to the electronictransmission status of the 837 batch, not the billing status. ORIGINAL: original transmissions are claims/encounters which have never been sent tothe receiver. Generally nearly all transmissions to a payer entity (as the ultimate destinationof the transaction) are original.REISSUE: In the case where a transmission was disrupted the receiver can request thatthe batch be sent again. Use “Reissue” when resending transmission batches that havebeen previously sent.

BHT02 is intended to convey the electronic transmission status of the 837 batch containedin this ST-SE envelope. The terms “original” and “reissue” refer to the electronictransmission status of the 837 batch, not the billing status. ORIGINAL: original transmissions are claims/encounters which have never been sent tothe receiver. Generally nearly all transmissions to a payer entity (as the ultimate destinationof the transaction) are original.REISSUE: In the case where a transmission was disrupted the receiver can request thatthe batch be sent again. Use “Reissue” when resending transmission batches that havebeen previously sent.

CodeList Summary (Total Codes: 65, Included: 2)Code Name00 Original18 Reissue

BHT03 127 Reference Identification O AN 1/30 Required

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Originator Application Transaction IdentifierIndustry: Originator Application Transaction Identifier

Use this reference identifier to identify the inventory file number of the tape or transmissionassigned by the submitter’s system.Use this reference identifier to identify the inventory file number of the tape or transmissionassigned by the submitter’s system.

BHT04 373 Date O DT 8/8 Required

Description: Date expressed as CCYYMMDDIndustry: Transaction Set Creation DateIndustry: Transaction Set Creation Date

Use this date to identify the date on which the submitter created the file.Use this date to identify the date on which the submitter created the file.

BHT05 337 Time O TM 4/8 Required

Description: Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, orHHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integerseconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D= tenths (0-9) and DD = hundredths (00-99)




Industry: Transaction Set Creation TimeIndustry: Transaction Set Creation Time

Use this time to identify the time of day that the submitter created the file.Use this time to identify the time of day that the submitter created the file.

BHT06 640 Transaction Type Code O ID 2/2 Required

Description: Code specifying the type of transactionIndustry: Claim or Encounter IdentifierIndustry: Claim or Encounter IdentifierAlias: Claim or Encounter IndicatorAlias: Claim or Encounter Indicator

Use RP when the entire ST-SE envelope contains encounter transmissions.Use RP when the transmission is being sent to an entity (usually not a payer or a normalprovider-payer transmission itermediary) for purposes other than adjudication of a claim.Such an entity could be a state health agency which is using the 837 for health datareporting purposes.

Use RP when the entire ST-SE envelope contains encounter transmissions.Use RP when the transmission is being sent to an entity (usually not a payer or a normalprovider-payer transmission itermediary) for purposes other than adjudication of a claim.Such an entity could be a state health agency which is using the 837 for health datareporting purposes.User Note 6: Use CH for ClaimsUse RP for Encounters

User Note 6: Use CH for ClaimsUse RP for Encounters

CodeList Summary (Total Codes: 446, Included: 2)Code NameCH Chargeable

Use this code when the transmission contains only fee-for-service claims or claimswith at least onechargeable line item. If it is not clear whether a transaction is a claim or encounter,the developersof this implementation guide recommend submitting the transaction as a claim.

Use this code when the transmission contains only fee-for-service claims or claimswith at least onechargeable line item. If it is not clear whether a transaction is a claim or encounter,the developersof this implementation guide recommend submitting the transaction as a claim.

RP ReportingUse this code to send a batch of encounters.Use this code to send a batch of encounters.

Semantics: 1. BHT03 is the number assigned by the originator to identify the transaction within the originator's business

application system.2. BHT04 is the date the transaction was created within the business application system.3. BHT05 is the time the transaction was created within the business application system.

Example:Example:BHT*0019*00*0123*19960618*0932*CH~BHT*0019*00*0123*19960618*0932*CH~



REF Transmission TypeIdentification

Pos: 015 Max: 1Heading - Optional


User Option (Usage): RequiredPurpose: To specify identifying information

Element Summary: Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification Qualifier M ID 2/3 Required

Description: Code qualifying the Reference Identification

CodeList Summary (Total Codes: 1503, Included: 1)Code Name87 Functional Category

Description: An organization or groups of organizations with a commonoperational orientation such as Quality Control Engineering, etc

REF02 127 Reference Identification C AN 1/30 Required

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Transmission Type CodeIndustry: Transmission Type Code

When piloting the transaction set, this value is 004010X096DA1.When sending the transaction set in a production mode, this value is 004010X096A1.When piloting the transaction set, this value is 004010X096DA1.When sending the transaction set in a production mode, this value is 004010X096A1.User Note 6: Always use only 004010X96A1The "D" suffix is not required as test submissions are identified by the value of "T" receivedin ISA15

User Note 6: Always use only 004010X96A1The "D" suffix is not required as test submissions are identified by the value of "T" receivedin ISA15

Syntax Rules: 1. R0203 - At least one of REF02 or REF03 is required.

Semantics: 1. REF04 contains data relating to the value cited in REF02.

Example:Example:REF*87*004010X096A1~REF*87*004010X096A1~



Loop Submitter Name Pos: 020 Repeat: 1Optional

Loop:1000A

Elements: N/A

User Option (Usage): RequiredPurpose: To supply the full name of an individual or organizational entity

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage020 NM1 Submitter Name O 1 Required045 PER Submitter EDI Contact Information O 2 Required

Semantics: 1. NM102 qualifies NM103.

Comments: 1. NM110 and NM111 further define the type of entity in NM101.

Notes:Notes:1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:NM1*41*2*ABC Submitter*****46*999999999~NM1*41*2*ABC Submitter*****46*999999999~



NM1 Submitter Name Pos: 020 Max: 1Heading - Optional

Loop:1000A

Elements: 7


Element Summary: Ref Id Element Name Req Type Min/Max UsageNM101 98 Entity Identifier Code M ID 2/3 Required

Description: Code identifying an organizational entity, a physical location, property or anindividual

CodeList Summary (Total Codes: 1312, Included: 1)Code Name41 Submitter

Description: Entity transmitting transaction set

NM102 1065 Entity Type Qualifier M ID 1/1 Required

Description: Code qualifying the type of entity

CodeList Summary (Total Codes: 14, Included: 2)Code Name1 Person2 Non-Person Entity

NM103 1035 Name Last or Organization Name O AN 1/35 Required

Description: Individual last name or organizational nameIndustry: Submitter Last or Organization NameIndustry: Submitter Last or Organization NameAlias: Submitter NameAlias: Submitter Name

NM104 1036 Name First O AN 1/25 Situational

Description: Individual first nameIndustry: Submitter First NameIndustry: Submitter First NameAlias: Submitter NameAlias: Submitter Name

Required if NM102=1 (person).Required if NM102=1 (person).

NM105 1037 Name Middle O AN 1/25 Situational

Description: Individual middle name or initialIndustry: Submitter Middle NameIndustry: Submitter Middle NameAlias: Submitter NameAlias: Submitter Name

Required if NM102=1 and the middle name/initial of the person is known.Required if NM102=1 and the middle name/initial of the person is known.

NM108 66 Identification Code Qualifier C ID 1/2 Required

Description: Code designating the system/method of code structure used for IdentificationCode (67)

CodeList Summary (Total Codes: 215, Included: 1)



Code Name46 Electronic Transmitter Identification Number (ETIN)

Description: A unique number assigned to each transmitter and softwaredeveloperEstablished by a trading partner agreementEstablished by a trading partner agreement

NM109 67 Identification Code C AN 2/80 Required

Description: Code identifying a party or other codeIndustry: Submitter IdentifierIndustry: Submitter IdentifierAlias: Submitter Primary Identification NumberAlias: Submitter Primary Identification Number

Syntax Rules: 1. P0809 - If either NM108 or NM109 is present, then the other is required.2. C1110 - If NM111 is present, then NM110 is required.



Notes:Notes:1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:NM1*41*2*ABC Submitter*****46*999999999~NM1*41*2*ABC Submitter*****46*999999999~



PER Submitter EDI ContactInformation

Pos: 045 Max: 2Heading - Optional

Loop:1000A

Elements: 8

User Option (Usage): RequiredPurpose: To identify a person or office to whom administrative communications should be directed

Element Summary: Ref Id Element Name Req Type Min/Max UsagePER01 366 Contact Function Code M ID 2/2 Required

Description: Code identifying the major duty or responsibility of the person or groupnamed

CodeList Summary (Total Codes: 230, Included: 1)Code NameIC Information Contact

PER02 93 Name O AN 1/60 Required

Description: Free-form nameIndustry: Submitter Contact NameIndustry: Submitter Contact Name

PER03 365 Communication Number Qualifier C ID 2/2 Required

Description: Code identifying the type of communication number

CodeList Summary (Total Codes: 40, Included: 4)Code NameED Electronic Data Interchange Access NumberEM Electronic MailFX FacsimileTE Telephone

PER04 364 Communication Number C AN 1/80 Required

Description: Complete communications number including country or area code whenapplicable

PER05 365 Communication Number Qualifier C ID 2/2 Situational

Description: Code identifying the type of communication numberUsed when additional contact numbers are to be communicated.Used when additional contact numbers are to be communicated.

CodeList Summary (Total Codes: 40, Included: 5)Code NameED Electronic Data Interchange Access NumberEM Electronic MailEX Telephone Extension

The use of this code indicates it is the extension of the number in PER04.The use of this code indicates it is the extension of the number in PER04.FX FacsimileTE Telephone

PER06 364 Communication Number C AN 1/80 Situational




Description: Complete communications number including country or area code whenapplicableThis data element is required when the submitter needs to convey additional submittercontact information.Used when additional contact numbers are to be communicated.

This data element is required when the submitter needs to convey additional submittercontact information.Used when additional contact numbers are to be communicated.


Description: Code identifying the type of communication numberUsed when additional contact numbers are to be communicated.Used when additional contact numbers are to be communicated.

CodeList Summary (Total Codes: 40, Included: 5)Code NameED Electronic Data Interchange Access NumberEM Electronic MailEX Telephone Extension

The use of this code indicates it is the extension of the number in PER06.The use of this code indicates it is the extension of the number in PER06.FX FacsimileTE Telephone


Description: Complete communications number including country or area code whenapplicableThis data element is required when the submitter needs to convey additional submittercontact information.Used when additional contact numbers are to be communicated.

This data element is required when the submitter needs to convey additional submittercontact information.Used when additional contact numbers are to be communicated.

Syntax Rules: 1. P0304 - If either PER03 or PER04 is present, then the other is required.2. P0506 - If either PER05 or PER06 is present, then the other is required.3. P0708 - If either PER07 or PER08 is present, then the other is required.

Notes:Notes:1. The contact information in this segment should point to the person in the submitter organization who deals withdata transmission issues. If data transmission problems arise, this is the person to contact in the submitterorganization.2. When the communication number represents a telephone number in the United States and other countriesusing the North American Dialing Plan (for voice, data, fax, etc.), the communication number should alwaysinclude the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB isthe telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as5342242525). The extension, when applicable, should be included in the communication number immediatelyafter the telephone number.

1. The contact information in this segment should point to the person in the submitter organization who deals withdata transmission issues. If data transmission problems arise, this is the person to contact in the submitterorganization.2. When the communication number represents a telephone number in the United States and other countriesusing the North American Dialing Plan (for voice, data, fax, etc.), the communication number should alwaysinclude the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB isthe telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as5342242525). The extension, when applicable, should be included in the communication number immediatelyafter the telephone number.

Example:Example:PER*IC*JANE DOE*TE*9005555555~PER*IC*JANE DOE*TE*9005555555~



Loop Receiver Name Pos: 020 Repeat: 1Optional

Loop:1000B

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage020 NM1 Receiver Name O 1 Required



Notes:Notes:1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:NM1*40*2*CSC HEALTHCARE*****46*112223333~NM1*40*2*CSC HEALTHCARE*****46*112223333~



NM1 Receiver Name Pos: 020 Max: 1Heading - Optional

Loop:1000B

Elements: 5




CodeList Summary (Total Codes: 1312, Included: 1)Code Name40 Receiver

Description: Entity to accept transmission



CodeList Summary (Total Codes: 14, Included: 1)Code Name2 Non-Person Entity


Description: Individual last name or organizational nameIndustry: Receiver NameIndustry: Receiver Name


Description: Code designating the system/method of code structure used for IdentificationCode (67)Industry: Information Receiver Identification NumberIndustry: Information Receiver Identification Number

CodeList Summary (Total Codes: 215, Included: 1)Code Name46 Electronic Transmitter Identification Number (ETIN)

Description: A unique number assigned to each transmitter and softwaredeveloper


Description: Code identifying a party or other codeIndustry: Receiver Primary IdentifierIndustry: Receiver Primary IdentifierAlias: Receiver Primary Identification NumberAlias: Receiver Primary Identification Number






Notes:Notes:1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore theSet Notes below.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:NM1*40*2*CSC HEALTHCARE*****46*112223333~NM1*40*2*CSC HEALTHCARE*****46*112223333~



Loop Billing/Pay-To ProviderHierarchical Level

Pos: 001 Repeat: >1Mandatory

Loop:2000A

Elements: N/A

User Option (Usage): RequiredPurpose: To identify dependencies among and the content of hierarchically related groups of data segments

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage001 HL Billing/Pay-To Provider Hierarchical Level M 1 Required003 PRV Billing/Pay-To Provider Specialty


010 CUR Foreign Currency Information O 1 Situational015 Loop 2010AA O 1 Required015 Loop 2010AB O 1 Situational

Comments: 1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating

line-item data to shipment data, and packaging data to line-item data.2. The HL segment defines a top-down/left-right ordered structure.3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction

set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in whichcase the value of HL01 would be "1" for the initial HL segment and would be incremented by one in eachsubsequent HL segment within the transaction.

4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.5. HL03 indicates the context of the series of segments following the current HL segment up to the next

occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequentsegments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.

6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HLsegment.

Notes:Notes:1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to thedestination payer identified in Loop ID-2010BC. The billing provider entity may be a health care provider, a billingservice, or some other representative of the provider2. The Billing/Pay-to Provider HL may contain information about the Pay-to Provider entity. If the Pay-to Providerentity is the same as the Billing Provider entity, then only use Loop ID-2010AA.3. If the Service Facility Provider is the same entity as the Billing or the Pay-to Provider then do not use Loop2310E.4. If the Billing or Pay-to Provider is also the Service Facility Providerand Loop ID 2310E is not used, the Loop ID-2000 PRV must be used toindicate which entity (Billing or Pay-to) is the Service Facility Provider.5. Because this is a required segment, this is a required loop. SeeAppendix A for further details on ASC X12 nomenclature.6. Receiving trading partners may have system limitations regarding thesize of the transmission they can receive. The developers of this implementation guide recommend that tradingpartners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While theimplementation guide sets no specific limit to the number of Billing/Pay-to Provider Hierarchical Level loops, thereis an implied maximum of 5000.

1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to thedestination payer identified in Loop ID-2010BC. The billing provider entity may be a health care provider, a billingservice, or some other representative of the provider2. The Billing/Pay-to Provider HL may contain information about the Pay-to Provider entity. If the Pay-to Providerentity is the same as the Billing Provider entity, then only use Loop ID-2010AA.3. If the Service Facility Provider is the same entity as the Billing or the Pay-to Provider then do not use Loop2310E.4. If the Billing or Pay-to Provider is also the Service Facility Providerand Loop ID 2310E is not used, the Loop ID-2000 PRV must be used toindicate which entity (Billing or Pay-to) is the Service Facility Provider.5. Because this is a required segment, this is a required loop. SeeAppendix A for further details on ASC X12 nomenclature.6. Receiving trading partners may have system limitations regarding thesize of the transmission they can receive. The developers of this implementation guide recommend that tradingpartners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While theimplementation guide sets no specific limit to the number of Billing/Pay-to Provider Hierarchical Level loops, thereis an implied maximum of 5000.

Example:Example:HL*1**20*1~HL*1**20*1~



HL Billing/Pay-To ProviderHierarchical Level

Pos: 001 Max: 1Detail - Mandatory

Loop:2000A

Elements: 3


Element Summary: Ref Id Element Name Req Type Min/Max UsageHL01 628 Hierarchical ID Number M AN 1/12 Required

Description: A unique number assigned by the sender to identify a particular datasegment in a hierarchical structureHL01 must begin with “1" and be incremented by one each time an HL is used in thetransaction. Only numeric values are allowed in HL01.HL01 must begin with “1" and be incremented by one each time an HL is used in thetransaction. Only numeric values are allowed in HL01.

HL03 735 Hierarchical Level Code M ID 1/2 Required

Description: Code defining the characteristic of a level in a hierarchical structure

CodeList Summary (Total Codes: 170, Included: 1)Code Name20 Information Source

Description: Identifies the payor, maintainer, or source of the information

HL04 736 Hierarchical Child Code O ID 1/1 Required

Description: Code indicating if there are hierarchical child data segments subordinate tothe level being describedThe claim loop (Loop ID-2300) can be used only when HL04 has no subordinate levels(HL04 = 0).The claim loop (Loop ID-2300) can be used only when HL04 has no subordinate levels(HL04 = 0).

CodeList Summary (Total Codes: 2, Included: 1)Code Name1 Additional Subordinate HL Data Segment in This Hierarchical Structure.







Notes:Notes:1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to thedestination payer identified in Loop ID-2010BC. The billing provider entity may be a health care provider, a billing 1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to thedestination payer identified in Loop ID-2010BC. The billing provider entity may be a health care provider, a billing



service, or some other representative of the provider2. The Billing/Pay-to Provider HL may contain information about the Pay-to Provider entity. If the Pay-to Providerentity is the same as the Billing Provider entity, then only use Loop ID-2010AA.3. If the Service Facility Provider is the same entity as the Billing or the Pay-to Provider then do not use Loop2310E.4. If the Billing or Pay-to Provider is also the Service Facility Providerand Loop ID 2310E is not used, the Loop ID-2000 PRV must be used toindicate which entity (Billing or Pay-to) is the Service Facility Provider.5. Because this is a required segment, this is a required loop. SeeAppendix A for further details on ASC X12 nomenclature.6. Receiving trading partners may have system limitations regarding thesize of the transmission they can receive. The developers of this implementation guide recommend that tradingpartners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While theimplementation guide sets no specific limit to the number of Billing/Pay-to Provider Hierarchical Level loops, thereis an implied maximum of 5000.

service, or some other representative of the provider2. The Billing/Pay-to Provider HL may contain information about the Pay-to Provider entity. If the Pay-to Providerentity is the same as the Billing Provider entity, then only use Loop ID-2010AA.3. If the Service Facility Provider is the same entity as the Billing or the Pay-to Provider then do not use Loop2310E.4. If the Billing or Pay-to Provider is also the Service Facility Providerand Loop ID 2310E is not used, the Loop ID-2000 PRV must be used toindicate which entity (Billing or Pay-to) is the Service Facility Provider.5. Because this is a required segment, this is a required loop. SeeAppendix A for further details on ASC X12 nomenclature.6. Receiving trading partners may have system limitations regarding thesize of the transmission they can receive. The developers of this implementation guide recommend that tradingpartners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While theimplementation guide sets no specific limit to the number of Billing/Pay-to Provider Hierarchical Level loops, thereis an implied maximum of 5000.

Example:Example:HL*1**20*1~HL*1**20*1~



PRV Billing/Pay-To ProviderSpecialty Information

Pos: 003 Max: 1Detail - Optional

Loop:2000A

Elements: 3

User Option (Usage): SituationalPurpose: To specify the identifying characteristics of a provider

Element Summary: Ref Id Element Name Req Type Min/Max UsagePRV01 1221 Provider Code M ID 1/3 Required

Description: Code identifying the type of providerUser Note 6: BI = BillingPT = Pay To

User Note 6: BI = BillingPT = Pay To

CodeList Summary (Total Codes: 26, Included: 2)Code NameBI BillingPT Pay-To

PRV02 128 Reference Identification Qualifier M ID 2/3 Required

Description: Code qualifying the Reference IdentificationZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialtycode) which is available on the Washington Publishing Company web site:http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue ShieldAssociation and ASC X12N TG2 WG15.

ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialtycode) which is available on the Washington Publishing Company web site:http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue ShieldAssociation and ASC X12N TG2 WG15.

CodeList Summary (Total Codes: 1503, Included: 1)Code NameZZ Mutually Defined

PRV03 127 Reference Identification M AN 1/30 Required

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Provider Taxonomy CodeIndustry: Provider Taxonomy CodeAlias: Provider Specialty CodeAlias: Provider Specialty CodeUser Note 6: Provider Taxonomy CodeUser Note 6: Provider Taxonomy Code

ExternalCodeList Name: HCPT Description: Health Care Provider Taxonomy

Notes:Notes:1. Required when adjudication is known to be impacted by the provider taxonomy code, and the Service FacilityProvider is the same entity as the Billing and/or Pay-to Provider. In these cases, the Rendering Provider is beingidentified at this level for all subsequent claims/encounters in this HL and Loop ID-2310E is not used.2. PRV02 qualifies PRV03.

1. Required when adjudication is known to be impacted by the provider taxonomy code, and the Service FacilityProvider is the same entity as the Billing and/or Pay-to Provider. In these cases, the Rendering Provider is beingidentified at this level for all subsequent claims/encounters in this HL and Loop ID-2310E is not used.2. PRV02 qualifies PRV03.

Example:Example:



PRV*BI*ZZ*203BA0200N~PRV*BI*ZZ*203BA0200N~



CUR Foreign CurrencyInformation


Loop:2000A

Elements: 2

User Option (Usage): SituationalPurpose: To specify the currency (dollars, pounds, francs, etc.) used in a transaction

Element Summary: Ref Id Element Name Req Type Min/Max UsageCUR01 98 Entity Identifier Code M ID 2/3 Required


CodeList Summary (Total Codes: 1312, Included: 1)Code Name85 Billing Provider

CUR02 100 Currency Code M ID 3/3 Required

Description: Code (Standard ISO) for country in whose currency the charges are specified

ExternalCodeList Name: 5 Description: Countries, Currencies and Funds

Syntax Rules: 1. C0807 - If CUR08 is present, then CUR07 is required.2. C0907 - If CUR09 is present, then CUR07 is required.3. L101112 - If CUR10 is present, then at least one of CUR11 or CUR12 is required.4. C1110 - If CUR11 is present, then CUR10 is required.5. C1210 - If CUR12 is present, then CUR10 is required.6. L131415 - If CUR13 is present, then at least one of CUR14 or CUR15 is required.7. C1413 - If CUR14 is present, then CUR13 is required.8. C1513 - If CUR15 is present, then CUR13 is required.9. L161718 - If CUR16 is present, then at least one of CUR17 or CUR18 is required.

10. C1716 - If CUR17 is present, then CUR16 is required.11. C1816 - If CUR18 is present, then CUR16 is required.12. L192021 - If CUR19 is present, then at least one of CUR20 or CUR21 is required.13. C2019 - If CUR20 is present, then CUR19 is required.14. C2119 - If CUR21 is present, then CUR19 is required.

Comments: 1. See Figures Appendix for examples detailing the use of the CUR segment.

Notes:Notes:1. The developers of this implementation guide added the CUR segment to allow billing providers and billingservices to submit claims for services provided in foreign countries. The absence of the CUR segment indicatesthat the claim is submitted in the currency that is normally used by the receiver for processing claims. Forexample, claims submitted by United States (U.S.) providers to U.S. receivers are assumed to be in U.S. dollars.Claims submitted by Canadian providers to Canadian receivers are assumed to be in Canadian dollars.

1. The developers of this implementation guide added the CUR segment to allow billing providers and billingservices to submit claims for services provided in foreign countries. The absence of the CUR segment indicatesthat the claim is submitted in the currency that is normally used by the receiver for processing claims. Forexample, claims submitted by United States (U.S.) providers to U.S. receivers are assumed to be in U.S. dollars.Claims submitted by Canadian providers to Canadian receivers are assumed to be in Canadian dollars.



Example:Example:CUR*85*CAN~CUR*85*CAN~



Loop Billing Provider Name Pos: 015 Repeat: 1Optional

Loop:2010AA

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Billing Provider Name O 1 Required025 N3 Billing Provider Address O 1 Required030 N4 Billing Provider City/State/ZIP Code O 1 Required035 REF Billing Provider Secondary Identification O 8 Situational035 REF Credit/Debit Card Billing Information O 8 Situational040 PER Billing Provider Contact Information O 2 Situational



Notes:Notes:1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.2. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity.The billing entity does not have to be a health care provider to use this loop. However, some payers do notaccept claims from non-provider billing entities.

1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.2. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity.The billing entity does not have to be a health care provider to use this loop. However, some payers do notaccept claims from non-provider billing entities.

Example:Example:NM1*85*2*JONES HOSPITAL*****XX*45609312~NM1*85*2*JONES HOSPITAL*****XX*45609312~



NM1 Billing Provider Name Pos: 015 Max: 1Detail - Optional

Loop:2010AA

Elements: 5




CodeList Summary (Total Codes: 1312, Included: 1)Code Name85 Billing Provider

Use this code to indicate billing provider, billing submitter, and encounter reportingentity.Use this code to indicate billing provider, billing submitter, and encounter reportingentity.





Description: Individual last name or organizational nameIndustry: Billing Provider Last or Organizational NameIndustry: Billing Provider Last or Organizational NameAlias: Billing Provider NameAlias: Billing Provider NameUB-92 Ref. [UB-Name]: 1, Line 1 [Provider Name, Address and Telephone Number]UB-92 Ref. [UB-Name]: 1, Line 1 [Provider Name, Address and Telephone Number]EMC v.6.0 Reference: Record Type 10 Field No. 12EMC v.6.0 Reference: Record Type 10 Field No. 12


Description: Code designating the system/method of code structure used for IdentificationCode (67)If “XX - NPI” is used, then either the Employer’s Identification Number or the SocialSecurity Number of the provider must be carried in the REF in this loop.If “XX - NPI” is used, then either the Employer’s Identification Number or the SocialSecurity Number of the provider must be carried in the REF in this loop.User Note 6: Use this qualifier with the National Provider Identifier, if available, otherwise use 24, 34 withthe Tax ID number.If entity is different from the billing provider this rule applies to Loop 2010AB.Same rule applies for Referring Provider 2310C Loop and Attending Provider 2310A Loop.

User Note 6: Use this qualifier with the National Provider Identifier, if available, otherwise use 24, 34 withthe Tax ID number.If entity is different from the billing provider this rule applies to Loop 2010AB.Same rule applies for Referring Provider 2310C Loop and Attending Provider 2310A Loop.

CodeList Summary (Total Codes: 215, Included: 3)Code Name24 Employer's Identification Number34 Social Security NumberXX Health Care Financing Administration National Provider Identifier


Code Name


Description: Required value if the National Provider ID is mandated for use.Otherwise, one of the other listed codes may be used.


Description: Code identifying a party or other codeIndustry: Billing Provider IdentifierIndustry: Billing Provider IdentifierAlias: Billing Provider Primary IDAlias: Billing Provider Primary IDUser Note 6: Example:NM1*85*2*MD OFC*****XX*1234567891~N3*ADDRESS~N4*CITY*STATE*ZIP~REF*EI*951234560~REF*1B*00A123450~

User Note 6: Example:NM1*85*2*MD OFC*****XX*1234567891~N3*ADDRESS~N4*CITY*STATE*ZIP~REF*EI*951234560~REF*1B*00A123450~

ExternalCodeList Name: 537 Description: Health Care Financing Administration National Provider Identifier




Notes:Notes:1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.2. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity.The billing entity does not have to be a health care provider to use this loop. However, some payers do notaccept claims from non-provider billing entities.

1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.2. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity.The billing entity does not have to be a health care provider to use this loop. However, some payers do notaccept claims from non-provider billing entities.

Example:Example:NM1*85*2*JONES HOSPITAL*****XX*45609312~NM1*85*2*JONES HOSPITAL*****XX*45609312~



N3 Billing Provider Address Pos: 025 Max: 1Detail - Optional

Loop:2010AA

Elements: 2

User Option (Usage): RequiredPurpose: To specify the location of the named party

Element Summary: Ref Id Element Name Req Type Min/Max UsageN301 166 Address Information M AN 1/55 Required

Description: Address informationIndustry: Billing Provider Address LineIndustry: Billing Provider Address LineUB-92 Ref. [UB-Name]: 1, Line 2 [Provider Name, Address and Telephone Number]UB-92 Ref. [UB-Name]: 1, Line 2 [Provider Name, Address and Telephone Number]EMC v.6.0 Reference: Record Type 10 Field No. 13EMC v.6.0 Reference: Record Type 10 Field No. 13User Note 6: When submitting with NPI provide the physical address where services were rendered.User Note 6: When submitting with NPI provide the physical address where services were rendered.

N302 166 Address Information O AN 1/55 Situational

Description: Address informationIndustry: Billing Provider Address LineIndustry: Billing Provider Address Line

Required if a second address line exists.Required if a second address line exists.

Example:Example:N3*225 MAIN STREET BARKLEY BUILDING~N3*225 MAIN STREET BARKLEY BUILDING~



N4 Billing Provider City/State/ZIPCode


Loop:2010AA

Elements: 4

User Option (Usage): RequiredPurpose: To specify the geographic place of the named party

Element Summary: Ref Id Element Name Req Type Min/Max UsageN401 19 City Name O AN 2/30 Required

Description: Free-form text for city nameIndustry: Billing Provider City NameIndustry: Billing Provider City NameUB-92 Ref. [UB-Name]: 1, Line 3 [Provider Name, Address and Telephone Number]UB-92 Ref. [UB-Name]: 1, Line 3 [Provider Name, Address and Telephone Number]EMC v.6.0 Reference: Record Type 10 Field No. 14EMC v.6.0 Reference: Record Type 10 Field No. 14

N402 156 State or Province Code O ID 2/2 Required

Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Billing Provider State or Province CodeIndustry: Billing Provider State or Province CodeUB-92 Ref. [UB-Name]: 1, Line 3 [Provider Name, Address and Telephone Number]UB-92 Ref. [UB-Name]: 1, Line 3 [Provider Name, Address and Telephone Number]EMC v.6.0 Reference: Record Type 10 Field No. 15EMC v.6.0 Reference: Record Type 10 Field No. 15

ExternalCodeList Name: 22 Description: States and Outlying Areas of the U.S.

N403 116 Postal Code O ID 3/15 Required

Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Billing Provider Postal Zone or ZIP CodeIndustry: Billing Provider Postal Zone or ZIP CodeUB-92 Ref. [UB-Name]: 1, Line 3 [Provider Name, Address and Telephone Number]UB-92 Ref. [UB-Name]: 1, Line 3 [Provider Name, Address and Telephone Number]EMC v.6.0 Reference: Record Type 10 Field No. 16EMC v.6.0 Reference: Record Type 10 Field No. 16

ExternalCodeList Name: 51 Description: ZIP Code

N404 26 Country Code O ID 2/3 Situational

Description: Code identifying the countryUB-92 Ref. [UB-Name]: 1, Line 4, Positions 23-25 [Provider Name, Address andTelephone Number]UB-92 Ref. [UB-Name]: 1, Line 4, Positions 23-25 [Provider Name, Address andTelephone Number]EMC v.6.0 Reference: Record Type 10 Field No. 18EMC v.6.0 Reference: Record Type 10 Field No. 18

This data element is required when the address is outside of the U.S.This data element is required when the address is outside of the U.S.


Syntax Rules:



1. C0605 - If N406 is present, then N405 is required.

Comments: 1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.2. N402 is required only if city name (N401) is in the U.S. or Canada.

Example:Example:N4*CENTERVILLE*PA*17111~N4*CENTERVILLE*PA*17111~



REF Billing Provider SecondaryIdentification


Loop:2010AA

Elements: 2

User Option (Usage): SituationalPurpose: To specify identifying information


Description: Code qualifying the Reference IdentificationCodes 8U, LU, ST, TT, 06, IJ, RB, and EM were added to this implementation guide tosupport credit/debit card information billing. See Appendix G, Credit/Debit Card Use, fordetails.

Codes 8U, LU, ST, TT, 06, IJ, RB, and EM were added to this implementation guide tosupport credit/debit card information billing. See Appendix G, Credit/Debit Card Use, fordetails.User Note 6: Use 0B for CA State license #Use 1B for BSC Provider IDDo not use if the information is the same as 2310 Loop

User Note 6: Use 0B for CA State license #Use 1B for BSC Provider IDDo not use if the information is the same as 2310 Loop

CodeList Summary (Total Codes: 1503, Included: 17)Code Name0B State License Number1A Blue Cross Provider Number

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:51 (A-C) [Provider Number]51 (A-C) [Provider Number]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 9, 10Record Type 30 Field No. 24Record Type 10 Field No. 9, 10Record Type 30 Field No. 24

1B Blue Shield Provider Number1C Medicare Provider Number


EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 6Record Type 30 Field No. 24Record Type 10 Field No. 6Record Type 30 Field No. 24

1D Medicaid Provider NumberUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:51 (A-C) [Provider Number]51 (A-C) [Provider Number]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 7Record Type 10 Field No. 7

1G Provider UPIN Number1H CHAMPUS Identification Number


EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 8Record Type 30 Field No. 24Record Type 10 Field No. 8Record Type 30 Field No. 24


Code Name


1J Facility ID NumberB3 Preferred Provider Organization NumberBQ Health Maintenance Organization Code Number

Description: A unique number assigned to each individual Health MaintenanceOrganization (HMO) health insurance plan (assigned by the HMO)

EI Employer's Identification NumberUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:5 [Payer Identification]5 [Payer Identification]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 4, 5Record Type 10 Field No. 4, 5

FH Clinic NumberDescription: A unique number identifying the clinic location that rendered services

G2 Provider Commercial NumberDescription: A unique number assigned to a provider by a commercial insurerUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:51 (A-C) [Provider Number]51 (A-C) [Provider Number]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 9, 10Record Type 30 Field No. 24Record Type 10 Field No. 9, 10Record Type 30 Field No. 24

G5 Provider Site NumberLU Location NumberSY Social Security Number

The social security number may not be used for Medicare.The social security number may not be used for Medicare.UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:5 [Payer Identification]5 [Payer Identification]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 10 Field No. 4, 5Record Type 10 Field No. 4, 5

X5 State Industrial Accident Provider Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Billing Provider Additional IdentifierIndustry: Billing Provider Additional IdentifierUser Note 6: Use only California State License Number or BSC Provider ID with the appropriate REF01qualifier. Do not use if the information is the same as 2310 Loop.

User Note 6: Use only California State License Number or BSC Provider ID with the appropriate REF01qualifier. Do not use if the information is the same as 2310 Loop.



Notes:Notes:1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.2. If the reason the number is being used in this REF can be met by the NPI, carried in the NM108/09 of this loop,then this REF is not used.

1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.2. If the reason the number is being used in this REF can be met by the NPI, carried in the NM108/09 of this loop,then this REF is not used.



3. If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’s Identification Number or theSocial Security Number of the provider must be carried in this REF. The number sent is the one which is used onthe 1099. If additional numbers are needed the REF can be run up to 8 times.

3. If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’s Identification Number or theSocial Security Number of the provider must be carried in this REF. The number sent is the one which is used onthe 1099. If additional numbers are needed the REF can be run up to 8 times.

Example:Example:REF*SY*987654~REF*SY*987654~

User Note 6:User Note 6:Repeat the REF segment to report other identification numbers.Repeat the REF segment to report other identification numbers.



REF Credit/Debit Card BillingInformation


Loop:2010AA

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 8)Code Name06 System Number8U Bank Assigned Security IdentifierEM Electronic Payment Reference NumberIJ Standard Industry Classification (SIC) CodeLU Location NumberRB Rate code numberST Store NumberTT Terminal Code

Description: A code assigned by a transportation carrier that identifies a freightterminal


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Billing Provider Credit Card IdentifierIndustry: Billing Provider Credit Card Identifier



Notes:Notes:1. See Appendix G for use of this segment.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

1. See Appendix G for use of this segment.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

Example:Example:REF*8U*1112223333~REF*8U*1112223333~



PER Billing Provider ContactInformation


Loop:2010AA

Elements: 8

User Option (Usage): SituationalPurpose: To identify a person or office to whom administrative communications should be directed

Element Summary: Ref Id Element Name Req Type Min/Max UsagePER01 366 Contact Function Code M ID 2/2 Required

Description: Code identifying the major duty or responsibility of the person or groupnamed

CodeList Summary (Total Codes: 230, Included: 1)Code NameIC Information Contact

PER02 93 Name O AN 1/60 Required

Description: Free-form nameIndustry: Billing Provider Contact NameIndustry: Billing Provider Contact Name

PER03 365 Communication Number Qualifier C ID 2/2 Required


CodeList Summary (Total Codes: 40, Included: 3)Code NameEM Electronic MailFX Facsimile

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:1, Line 4, Positions 12-21 [Provider Name, Address and Telephone Number]1, Line 4, Positions 12-21 [Provider Name, Address and Telephone Number]


TE TelephoneUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:1, Line 4, Positions 1-10 [Provider Name, Address and Telephone Number]1, Line 4, Positions 1-10 [Provider Name, Address and Telephone Number]


PER04 364 Communication Number C AN 1/80 Required




CodeList Summary (Total Codes: 40, Included: 4)Code NameEM Electronic MailEX Telephone Extension


Code Name


FX FacsimileUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:1, Line 4, Positions 12-21 [Provider Name, Address and Telephone Number]1, Line 4, Positions 12-21 [Provider Name, Address and Telephone Number]


TE TelephoneUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:1, Line 4, Positions 1-10 [Provider Name, Addressand Telephone Number]1, Line 4, Positions 1-10 [Provider Name, Addressand Telephone Number]






CodeList Summary (Total Codes: 40, Included: 4)Code NameEM Electronic MailEX Telephone ExtensionFX Facsimile

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:1, Line 4, Positions 12-21 [Provider Name, Address and Telephone Number]1, Line 4, Positions 12-21 [Provider Name, Address and Telephone Number]


TE TelephoneUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:1, Line 4, Positions 1-10 [Provider Name, Address and Telephone Number]1, Line 4, Positions 1-10 [Provider Name, Address and Telephone Number]




Syntax Rules: 1. P0304 - If either PER03 or PER04 is present, then the other is required.2. P0506 - If either PER05 or PER06 is present, then the other is required.3. P0708 - If either PER07 or PER08 is present, then the other is required.

Notes:Notes:1. Each communication number should always include the area code. The extension, when applicable, should beincluded in the appropriate PER element immediately after the telephone number (e.g., if the telephone number isincluded in PER03 then the extension should be in PER05).2. Required if this information is different than that contained in the Loop 1000A - Submitter PER segment.

1. Each communication number should always include the area code. The extension, when applicable, should beincluded in the appropriate PER element immediately after the telephone number (e.g., if the telephone number isincluded in PER03 then the extension should be in PER05).2. Required if this information is different than that contained in the Loop 1000A - Submitter PER segment.



3. When the communication number represents a telephone number in the United States and other countriesusing the North American Dialing Plan (for voice, data, fax, etc.), the communication number should alwaysinclude the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB isthe telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as5342242525). The extension, when applicable, should be included in the communication number immediatelyafter the telephone number.4. By definition of the standard, if PER05 is used, PER04 is required, and if PER07 is used, PER08 is required.

3. When the communication number represents a telephone number in the United States and other countriesusing the North American Dialing Plan (for voice, data, fax, etc.), the communication number should alwaysinclude the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB isthe telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as5342242525). The extension, when applicable, should be included in the communication number immediatelyafter the telephone number.4. By definition of the standard, if PER05 is used, PER04 is required, and if PER07 is used, PER08 is required.

Example:Example:PER*IC*JOHN SMITH*TE*8007775555~PER*IC*JOHN SMITH*TE*8007775555~



Loop Pay-To Provider Name Pos: 015 Repeat: 1Optional

Loop:2010AB

Elements: N/A

User Option (Usage): SituationalPurpose: To supply the full name of an individual or organizational entity

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Pay-To Provider Name O 1 Situational025 N3 Pay-To Provider Address O 1 Required030 N4 Pay-To Provider City/State/ZIP Code O 1 Required035 REF Pay-To Provider Secondary Identification O 5 Situational



Notes:Notes:1. Required if the Pay-to Provider is a different entity than the Billing Provider.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.

1. Required if the Pay-to Provider is a different entity than the Billing Provider.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.

Example:Example:NM1*87*2*ELLIS HOSPITAL*****24*123456789~NM1*87*2*ELLIS HOSPITAL*****24*123456789~



NM1 Pay-To Provider Name Pos: 015 Max: 1Detail - Optional

Loop:2010AB

Elements: 5




CodeList Summary (Total Codes: 1312, Included: 1)Code Name87 Pay-to Provider




If this entity is the Service Facility Provider, it is not necessary to use the ServiceFacility Provider NM1 loop, loop 2310D.If this entity is the Service Facility Provider, it is not necessary to use the ServiceFacility Provider NM1 loop, loop 2310D.


Description: Individual last name or organizational nameIndustry: Pay-to Provider Last or Organizational NameIndustry: Pay-to Provider Last or Organizational NameAlias: Pay-to Provider Last Name or Organizational NameAlias: Pay-to Provider Last Name or Organizational Name


Description: Code designating the system/method of code structure used for IdentificationCode (67)If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’sIdentification Number or the Social Security Number of the provider must be carried in thisREF. The number sent is the one which is used on the 1099. If additional numbers areneeded the REF can be run up to 5 times.

If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’sIdentification Number or the Social Security Number of the provider must be carried in thisREF. The number sent is the one which is used on the 1099. If additional numbers areneeded the REF can be run up to 5 times.

CodeList Summary (Total Codes: 215, Included: 3)Code Name24 Employer's Identification Number34 Social Security Number

The social security number may not be used for Medicare.The social security number may not be used for Medicare.XX Health Care Financing Administration National Provider Identifier



Description: Code identifying a party or other code




Industry: Pay-to Provider IdentifierIndustry: Pay-to Provider IdentifierAlias: Pay-to Provider Primary Identification NumberAlias: Pay-to Provider Primary Identification Number





Notes:Notes:1. Required if the Pay-to Provider is a different entity than the Billing Provider.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.

1. Required if the Pay-to Provider is a different entity than the Billing Provider.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.

Example:Example:NM1*87*2*ELLIS HOSPITAL*****24*123456789~NM1*87*2*ELLIS HOSPITAL*****24*123456789~



N3 Pay-To Provider Address Pos: 025 Max: 1Detail - Optional

Loop:2010AB

Elements: 2



Description: Address informationIndustry: Pay-to Provider Address LineIndustry: Pay-to Provider Address LineAlias: Pay-to Provider Address 1Alias: Pay-to Provider Address 1


Description: Address informationIndustry: Pay-to Provider Address LineIndustry: Pay-to Provider Address LineAlias: Pay-to Provider Address 2Alias: Pay-to Provider Address 2


Example:Example:N3*2216 N. MAIN STREET*COLDER BUILDING~N3*2216 N. MAIN STREET*COLDER BUILDING~



N4 Pay-To Provider City/State/ZIPCode


Loop:2010AB

Elements: 4



Description: Free-form text for city nameIndustry: Pay-to Provider City NameIndustry: Pay-to Provider City Name


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Pay-to Provider State CodeIndustry: Pay-to Provider State Code



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Pay-to Provider Postal Zone or ZIP CodeIndustry: Pay-to Provider Postal Zone or ZIP CodeAlias: Pay-to Provider Zip CodeAlias: Pay-to Provider Zip Code



Description: Code identifying the countryAlias: Pay-to Provider Country CodeAlias: Pay-to Provider Country Code

Required if the address is outside the U.S.Required if the address is outside the U.S.


Syntax Rules: 1. C0605 - If N406 is present, then N405 is required.


Example:Example:



N4*MADISON* NY*18298~N4*MADISON* NY*18298~



REF Pay-To Provider SecondaryIdentification


Loop:2010AB

Elements: 2



Description: Code qualifying the Reference IdentificationUser Note 6: Use 0B for CA State license #Use 1B for BSC Provider ID

User Note 6: Use 0B for CA State license #Use 1B for BSC Provider ID

CodeList Summary (Total Codes: 1503, Included: 17)Code Name0B State License Number1A Blue Cross Provider Number1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider Number1G Provider UPIN Number1H CHAMPUS Identification Number1J Facility ID NumberB3 Preferred Provider Organization NumberBQ Health Maintenance Organization Code Number

Description: A unique number assigned to each individual Health MaintenanceOrganization (HMO) health insurance plan (assigned by the HMO)

EI Employer's Identification NumberFH Clinic Number

Description: A unique number identifying the clinic location that rendered servicesG2 Provider Commercial Number

Description: A unique number assigned to a provider by a commercial insurerG5 Provider Site NumberLU Location NumberSY Social Security Number

The social security number may not be used for Medicare.The social security number may not be used for Medicare.X5 State Industrial Accident Provider Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Pay-to Provider Additional IdentifierIndustry: Pay-to Provider Additional Identifier





Notes:Notes:1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.2. If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’s Identification Number or theSocial Security Number of the provider must be carried in this REF. The number sent is the one which is used onthe 1099. If additional numbers are needed the REF can be run up to 5 times.

1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.2. If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’s Identification Number or theSocial Security Number of the provider must be carried in this REF. The number sent is the one which is used onthe 1099. If additional numbers are needed the REF can be run up to 5 times.

Example:Example:REF*1G*98765~REF*1G*98765~



Loop Subscriber Hierarchical Level Pos: 001 Repeat: >1Mandatory

Loop:2000B

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage001 HL Subscriber Hierarchical Level M 1 Required005 SBR Subscriber Information O 1 Required015 Loop 2010BA O 1 Required015 Loop 2010BB O 1 Situational015 Loop 2010BC O 1 Required015 Loop 2010BD O 1 Situational130 Loop 2300 O 100 Situational







Notes:Notes:1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip thesubsequent (PATIENT) HL, and proceed directly to Loop ID-2300.2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for thedestination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber(Loop ID-2010BA), his or her insurance (Loop ID-2010BC), and responsible party (Loop ID-2010BD). In addition,information about the credit/debit card holder is placed in this HL (Loop ID-2010BB). The credit/debit card holdermay or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using LoopID-2010BD.3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature. 4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.

1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip thesubsequent (PATIENT) HL, and proceed directly to Loop ID-2300.2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for thedestination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber(Loop ID-2010BA), his or her insurance (Loop ID-2010BC), and responsible party (Loop ID-2010BD). In addition,information about the credit/debit card holder is placed in this HL (Loop ID-2010BB). The credit/debit card holdermay or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using LoopID-2010BD.3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature. 4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.

Example:Example:HL*124*123*22*1~HL*124*123*22*1~



HL Subscriber Hierarchical Level Pos: 001 Max: 1Detail - Mandatory

Loop:2000B

Elements: 4



Description: A unique number assigned by the sender to identify a particular datasegment in a hierarchical structure

HL02 734 Hierarchical Parent ID Number O AN 1/12 Required

Description: Identification number of the next higher hierarchical data segment that thedata segment being described is subordinate to



CodeList Summary (Total Codes: 170, Included: 1)Code Name22 Subscriber

Description: Identifies the employee or group member who is covered forinsurance and to whom, or on behalf of whom, the insurer agrees to pay benefits


Description: Code indicating if there are hierarchical child data segments subordinate tothe level being describedThe claim loop (Loop ID-2300) can be used both when HL04 has no subordinate levels(HL04 = 0) or when HL04 has subordinate levels indicated (HL04 = 1).In the first case (HL04 = 0), the subscriber is the patient and there are no dependentclaims. The second case (HL04 = 1) happens when claims/encounters for both thesubscriber and a dependent of theirs are being sent under the same billing provider HL(e.g., a father and son are both involved in the same automobile accident and are treatedby the same provider). In that case, the subscriber HL04 = 1 because there is a dependentto this subscriber, but the 2300 loop for the subscriber/patient (father) would begin after thesubscriber HL. The dependent HL (son) would then be run and the 2300 loop for thedependent/patient would be run after that HL. HL04=1 would also be used when aclaim/encounter for a only a dependent is being sent.

The claim loop (Loop ID-2300) can be used both when HL04 has no subordinate levels(HL04 = 0) or when HL04 has subordinate levels indicated (HL04 = 1).In the first case (HL04 = 0), the subscriber is the patient and there are no dependentclaims. The second case (HL04 = 1) happens when claims/encounters for both thesubscriber and a dependent of theirs are being sent under the same billing provider HL(e.g., a father and son are both involved in the same automobile accident and are treatedby the same provider). In that case, the subscriber HL04 = 1 because there is a dependentto this subscriber, but the 2300 loop for the subscriber/patient (father) would begin after thesubscriber HL. The dependent HL (son) would then be run and the 2300 loop for thedependent/patient would be run after that HL. HL04=1 would also be used when aclaim/encounter for a only a dependent is being sent.

CodeList Summary (Total Codes: 2, Included: 2)Code Name0 No Subordinate HL Segment in This Hierarchical Structure.1 Additional Subordinate HL Data Segment in This Hierarchical Structure.



set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which



case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in eachsubsequent HL segment within the transaction.




Notes:Notes:1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip thesubsequent (PATIENT) HL, and proceed directly to Loop ID-2300.2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for thedestination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber(Loop ID-2010BA), his or her insurance (Loop ID-2010BC), and responsible party (Loop ID-2010BD). In addition,information about the credit/debit card holder is placed in this HL (Loop ID-2010BB). The credit/debit card holdermay or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using LoopID-2010BD.3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature. 4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.

1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip thesubsequent (PATIENT) HL, and proceed directly to Loop ID-2300.2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for thedestination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber(Loop ID-2010BA), his or her insurance (Loop ID-2010BC), and responsible party (Loop ID-2010BD). In addition,information about the credit/debit card holder is placed in this HL (Loop ID-2010BB). The credit/debit card holdermay or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using LoopID-2010BD.3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature. 4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.




SBR Subscriber Information Pos: 005 Max: 1Detail - Optional

Loop:2000B

Elements: 5

User Option (Usage): RequiredPurpose: To record information specific to the primary insured and the insurance carrier for that insured

Element Summary: Ref Id Element Name Req Type Min/Max UsageSBR01 1138 Payer Responsibility Sequence Number

CodeM ID 1/1 Required

Description: Code identifying the insurance carrier's level of responsibility for a paymentof a claimUB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]

51 (A-C) [Provider Number]

52 (A-C) [Release of Information Certification Indicator]

53 (A-C) [Assignment of Benefits Certification Indicator]

54 (A-C) [Prior Payments - Payers and Patient]

55 (A-C) [Estimated Amount Due]

58 (A-C) [Insured’s Name]

59 (A-C) [Patient’s Relationship to Insured]

60 (A-C) [Certificate/Social Security Number/Health Insurance Claim/ IdentificationNumber]

61 (A-C) [Insured Group Name]

62 (A-C) [Insurance Group Number]

63 (A-C) [Treatment Authorization Code]

64 (A-C) [Employment Status Code of the Insured]

65 (A-C) [Employer Name of the Insured]

66 (A-C) [Employer Location of the Insured]

UB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]














66 (A-C) [Employer Location of the Insured]EMC v.6.0 Reference: Record Type 30 Field No. 2 (Sequence 01-03)

Record Type 31 Field No. 2 (Sequence 01-03)


Record Type 40 Field No. 5, 6, 7

EMC v.6.0 Reference: Record Type 30 Field No. 2 (Sequence 01-03)




CodeList Summary (Total Codes: 6, Included: 3)Code NameP Primary


Code Name


S SecondaryT Tertiary

Use to indicate ’payer of last resort’.Use to indicate ’payer of last resort’.

SBR02 1069 Individual Relationship Code O ID 2/2 Situational

Description: Code indicating the relationship between two individuals or entitiesAlias: Patients Relationship to InsuredAlias: Patients Relationship to InsuredUB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]UB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]EMC v.6.0 Reference: Record Type 30 Field No. 18EMC v.6.0 Reference: Record Type 30 Field No. 18

Use this code only when the subscriber is the same person as the patient. If the subscriberis not the same person as the patient, do not use this element.Use this code only when the subscriber is the same person as the patient. If the subscriberis not the same person as the patient, do not use this element.

CodeList Summary (Total Codes: 153, Included: 1)Code Name18 Self

SBR03 127 Reference Identification O AN 1/30 Situational

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Insured Group or Policy NumberIndustry: Insured Group or Policy NumberAlias: Group NumberAlias: Group NumberUB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number]UB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number]EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03)

Use this element to carry the subscriber’s group number but not the number that uniquelyidentifies the subscriber. The subscriber’s number should be carried in NM109. Using codeIL in NM101 identifies the number in NM109 as the insured’s Identification Number.

Use this element to carry the subscriber’s group number but not the number that uniquelyidentifies the subscriber. The subscriber’s number should be carried in NM109. Using codeIL in NM101 identifies the number in NM109 as the insured’s Identification Number.User Note 6: Claims for members in National Account groups require submission of the group numberfound on their ID Card.

User Note 6: Claims for members in National Account groups require submission of the group numberfound on their ID Card.

SBR04 93 Name O AN 1/60 Situational

Description: Free-form nameIndustry: Insured Group NameIndustry: Insured Group NameAlias: Plan Name (Group Name)Alias: Plan Name (Group Name)UB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name]UB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name]EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03)

Used only when no group number is reported in SBR03.Used only when no group number is reported in SBR03.

SBR09 1032 Claim Filing Indicator Code O ID 1/2 Situational

Description: Code identifying type of claimEMC v.6.0 Reference: Record Type 30 Field No. 4 (not all codes map)EMC v.6.0 Reference: Record Type 30 Field No. 4 (not all codes map)

Required prior to mandated used of PlanID. Not used after PlanID is mandated.Required prior to mandated used of PlanID. Not used after PlanID is mandated.

CodeList Summary (Total Codes: 45, Included: 24)Code Name09 Self-pay

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code ARecord Type 30 Field No. 4 Code A


Code Name


10 Central Certification11 Other Non-Federal Programs12 Preferred Provider Organization (PPO)

Same as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment13 Point of Service (POS)

Same as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment14 Exclusive Provider Organization (EPO)

Same as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment15 Indemnity Insurance16 Health Maintenance Organization (HMO) Medicare RiskAM Automobile Medical

Same as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim PaymentBL Blue Cross/Blue Shield

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code GRecord Type 30 Field No. 4 Code G

CH ChampusEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code HRecord Type 30 Field No. 4 Code H

CI Commercial Insurance Co.EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code FRecord Type 30 Field No. 4 Code F

DS DisabilitySame as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment

HM Health Maintenance OrganizationThere is no map to EMC v.6.0. (Same as the qualifier used in CLP06 of the 835Health Care Claim Payment)There is no map to EMC v.6.0. (Same as the qualifier used in CLP06 of the 835Health Care Claim Payment)

LI LiabilityLM Liability Medical

Same as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim PaymentMA Medicare Part A

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code C (Same as the qualifier used in CLP06 of 835Health Care Claim Payment)Record Type 30 Field No. 4 Code C (Same as the qualifier used in CLP06 of 835Health Care Claim Payment)

MB Medicare Part BSame as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment

MC MedicaidEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code DRecord Type 30 Field No. 4 Code D

OF Other Federal ProgramEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code ERecord Type 30 Field No. 4 Code E

TV Title VSame as the qualifier used in CLP06 of the 835 Health Care Claim PaymentSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment

VA Veteran Administration PlanSame as the qualifier used in CLP06 of the 835 Health Care Claim Payment.Refers to Veterans Affairs Plan.Same as the qualifier used in CLP06 of the 835 Health Care Claim Payment.Refers to Veterans Affairs Plan.


Code Name


WC Workers' Compensation Health ClaimEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 4 Code B (Same as the qualifier used in CLP06 of 835Health Care Claim Payment)Record Type 30 Field No. 4 Code B (Same as the qualifier used in CLP06 of 835Health Care Claim Payment)

ZZ Mutually DefinedUnknownRequired value if the HIPAA Individual Identifier is mandated for use. Otherwise,the MI qualifier is used.

UnknownRequired value if the HIPAA Individual Identifier is mandated for use. Otherwise,the MI qualifier is used.

Semantics: 1. SBR02 specifies the relationship to the person insured.2. SBR03 is policy or group number.3. SBR04 is plan name.4. SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value

indicates the payer is not the destination payer.

Example:Example:SBR*P**GRP01020102******CI~SBR*P**GRP01020102******CI~



Loop Subscriber Name Pos: 015 Repeat: 1Optional

Loop:2010BA

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Subscriber Name O 1 Required025 N3 Subscriber Address O 1 Situational030 N4 Subscriber City/State/ZIP Code O 1 Situational032 DMG Subscriber Demographic Information O 1 Situational035 REF Subscriber Secondary Identification O 4 Situational035 REF Property and Casualty Claim Number O 1 Situational



Notes:Notes:1. In worker’s compensation or other property and casualty claims, the “subscriber” may be a non-person entity(i.e., the employer). However, this varies by state.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. In worker’s compensation or other property and casualty claims, the “subscriber” may be a non-person entity(i.e., the employer). However, this varies by state.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:NM1*IL*1*DOE*JOHN*T***MI*739004273~NM1*IL*1*DOE*JOHN*T***MI*739004273~



NM1 Subscriber Name Pos: 015 Max: 1Detail - Optional

Loop:2010BA

Elements: 8




CodeList Summary (Total Codes: 1312, Included: 1)Code NameIL Insured or Subscriber





Description: Individual last name or organizational nameIndustry: Subscriber Last NameIndustry: Subscriber Last NameUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 12 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 12 (Sequence 01-03)


Description: Individual first nameIndustry: Subscriber First NameIndustry: Subscriber First NameUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 13 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 13 (Sequence 01-03)

This data element is required when NM102 equals one (1).This data element is required when NM102 equals one (1).


Description: Individual middle name or initialIndustry: Subscriber Middle NameIndustry: Subscriber Middle NameAlias: Subscriber’s Middle InitialAlias: Subscriber’s Middle InitialUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 14 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 14 (Sequence 01-03)

This data element is required when NM102 = 1 and the Middle Name or Initial of the personis known.This data element is required when NM102 = 1 and the Middle Name or Initial of the personis known.

NM107 1039 Name Suffix O AN 1/10 Situational




Description: Suffix to individual nameIndustry: Subscriber Name SuffixIndustry: Subscriber Name Suffix

This data element is required when the NM102 equals one (1) and the name suffix isknown. Examples: I, II, III, IV, Jr, Sr.This data element is required when the NM102 equals one (1) and the name suffix isknown. Examples: I, II, III, IV, Jr, Sr.

NM108 66 Identification Code Qualifier C ID 1/2 Situational

Description: Code designating the system/method of code structure used for IdentificationCode (67)This data element is required when NM102 equals one (1).MI is also intended to be used in claims submitted to the Indian Health Service/ContractHealthServices (IHS/CHS) Fiscal Intermediary for the purpose of reporting the TribeResidency Code (Tribe County State). In the event that a Social Security Number is alsoavailable on an IHS/CHS claim, put the SSN in REF02.

This data element is required when NM102 equals one (1).MI is also intended to be used in claims submitted to the Indian Health Service/ContractHealthServices (IHS/CHS) Fiscal Intermediary for the purpose of reporting the TribeResidency Code (Tribe County State). In the event that a Social Security Number is alsoavailable on an IHS/CHS claim, put the SSN in REF02.

CodeList Summary (Total Codes: 215, Included: 2)Code NameMI Member Identification Number

The code MI is intended to be the subscriber’s identification number as assignedby the payer. Payers use different terminology to convey thesame number, therefore, the 837 Institutional Workgroup recommends using MI -Member Identification Number to convey the following terms: Insured’s ID,Subscriber’s ID, Medicaid Recipient ID, Health Insurance Claim Number (HIC), etc.


ZZ Mutually DefinedThe value ‘ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.

The value ‘ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.

NM109 67 Identification Code C AN 2/80 Situational

Description: Code identifying a party or other codeIndustry: Subscriber Primary IdentifierIndustry: Subscriber Primary IdentifierUB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]UB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)

This data element is required when NM102 equals one (1).This data element is required when NM102 equals one (1).User Note 6: Use ID Number exactly as it appears on the Subscriber's ID Card.User Note 6: Use ID Number exactly as it appears on the Subscriber's ID Card.




Notes:Notes:





Example:Example:NM1*IL*1*DOE*JOHN*T***MI*739004273~NM1*IL*1*DOE*JOHN*T***MI*739004273~



N3 Subscriber Address Pos: 025 Max: 1Detail - Optional

Loop:2010BA

Elements: 2

User Option (Usage): SituationalPurpose: To specify the location of the named party


Description: Address informationIndustry: Subscriber Address LineIndustry: Subscriber Address LineUB-92 Ref. [UB-Name]: 84, Line b [Remarks]UB-92 Ref. [UB-Name]: 84, Line b [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 4 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 4 (Sequence 01-03)


Description: Address informationIndustry: Subscriber Address LineIndustry: Subscriber Address LineEMC v.6.0 Reference: Record Type 31 Field No. 5 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 5 (Sequence 01-03)


Notes:Notes:1. This segment is required when the Patient is the same person as the Subscriber. (Required when Loop ID2000B, SBR02- 18 (self)).1. This segment is required when the Patient is the same person as the Subscriber. (Required when Loop ID2000B, SBR02- 18 (self)).

Example:Example:N3*125 CITY AVENUE~N3*125 CITY AVENUE~



N4 Subscriber City/State/ZIP Code Pos: 030 Max: 1Detail - Optional

Loop:2010BA

Elements: 4

User Option (Usage): SituationalPurpose: To specify the geographic place of the named party


Description: Free-form text for city nameIndustry: Subscriber City NameIndustry: Subscriber City NameUB-92 Ref. [UB-Name]: 84, Line c [Remarks]UB-92 Ref. [UB-Name]: 84, Line c [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 6 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 6 (Sequence 01-03)


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Subscriber State CodeIndustry: Subscriber State CodeUB-92 Ref. [UB-Name]: 84, Line c [Remarks]UB-92 Ref. [UB-Name]: 84, Line c [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 7 (Sequence 01-03)



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Subscriber Postal Zone or ZIP CodeIndustry: Subscriber Postal Zone or ZIP CodeUB-92 Ref. [UB-Name]: 84, Line d [Remarks]UB-92 Ref. [UB-Name]: 84, Line d [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 8 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 8 (Sequence 01-03)



Description: Code identifying the countryThis data element is required when the address is outside of the U.S.This data element is required when the address is outside of the U.S.



Comments:



1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.2. N402 is required only if city name (N401) is in the U.S. or Canada.





DMG Subscriber DemographicInformation


Loop:2010BA

Elements: 3

User Option (Usage): SituationalPurpose: To supply demographic information

Element Summary: Ref Id Element Name Req Type Min/Max UsageDMG01 1250 Date Time Period Format Qualifier C ID 2/3 Required

Description: Code indicating the date format, time format, or date and time format

CodeList Summary (Total Codes: 39, Included: 1)Code NameD8 Date Expressed in Format CCYYMMDD

DMG02 1251 Date Time Period C AN 1/35 Required

Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Subscriber Birth DateIndustry: Subscriber Birth DateAlias: Date of Birth - PatientAlias: Date of Birth - PatientEMC v.6.0 Reference: Record Type 20 Field No. 8EMC v.6.0 Reference: Record Type 20 Field No. 8

DMG03 1068 Gender Code O ID 1/1 Required

Description: Code indicating the sex of the individualIndustry: Subscriber Gender CodeIndustry: Subscriber Gender CodeAlias: Gender - PatientAlias: Gender - PatientEMC v.6.0 Reference: Record Type 30 Field No. 15EMC v.6.0 Reference: Record Type 30 Field No. 15

CodeList Summary (Total Codes: 7, Included: 3)Code NameF FemaleM MaleU Unknown

Syntax Rules: 1. P0102 - If either DMG01 or DMG02 is present, then the other is required.

Semantics: 1. DMG02 is the date of birth.2. DMG07 is the country of citizenship.3. DMG09 is the age in years.


Example:Example:DMG*D8*19290730*M~DMG*D8*19290730*M~



REF Subscriber SecondaryIdentification


Loop:2010BA

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 4)Code Name1W Member Identification Number

If NM108 = MI, this qualifier cannot be used.If NM108 = MI, this qualifier cannot be used.23 Client Number

This code is intended to be used only in claims submitted to the Indian HealthService/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purposeof reporting the Health Record Number.

This code is intended to be used only in claims submitted to the Indian HealthService/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purposeof reporting the Health Record Number.

IG Insurance Policy NumberSY Social Security Number

The social security number may not be used for Medicare.The social security number may not be used for Medicare.


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Subscriber Supplemental IdentifierIndustry: Subscriber Supplemental Identifier



Notes:Notes:1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.




REF Property and Casualty ClaimNumber


Loop:2010BA

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 1)Code NameY4 Agency Claim Number

REQUIREDREQUIRED


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Property Casualty Claim NumberIndustry: Property Casualty Claim Number



Notes:Notes:1. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims.Providers receive this number from the property and casualty payer during eligibility determinations or some othercommunication with that payer. See Section 4.2, Property and Casualty, for additional information about propertyand casualty claims.2. In the case where the patient is the same person as the subscriber, the property and casualty claim number isplaced in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number isplaced in Loop ID-2010CA. This number should be transmitted in only one place.3. Not required for HIPAA (The statutory definition of a health plan does not specifically include workers’compensation programs, property and casualty programs, or disability insurance programs, and, consequently,we are not requiring them to comply with the standards.) but may be required for other uses.

1. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims.Providers receive this number from the property and casualty payer during eligibility determinations or some othercommunication with that payer. See Section 4.2, Property and Casualty, for additional information about propertyand casualty claims.2. In the case where the patient is the same person as the subscriber, the property and casualty claim number isplaced in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number isplaced in Loop ID-2010CA. This number should be transmitted in only one place.3. Not required for HIPAA (The statutory definition of a health plan does not specifically include workers’compensation programs, property and casualty programs, or disability insurance programs, and, consequently,we are not requiring them to comply with the standards.) but may be required for other uses.

Example:Example:REF*Y4*4445555~REF*Y4*4445555~



Loop Credit/Debit Card AccountHolder Name

Pos: 015 Repeat: 1Optional

Loop:2010BB

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Credit/Debit Card Account Holder Name O 1 Situational035 REF Credit/Debit Card Information O 2 Situational



Notes:Notes:1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

Example:Example:NM1*AO*1*DOE*JOHN*T***MI*739004273~NM1*AO*1*DOE*JOHN*T***MI*739004273~



NM1 Credit/Debit Card AccountHolder Name


Loop:2010BB

Elements: 8



Description: Code identifying an organizational entity, a physical location, property or anindividualCode AO was added to this implementation guide to support credit/debit card informationbilling. See Appendix G, Credit/Debit Card Use, for details.Code AO was added to this implementation guide to support credit/debit card informationbilling. See Appendix G, Credit/Debit Card Use, for details.

CodeList Summary (Total Codes: 1312, Included: 1)Code NameAO Account Of





Description: Individual last name or organizational nameIndustry: Credit or Debit Card Holder Last or Organizational NameIndustry: Credit or Debit Card Holder Last or Organizational NameAlias: Account Holder Last NameAlias: Account Holder Last Name


Description: Individual first nameIndustry: Credit or Debit Card Holder First NameIndustry: Credit or Debit Card Holder First NameAlias: Account Holder First NameAlias: Account Holder First Name



Description: Individual middle name or initialIndustry: Credit or Debit Card Holder Middle NameIndustry: Credit or Debit Card Holder Middle NameAlias: Account Holder Middle InitialAlias: Account Holder Middle Initial



Description: Suffix to individual nameIndustry: Credit or Debit Card Holder Name SuffixIndustry: Credit or Debit Card Holder Name Suffix









Description: Code identifying a party or other codeIndustry: Credit or Debit Card NumberIndustry: Credit or Debit Card NumberAlias: Credit/Debit Card Account NumberAlias: Credit/Debit Card Account Number




Notes:Notes:1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

Example:Example:NM1*AO*1*DOE*JOHN*T***MI*739004273~NM1*AO*1*DOE*JOHN*T***MI*739004273~



REF Credit/Debit CardInformation


Loop:2010BB

Elements: 2



Description: Code qualifying the Reference IdentificationCodes AB and BB were added to this implementation guide to support credit/debit cardinformation billing. See Appendix G, Credit/Debit Card Use, for additional details.Codes AB and BB were added to this implementation guide to support credit/debit cardinformation billing. See Appendix G, Credit/Debit Card Use, for additional details.

CodeList Summary (Total Codes: 1503, Included: 2)Code NameAB Acceptable Source Purchaser IDBB Authorization Number

Description: Proves that permission was obtained to provide a service


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Credit or Debit Card Authorization NumberIndustry: Credit or Debit Card Authorization Number



Notes:Notes:1. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

1. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

Example:Example:REF*AB*030385074~REF*AB*030385074~



Loop Payer Name Pos: 015 Repeat: 1Optional

Loop:2010BC

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Payer Name O 1 Required025 N3 Payer Address O 1 Situational030 N4 Payer City/State/ZIP Code O 1 Situational035 REF Payer Secondary Identification O 3 Situational



Notes:Notes:1. This is a destination payer.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. This is a destination payer.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:NM1*PR*2*UNION MUTUAL OF OREGON*****PI*43140~NM1*PR*2*UNION MUTUAL OF OREGON*****PI*43140~



NM1 Payer Name Pos: 015 Max: 1Detail - Optional

Loop:2010BC

Elements: 5




CodeList Summary (Total Codes: 1312, Included: 1)Code NamePR Payer





Description: Individual last name or organizational nameIndustry: Payer NameIndustry: Payer NameUB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]UB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]EMC v.6.0 Reference: Record Type 30 Field No. 8b (Sequence 01-03)


EMC v.6.0 Reference: Record Type 30 Field No. 8b (Sequence 01-03)



Description: Code designating the system/method of code structure used for IdentificationCode (67)EMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (Sequence 01-03)

CodeList Summary (Total Codes: 215, Included: 2)Code NamePI Payor IdentificationXV Health Care Financing Administration National Payer Identification Number

(PAYERID)Description: Required if the National PlanID is mandated for use. Otherwise, oneof the other listed codes may be used.Code Source:Code Source:540: Health Care Financing Administration National PlanID540: Health Care Financing Administration National PlanID


Description: Code identifying a party or other code




Industry: Payer IdentifierIndustry: Payer IdentifierAlias: Primary Payer IDAlias: Primary Payer ID

ExternalCodeList Name: 540 Description: Health Care Financing Administration National PlanID




Notes:Notes:1. This is a destination payer.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. This is a destination payer.2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.




N3 Payer Address Pos: 025 Max: 1Detail - Optional

Loop:2010BC

Elements: 2



Description: Address informationIndustry: Payer Address LineIndustry: Payer Address LineEMC v.6.0 Reference: Record Type 32 Field No. 5 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 5 (Sequence 01-03)


Description: Address informationIndustry: Payer Address LineIndustry: Payer Address LineEMC v.6.0 Reference: Record Type 32 Field No. 6 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 6 (Sequence 01-03)


Notes:Notes:1. Payer Address is required when the submitter intends for the claim to be printed on paper at the next EDIlocation (e.g., a clearinghouse).1. Payer Address is required when the submitter intends for the claim to be printed on paper at the next EDIlocation (e.g., a clearinghouse).

Example:Example:N3*225 MAIN STREET*BARKLEY BUILDING~N3*225 MAIN STREET*BARKLEY BUILDING~



N4 Payer City/State/ZIP Code Pos: 030 Max: 1Detail - Optional

Loop:2010BC

Elements: 4



Description: Free-form text for city nameIndustry: Payer City NameIndustry: Payer City NameEMC v.6.0 Reference: Record Type 32 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 7 (Sequence 01-03)


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Payer State CodeIndustry: Payer State CodeEMC v.6.0 Reference: Record Type 32 Field No. 8 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 8 (Sequence 01-03)



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Payer Postal Zone or ZIP CodeIndustry: Payer Postal Zone or ZIP CodeEMC v.6.0 Reference: Record Type 32 Field No. 9 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 9 (Sequence 01-03)



Description: Code identifying the countryAlias: Payer Country CodeAlias: Payer Country Code







Notes:Notes:1. Payer Address is required when the submitter intends for the claim to be printed on paper at the next EDIlocation (e.g., a clearinghouse).1. Payer Address is required when the submitter intends for the claim to be printed on paper at the next EDIlocation (e.g., a clearinghouse).




REF Payer SecondaryIdentification


Loop:2010BC

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 4)Code Name2U Payer Identification Number

This code can be used to identify any payer’s identification number (the payer canbe Medicaid, a commercial payer, TPA, etc). Whatever number is used has beendefined between trading partners.

This code can be used to identify any payer’s identification number (the payer canbe Medicaid, a commercial payer, TPA, etc). Whatever number is used has beendefined between trading partners.

FY Claim Office NumberDescription: The identification of the specific payer's location designated asresponsible for the submitted claim

NF National Association of Insurance Commissioners (NAIC) CodeDescription: A unique number assigned to each insurance companyCode Source:Code Source:245: National Association of Insurance Commissioners (NAIC) Code245: National Association of Insurance Commissioners (NAIC) Code

TJ Federal Taxpayer's Identification Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Payer Additional IdentifierIndustry: Payer Additional IdentifierEMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (Sequence 01-03)

Record Type 31 Field No. 15

EMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (Sequence 01-03)


ExternalCodeList Name: 245 Description: National Association of Insurance Commissioners (NAIC) Code



Notes:Notes:1. Required if additional identification numbers other than the primary identification number in NM108/09 in thisloop are necessary to adjudicate the claim/encounter.1. Required if additional identification numbers other than the primary identification number in NM108/09 in thisloop are necessary to adjudicate the claim/encounter.

Example:Example:



REF*FY*435261708~REF*FY*435261708~



Loop Responsible Party Name Pos: 015 Repeat: 1Optional

Loop:2010BD

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Responsible Party Name O 1 Situational025 N3 Responsible Party Address O 1 Required030 N4 Responsible Party City/State/ZIP Code O 1 Required



Notes:Notes:1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financialresponsibility for the bill.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required for Medicare claims where there is no authorized representative and the provider of medical serviceshas neither the responsible party’s signature nor the patient’s signature on file.

1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financialresponsibility for the bill.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required for Medicare claims where there is no authorized representative and the provider of medical serviceshas neither the responsible party’s signature nor the patient’s signature on file.

Example:Example:NM1*QD*1*JONES*LISA~NM1*QD*1*JONES*LISA~



NM1 Responsible Party Name Pos: 015 Max: 1Detail - Optional

Loop:2010BD

Elements: 6




CodeList Summary (Total Codes: 1312, Included: 1)Code NameQD Responsible Party

Description: Person responsible for the affairs of the person having servicesrendered





Description: Individual last name or organizational nameIndustry: Responsible Party Last or Organization NameIndustry: Responsible Party Last or Organization Name


Description: Individual first nameIndustry: Responsible Party First NameIndustry: Responsible Party First Name



Description: Individual middle name or initialIndustry: Responsible Party Middle NameIndustry: Responsible Party Middle Name



Description: Suffix to individual nameIndustry: Responsible Party Suffix NameIndustry: Responsible Party Suffix NameAlias: Responsible Party GenerationAlias: Responsible Party Generation

Required if known.Required if known.

Syntax Rules:



1. P0809 - If either NM108 or NM109 is present, then the other is required.2. C1110 - If NM111 is present, then NM110 is required.



Notes:Notes:1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financialresponsibility for the bill.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required for Medicare claims where there is no authorized representative and the provider of medical serviceshas neither the responsible party’s signature nor the patient’s signature on file.

1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financialresponsibility for the bill.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required for Medicare claims where there is no authorized representative and the provider of medical serviceshas neither the responsible party’s signature nor the patient’s signature on file.

Example:Example:NM1*QD*1*JONES*LISA~NM1*QD*1*JONES*LISA~



N3 Responsible Party Address Pos: 025 Max: 1Detail - Optional

Loop:2010BD

Elements: 2



Description: Address informationIndustry: Responsible Party Address LineIndustry: Responsible Party Address LineAlias: Responsible Party Address 1Alias: Responsible Party Address 1


Description: Address informationIndustry: Responsible Party Address LineIndustry: Responsible Party Address LineAlias: Responsible Party Address 2Alias: Responsible Party Address 2


Example:Example:N3*123 MAIN STREET~N3*123 MAIN STREET~



N4 Responsible PartyCity/State/ZIP Code


Loop:2010BD

Elements: 4



Description: Free-form text for city nameIndustry: Responsible Party City NameIndustry: Responsible Party City Name


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Responsible Party State CodeIndustry: Responsible Party State Code



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Responsible Party Postal Zone or ZIP CodeIndustry: Responsible Party Postal Zone or ZIP CodeAlias: Responsible Party Zip CodeAlias: Responsible Party Zip Code



Description: Code identifying the countryAlias: Responsible Party Country CodeAlias: Responsible Party Country Code

Required if the address is outside the U.S.Required if the address is outside the U.S.




Example:Example:



N4*ANY TOWN*TX*75123~N4*ANY TOWN*TX*75123~



Loop Claim information Pos: 130 Repeat: 100Optional

Loop: 2300 Elements: N/A

User Option (Usage): SituationalPurpose: To specify basic data about the claim

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage130 CLM Claim information O 1 Required135 DTP Discharge Hour O 1 Situational135 DTP Statement Dates O 1 Required135 DTP Admission Date/Hour O 1 Situational140 CL1 Institutional Claim Code O 1 Situational155 PWK Claim Supplemental Information O 10 Situational160 CN1 Contract Information O 1 Situational175 AMT Payer Estimated Amount Due O 1 Situational175 AMT Patient Estimated Amount Due O 1 Situational175 AMT Patient Paid Amount O 1 Situational175 AMT Credit/Debit Card Maximum Amount O 1 Situational180 REF Adjusted Repriced Claim Number O 1 Situational180 REF Repriced Claim Number O 1 Situational180 REF Claim Identification Number For

Clearinghouses and Other TransmissionIntermediaries

O 1 Situational

180 REF Document Identification Code O 2 Situational180 REF Original Reference Number (ICN/DCN) O 1 Situational180 REF Investigational Device Exemption Number O 1 Situational180 REF Service Authorization Exception Code O 1 Situational180 REF Peer Review Organization (PRO) Approval

NumberO 1 Situational

180 REF Prior Authorization or Referral Number O 2 Situational180 REF Medical Record Number O 1 Situational180 REF Demonstration Project Identifier O 1 Situational185 K3 File Information O 10 Situational190 NTE Claim Note O 10 Situational190 NTE Billing Note O 1 Situational216 CR6 Home Health Care Information O 1 Situational220 CRC Home Health Functional Limitations O 3 Situational220 CRC Home Health Activities Permitted O 3 Situational220 CRC Home Health Mental Status O 2 Situational231 HI Principal, Admitting, E-Code and Patient

Reason For Visit Diagnosis InformationO 1 Situational

231 HI Diagnosis Related Group (DRG)Information

O 1 Situational

231 HI Other Diagnosis Information O 2 Situational231 HI Principal Procedure Information O 1 Situational231 HI Other Procedure Information O 2 Situational231 HI Occurrence Span Information O 2 Situational


Pos Id Segment Name Req Max Use Repeat Usage


231 HI Occurrence Information O 2 Situational231 HI Value Information O 2 Situational231 HI Condition Information O 2 Situational231 HI Treatment Code Information O 2 Situational240 QTY Claim Quantity O 4 Situational241 HCP Claim Pricing/Repricing Information O 1 Situational242 Loop 2305 O 6 Situational250 Loop 2310A O 1 Situational250 Loop 2310B O 1 Situational250 Loop 2310C O 1 Situational250 Loop 2310E O 1 Situational290 Loop 2320 O 10 Situational365 Loop 2400 O 999 Required

Semantics: 1. CLM02 is the total amount of all submitted charges of service segments for this claim.2. 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.3. 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 theprovider.

4. 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.

5. 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.

6. 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.

Notes:Notes:1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is thesubscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.

1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is thesubscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.

Example:Example:CLM*01319300001*500***11:A:1*Y*A*Y*Y***02******N~CLM*01319300001*500***11:A:1*Y*A*Y*Y***02******N~



CLM Claim information Pos: 130 Max: 1Detail - Optional

Loop: 2300 Elements: 9

User Option (Usage): RequiredPurpose: To specify basic data about the claim

Element Summary: Ref Id Element Name Req Type Min/Max UsageCLM01 1028 Claim Submitter's Identifier M AN 1/38 Required

Description: Identifier used to track a claim from creation by the health care providerthrough paymentIndustry: Patient Account NumberIndustry: Patient Account NumberAlias: Patient Control NumberAlias: Patient Control NumberUB-92 Ref. [UB-Name]: 3 [Patient Control Number]UB-92 Ref. [UB-Name]: 3 [Patient Control Number]EMC v.6.0 Reference: Record Type 20 Field No. 3EMC v.6.0 Reference: Record Type 20 Field No. 3

The number that the submitter transmits in this position is echoed back to the submitter inthe 835 and other transactions. This permits the submitter to use the value in this field as akey in the submitter’s system to match the claim to the payment information returned in the835 transaction. The two recommended identifiers are either the patient account number orthe claim number in the billing provider’s system.The MAXIMUM NUMBER OF CHARACTERS to be supported for this field is ’20’. AProvider may submit fewer characters depending upon their needs. However, the HIPAAmaximum requirement to be supported by any responding system is ’20’. Charactersbeyond 20 are not required to be stored nor returned by any receiving system.


CLM02 782 Monetary Amount O R 1/18 Required

Description: Monetary amountIndustry: Total Claim Charge AmountIndustry: Total Claim Charge AmountAlias: Total Claim ChargesAlias: Total Claim ChargesUB-92 Ref. [UB-Name]: 47 (Revenue Code 001) This amount is the total of the SV2segments, with the exception of Revenue Code 001. [Total Charges (by Revenue CodeCategory)]

UB-92 Ref. [UB-Name]: 47 (Revenue Code 001) This amount is the total of the SV2segments, with the exception of Revenue Code 001. [Total Charges (by Revenue CodeCategory)]EMC v.6.0 Reference: Record Type 90 Field No. 13 (Total of Field No. 13 and Field No.15. This amount is the total of the SV2 segments, with the exception of Revenue Code001.)

EMC v.6.0 Reference: Record Type 90 Field No. 13 (Total of Field No. 13 and Field No.15. This amount is the total of the SV2 segments, with the exception of Revenue Code001.)Use this element to indicate the total amount of all submitted charges of service segmentsfor this claim.Zero may be a valid amount.

Use this element to indicate the total amount of all submitted charges of service segmentsfor this claim.Zero may be a valid amount.

CLM05 C023 Health Care Service LocationInformation

O Comp Required

Description: To provide information that identifies the place of service or the type of billrelated to the location at which a health care service was renderedAlias: Type of BillAlias: Type of Bill

CLM05-01 1331 Facility Code Value M AN 1/2 Required

Description: Code identifying the type of facility where services were performed; the firstand second positions of the Uniform Bill Type code or the Place of Service code from theElectronic Media Claims National Standard FormatIndustry: Facility Type CodeIndustry: Facility Type Code




UB-92 Ref. [UB-Name]: 4, Positions 1-2 [Type of Bill]UB-92 Ref. [UB-Name]: 4, Positions 1-2 [Type of Bill]EMC v.6.0 Reference: Record Type 40 Field No. 4, Positions 1-2

Record Type 10 Field No. 2, Positions 1-2

Record Type 95 Field No. 5, Position 1-2 (Batch Control)

EMC v.6.0 Reference: Record Type 40 Field No. 4, Positions 1-2



ExternalCodeList Name: 236 Description: Uniform Billing Claim Form Bill Type

CLM05-02 1332 Facility Code Qualifier O ID 1/2 Required

Description: Code identifying the type of facility referenced

CodeList Summary (Total Codes: 2, Included: 1)Code NameA Uniform Billing Claim Form Bill Type

CODE SOURCE:CODE SOURCE:236: Uniform Billing Claim Form Bill Type236: Uniform Billing Claim Form Bill Type

CLM05-03 1325 Claim Frequency Type Code O ID 1/1 Required

Description: Code specifying the frequency of the claim; this is the third position of theUniform Billing Claim Form Bill TypeIndustry: Claim Frequency CodeIndustry: Claim Frequency CodeUB-92 Ref. [UB-Name]: 4, Position 3 [Type of Bill]UB-92 Ref. [UB-Name]: 4, Position 3 [Type of Bill]EMC v.6.0 Reference: Record Type 40 Field No. 4, Position 3

Record Type 10 Field No. 2, Position 3

Record Type 95 Field No. 5, Position 3 (Batch Control)

EMC v.6.0 Reference: Record Type 40 Field No. 4, Position 3



ExternalCodeList Name: 235 Description: Claim Frequency Type Code

CLM06 1073 Yes/No Condition or Response Code O ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Provider or Supplier Signature IndicatorIndustry: Provider or Supplier Signature IndicatorAlias: Provider Signature on FileAlias: Provider Signature on File

CodeList Summary (Total Codes: 4, Included: 2)Code NameN NoY Yes

CLM07 1359 Provider Accept Assignment Code O ID 1/1 Situational

Description: Code indicating whether the provider accepts assignmentIndustry: Medicare Assignment CodeIndustry: Medicare Assignment Code

CLM07 indicates whether the provider accepts Medicare assignment.CLM07 indicates whether the provider accepts Medicare assignment.




Code NameA AssignedC Not Assigned


Description: Code indicating a Yes or No condition or responseIndustry: Benefits Assignment Certification IndicatorIndustry: Benefits Assignment Certification IndicatorAlias: Assignment of Benefits IndicatorAlias: Assignment of Benefits IndicatorUB-92 Ref. [UB-Name]: 53 (A-C) [Assignment of Benefits Certification Indicator]UB-92 Ref. [UB-Name]: 53 (A-C) [Assignment of Benefits Certification Indicator]EMC v.6.0 Reference: Record Type 30 Field No. 17 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 17 (Sequence 01-03)

Use this value as an assignment of benefits indicator. Use a “Y” value to indicate that theinsured or authorized person authorizes benefits to be assigned to the provider. Use an “N”value to indicate that benefits have not been assigned to the provider.



CLM09 1363 Release of Information Code O ID 1/1 Required

Description: Code indicating whether the provider has on file a signed statement by thepatient authorizing the release of medical data to other organizationsUB-92 Ref. [UB-Name]: 52 (A-C) [Release of Information Certification Indicator]UB-92 Ref. [UB-Name]: 52 (A-C) [Release of Information Certification Indicator]EMC v.6.0 Reference: Record Type 30 Field No. 16 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 16 (Sequence 01-03)

CodeList Summary (Total Codes: 6, Included: 6)Code NameA Appropriate Release of Information on File at Health Care Service Provider or at

Utilization Review OrganizationI Informed Consent to Release Medical Information for Conditions or Diagnoses

Regulated by Federal StatutesM The Provider has Limited or Restricted Ability to Release Data Related to a Claim

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:52 Code R [Restricted or Modified Release]52 Code R [Restricted or Modified Release]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 16 Code RRecord Type 30 Field No. 16 Code R

N No, Provider is Not Allowed to Release DataUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:52 Code N [No Release]52 Code N [No Release]

O On file at Payor or at Plan SponsorY Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data

Related to a ClaimUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:52 Code Y [Yes]52 Code Y [Yes]


Description: Code indicating a Yes or No condition or responseIndustry: Explanation of Benefits IndicatorIndustry: Explanation of Benefits IndicatorAlias: Explanation of Benefits (EOB) IndicatorAlias: Explanation of Benefits (EOB) Indicator





CLM20 1514 Delay Reason Code O ID 1/2 Situational

Description: Code indicating the reason why a request was delayedDelay Reason CodeThis element may be used if a particular claim is being transmitted in response to a requestfor information (e.g., a 277), and the response has been delayed.Required when claim is submitted late (past contracted date of filing limitations) and any ofthe codes below apply.

Delay Reason CodeThis element may be used if a particular claim is being transmitted in response to a requestfor information (e.g., a 277), and the response has been delayed.Required when claim is submitted late (past contracted date of filing limitations) and any ofthe codes below apply.

CodeList Summary (Total Codes: 14, Included: 11)Code Name1 Proof of Eligibility Unknown or Unavailable2 Litigation3 Authorization Delays4 Delay in Certifying Provider5 Delay in Supplying Billing Forms6 Delay in Delivery of Custom-made Appliances7 Third Party Processing Delay8 Delay in Eligibility Determination9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing

Limitation Rules10 Administration Delay in the Prior Approval Process11 Other







Notes:Notes:1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is the

1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is the



subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.

subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.




DTP Discharge Hour Pos: 135 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To specify any or all of a date, a time, or a time period

Element Summary: Ref Id Element Name Req Type Min/Max UsageDTP01 374 Date/Time Qualifier M ID 3/3 Required

Description: Code specifying type of date or time, or both date and timeIndustry: Date Time QualifierIndustry: Date Time Qualifier

CodeList Summary (Total Codes: 1112, Included: 1)Code Name096 Discharge

DTP02 1250 Date Time Period Format Qualifier M ID 2/3 Required


CodeList Summary (Total Codes: 39, Included: 1)Code NameTM Time Expressed in Format HHMM

Description: Time expressed in the format HHMM where HH is the numericalexpression of hours in the day based on a twenty-four hour clock and MM is thenumerical expression of minutes within an hour

DTP03 1251 Date Time Period M AN 1/35 Required

Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Discharge HourIndustry: Discharge HourUB-92 Ref. [UB-Name]: 21 [Discharge Hour]UB-92 Ref. [UB-Name]: 21 [Discharge Hour]EMC v.6.0 Reference: Record Type 20 Field No. 22EMC v.6.0 Reference: Record Type 20 Field No. 22

Semantics: 1. DTP02 is the date or time or period format that will appear in DTP03.

Notes:Notes:1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all final inpatient claims/encounters.

1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all final inpatient claims/encounters.

Example:Example:DTP*096*TM*1130~DTP*096*TM*1130~



DTP Statement Dates Pos: 135 Max: 1Detail - Optional


User Option (Usage): RequiredPurpose: To specify any or all of a date, a time, or a time period



CodeList Summary (Total Codes: 1112, Included: 1)Code Name434 Statement

Description: Date on which billing document was created



CodeList Summary (Total Codes: 39, Included: 2)Code NameD8 Date Expressed in Format CCYYMMDDRD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Description: A range of dates expressed in the format CCYYMMDD-CCYYMMDDwhere CCYY is the numerical expression of the century CC and year YY, MM is thenumerical expression of the month within the year, and DD is the numericalexpression of the day within the year; the first occurrence of CCYYMMDD is thebeginning date and the second occurrence is the ending dateUse RD8 in DTP02 if it is necessary to indicate begin/end for from/to statementdates.Use RD8 in DTP02 if it is necessary to indicate begin/end for from/to statementdates.


Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Statement From or To DateIndustry: Statement From or To DateUB-92 Ref. [UB-Name]: 6 (From) and (Through) [Statement Covers Period]UB-92 Ref. [UB-Name]: 6 (From) and (Through) [Statement Covers Period]EMC v.6.0 Reference: Record Type 20 Field No. 19, 20EMC v.6.0 Reference: Record Type 20 Field No. 19, 20


Example:Example:DTP*434*RD8*19981209-19981214~DTP*434*RD8*19981209-19981214~



DTP Admission Date/Hour Pos: 135 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name435 Admission

Description: Date of entrance to a health care establishment



CodeList Summary (Total Codes: 39, Included: 1)Code NameDT Date and Time Expressed in Format CCYYMMDDHHMM


Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Admission Date and HourIndustry: Admission Date and HourUB-92 Ref. [UB-Name]: 17 [Admission/Start of Care Date]

18 [Admission Hour]

UB-92 Ref. [UB-Name]: 17 [Admission/Start of Care Date]

18 [Admission Hour]EMC v.6.0 Reference: Record Type 20 Field No. 17 (Admission Date)

Record Type 20 Field No. 18 (Admission Hour)

EMC v.6.0 Reference: Record Type 20 Field No. 17 (Admission Date)



Notes:Notes:1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all Inpatient claims.

1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all Inpatient claims.

Example:Example:DTP*435*DT*199610131242~DTP*435*DT*199610131242~



CL1 Institutional Claim Code Pos: 140 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To supply information specific to hospital claims

Element Summary: Ref Id Element Name Req Type Min/Max UsageCL101 1315 Admission Type Code O ID 1/1 Situational

Description: Code indicating the priority of this admissionUB-92 Ref. [UB-Name]: 19 [Type of Admission]UB-92 Ref. [UB-Name]: 19 [Type of Admission]EMC v.6.0 Reference: Record Type 20 Field No. 10EMC v.6.0 Reference: Record Type 20 Field No. 10

Required when patient is being admitted to the hospital for inpatient services.Required when patient is being admitted to the hospital for inpatient services.

ExternalCodeList Name: 231 Description: Admission Type Code

CL102 1314 Admission Source Code O ID 1/1 Situational

Description: Code indicating the source of this admissionUB-92 Ref. [UB-Name]: 20 [Source of Admission]UB-92 Ref. [UB-Name]: 20 [Source of Admission]EMC v.6.0 Reference: Record Type 20 Field No. 11EMC v.6.0 Reference: Record Type 20 Field No. 11

Required for all inpatient admissions. Required on Medicare outpatient registrations fordiagnostic testing services.Required for all inpatient admissions. Required on Medicare outpatient registrations fordiagnostic testing services.

ExternalCodeList Name: 230 Description: Admission Source Code

CL103 1352 Patient Status Code O ID 1/2 Situational

Description: Code indicating patient status as of the "statement covers through date"UB-92 Ref. [UB-Name]: 22 [Patient Status]UB-92 Ref. [UB-Name]: 22 [Patient Status]EMC v.6.0 Reference: Record Type 20 Field No. 21EMC v.6.0 Reference: Record Type 20 Field No. 21

This element is required for inpatient claims/encounters.This element is required for inpatient claims/encounters.

ExternalCodeList Name: 239 Description: Patient Status Code

Notes:Notes:1. This segment is required when reporting hospital based admission and Medicare outpatient registrations onclaims/encounters. It may be used when provider wishes to communicate this information on non-Medicareoutpatient claims/encounters.

1. This segment is required when reporting hospital based admission and Medicare outpatient registrations onclaims/encounters. It may be used when provider wishes to communicate this information on non-Medicareoutpatient claims/encounters.

Example:Example:CL1*1*7*30~CL1*1*7*30~



PWK Claim SupplementalInformation



User Option (Usage): SituationalPurpose: To identify the type or transmission or both of paperwork or supporting information

Element Summary: Ref Id Element Name Req Type Min/Max UsagePWK01 755 Report Type Code M ID 2/2 Required

Description: Code indicating the title or contents of a document, report or supporting itemIndustry: Attachment Report Type CodeIndustry: Attachment Report Type Code

CodeList Summary (Total Codes: 522, Included: 19)Code NameAS Admission Summary

Description: A brief patient summary; it lists the patient's chief complaints and thereasons for admitting the patient to the hospital

B2 PrescriptionB3 Physician OrderB4 Referral FormCT CertificationDA Dental Models

Description: Cast of the teeth; they are usually taken before partial dentures orbraces are placed

DG Diagnostic ReportDescription: Report describing the results of lab tests x-rays or radiology films

DS Discharge SummaryDescription: Report listing the condition of the patient upon release from thehospital; it usually lists where the patient is being released to, what medication thepatient is taking and when to follow-up with the doctor

EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)Description: Summary of benefits paid on the claim

MT ModelsNN Nursing Notes

Description: Notes kept by the nurse regarding a patient's physical and mentalcondition, what medication the patient is on and when it should be given

OB Operative NoteDescription: Step-by-step notes of exactly what takes place during an operation

OZ Support Data for ClaimDescription: Medical records that would support procedures performed; tests givenand necessary for a claim

PN Physical Therapy NotesPO Prosthetics or Orthotic CertificationPZ Physical Therapy CertificationRB Radiology Films

Description: X-rays, videos, and other radiology diagnostic testsRR Radiology Reports


Code Name


Description: Reports prepared by a radiologists after the films or x-rays have beenreviewed

RT Report of Tests and Analysis Report

PWK02 756 Report Transmission Code O ID 1/2 Required

Description: Code defining timing, transmission method or format by which reports are tobe sentIndustry: Attachment Transmission CodeIndustry: Attachment Transmission Code

CodeList Summary (Total Codes: 51, Included: 5)Code NameAA Available on Request at Provider Site

Paperwork is available at the provider’s site. This means that the paperwork is notbeing sent with the claim at this time. Instead, it is available to the payer (orappropriate entity) at his or her request.


BM By MailEL Electronically OnlyEM E-MailFX By Fax

PWK05 66 Identification Code Qualifier C ID 1/2 Situational

Description: Code designating the system/method of code structure used for IdentificationCode (67)This data element is required when PWK02 DOES NOT equal ’AA’. Can be used whenPWK02 equals ’AA’ if the Provider wants to send a document control number for anattachment remaining at the Providers office.

This data element is required when PWK02 DOES NOT equal ’AA’. Can be used whenPWK02 equals ’AA’ if the Provider wants to send a document control number for anattachment remaining at the Providers office.

CodeList Summary (Total Codes: 215, Included: 1)Code NameAC Attachment Control Number

Description: Means of associating electronic claim with documentation forwardedby other means

PWK06 67 Identification Code C AN 2/80 Situational

Description: Code identifying a party or other codeIndustry: Attachment Control NumberIndustry: Attachment Control Number

Required if PWK02 equals BM, EL, EM or FX.Required if PWK02 equals BM, EL, EM or FX.

PWK07 352 Description O AN 1/80 Notrecommended

Description: A free-form description to clarify the related data elements and their contentIndustry: Attachment DescriptionIndustry: Attachment Description

This data element is used to add any additional information about the attachmentdescribed in this segment.This data element is used to add any additional information about the attachmentdescribed in this segment.

Syntax Rules: 1. P0506 - If either PWK05 or PWK06 is present, then the other is required.

Comments: 1. PWK05 and PWK06 may be used to identify the addressee by a code number.



2. PWK07 may be used to indicate special information to be shown on the specified report.3. PWK08 may be used to indicate action pertaining to a report.

Notes:Notes:1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope.2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope.2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

Example:Example:PWK*AS*BM***AC*DMN0012~PWK*AS*BM***AC*DMN0012~



CN1 Contract Information Pos: 160 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To specify basic data about the contract or contract line item

Element Summary: Ref Id Element Name Req Type Min/Max UsageCN101 1166 Contract Type Code M ID 2/2 Required

Description: Code identifying a contract type

CodeList Summary (Total Codes: 50, Included: 7)Code Name01 Diagnosis Related Group (DRG)

Description: A patient classification scheme, which provides means of relating thetype of patients a hospital treats to the costs incurred by the hospital, to determinequality of care and utilization of services in a hospital setting

02 Per DiemDescription: A contract which allows certain charges to be on a rate per day basis

03 Variable Per DiemDescription: A contract which allows certain charges to be on a rate per day basis,where the rate may not remain constant

04 FlatDescription: A contract between the provider of service and the destination payorwhereby the flat rate charges may differ from the total itemized charges

05 CapitatedDescription: A contract between the provider of service and the destination payorwhich allows payment to the provider of service on a per member per month basis

06 Percent09 Other

CN102 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Contract AmountIndustry: Contract Amount

Required if provider is contractually obligated to provide this information on the claim.Required if provider is contractually obligated to provide this information on the claim.

CN103 332 Percent O R 1/6 Situational

Description: Percent expressed as a percentIndustry: Contract PercentageIndustry: Contract PercentageAlias: Allowance or Charge PercentAlias: Allowance or Charge Percent


CN104 127 Reference Identification O AN 1/30 Situational

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Contract CodeIndustry: Contract Code





CN105 338 Terms Discount Percent O R 1/6 Situational

Description: Terms discount percentage, expressed as a percent, available to thepurchaser if an invoice is paid on or before the Terms Discount Due DateIndustry: Terms Discount PercentageIndustry: Terms Discount Percentage


CN106 799 Version Identifier O AN 1/30 Situational

Description: Revision level of a particular format, program, technique or algorithmIndustry: Contract Version IdentifierIndustry: Contract Version Identifier


Semantics: 1. CN102 is the contract amount.2. CN103 is the allowance or charge percent.3. CN104 is the contract code.4. CN106 is an additional identifying number for the contract.

Notes:Notes:1. The developers of this implementation guide recommend that for non-capitated situations, contract informationbe maintained in the receiver’s files and not be transmitted with each claim whenever possible. It isrecommended that submitters always include CN1 for encounters that include only capitated services.2. Required if the provider is contractually obligated to provide contract information on this claim.

1. The developers of this implementation guide recommend that for non-capitated situations, contract informationbe maintained in the receiver’s files and not be transmitted with each claim whenever possible. It isrecommended that submitters always include CN1 for encounters that include only capitated services.2. Required if the provider is contractually obligated to provide contract information on this claim.

Example:Example:CN1*02*550~CN1*02*550~



AMT Payer Estimated AmountDue



User Option (Usage): SituationalPurpose: To indicate the total monetary amount

Element Summary: Ref Id Element Name Req Type Min/Max UsageAMT01 522 Amount Qualifier Code M ID 1/3 Required

Description: Code to qualify amount

CodeList Summary (Total Codes: 1473, Included: 1)Code NameC5 Claim Amount Due - Estimated

Description: Approximate value rightfully belonging to the individual

AMT02 782 Monetary Amount M R 1/18 Required

Description: Monetary amountIndustry: Estimated Claim Due AmountIndustry: Estimated Claim Due AmountUB-92 Ref. [UB-Name]: 55 (A-C) [Estimated Amount Due]UB-92 Ref. [UB-Name]: 55 (A-C) [Estimated Amount Due]EMC v.6.0 Reference: Record Type 30 Field No. 26EMC v.6.0 Reference: Record Type 30 Field No. 26

Notes:Notes:1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Payer Estimated Amount Due is applicable to this claim.

1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Payer Estimated Amount Due is applicable to this claim.

Example:Example:AMT*C5*14523.1~AMT*C5*14523.1~



AMT Patient Estimated AmountDue






CodeList Summary (Total Codes: 1473, Included: 1)Code NameF3 Patient Responsibility - Estimated

Description: Approximate value one receiving medical care is obliged to pay


Description: Monetary amountIndustry: Patient Responsibility AmountIndustry: Patient Responsibility AmountUB-92 Ref. [UB-Name]: 55, Patient Line [Estimated Amount Due]UB-92 Ref. [UB-Name]: 55, Patient Line [Estimated Amount Due]EMC v.6.0 Reference: Record Type 20 Field No. 24EMC v.6.0 Reference: Record Type 20 Field No. 24

Notes:Notes:1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Responsibility Amount is applicable to this claim.

1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Responsibility Amount is applicable to this claim.

Example:Example:AMT*F3*123~AMT*F3*123~



AMT Patient Paid Amount Pos: 175 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameF5 Patient Amount Paid

Description: Monetary amount value already paid by one receiving medical care


Description: Monetary amountIndustry: Patient Amount PaidIndustry: Patient Amount PaidUB-92 Ref. [UB-Name]: 54, Line P [Prior Payments - Payers and Patient]UB-92 Ref. [UB-Name]: 54, Line P [Prior Payments - Payers and Patient]EMC v.6.0 Reference: Record Type 20 Field No. 23EMC v.6.0 Reference: Record Type 20 Field No. 23

Notes:Notes:1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Paid Amount is applicable to this claim.

1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Paid Amount is applicable to this claim.

Example:Example:AMT*F5*8.5~AMT*F5*8.5~



AMT Credit/Debit Card MaximumAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameMA Maximum Amount


Description: Monetary amountIndustry: Credit or Debit Card Maximum AmountIndustry: Credit or Debit Card Maximum Amount

Notes:Notes:1. Use this segment only for claims that contain credit/debit card information. This segment indicates themaximum amount that can be credited to the account indicated in 2010BB - CREDIT/DEBIT CARD ACCOUNTHOLDER NAME.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

1. Use this segment only for claims that contain credit/debit card information. This segment indicates themaximum amount that can be credited to the account indicated in 2010BB - CREDIT/DEBIT CARD ACCOUNTHOLDER NAME.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

Example:Example:AMT*MA*25~AMT*MA*25~



REF Adjusted Repriced ClaimNumber






CodeList Summary (Total Codes: 1503, Included: 1)Code Name9C Adjusted Repriced Claim Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Adjusted Repriced Claim Reference NumberIndustry: Adjusted Repriced Claim Reference Number



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is required when Repricers need to attach their own claim identification number to a previouslyadjusted (resubmitted) claim they are processing.

1. Reference numbers at this position apply to the entire claim.2. This segment is required when Repricers need to attach their own claim identification number to a previouslyadjusted (resubmitted) claim they are processing.

Example:Example:REF*9C*XDE1234579~REF*9C*XDE1234579~



REF Repriced Claim Number Pos: 180 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1503, Included: 1)Code Name9A Repriced Claim Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Repriced Claim Reference NumberIndustry: Repriced Claim Reference Number



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is required when the Repricers need to attach their own claim identification to a claim they areprocessing.

1. Reference numbers at this position apply to the entire claim.2. This segment is required when the Repricers need to attach their own claim identification to a claim they areprocessing.

Example:Example:REF*9A*3456749387~REF*9A*3456749387~



REF Claim Identification NumberFor Clearinghouses andOther TransmissionIntermediaries





Description: Code qualifying the Reference IdentificationNumber assigned by clearinghouse/van/etc.Number assigned by clearinghouse/van/etc.

CodeList Summary (Total Codes: 1503, Included: 1)Code NameD9 Claim Number

Description: Sequence number to track the number of claims opened within aparticular line of business


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Value Added Network Trace NumberIndustry: Value Added Network Trace Number



Notes:Notes:1. Used only by transmission intermediaries (Value-Added Networks, Automated Clearing Houses, and others)who need to attach their own unique claim number.2. This number can be used to facilitate front-end acknowledgements such as the 277 Health Care PayerUnsolicited Claim Status.

1. Used only by transmission intermediaries (Value-Added Networks, Automated Clearing Houses, and others)who need to attach their own unique claim number.2. This number can be used to facilitate front-end acknowledgements such as the 277 Health Care PayerUnsolicited Claim Status.

Example:Example:REF*D9*4373649430ABES~REF*D9*4373649430ABES~



REF Document IdentificationCode






CodeList Summary (Total Codes: 1503, Included: 1)Code NameDD Document Identification Code


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Document Control IdentifierIndustry: Document Control IdentifierEMC v.6.0 Reference: Record Type 71 Field No. 4EMC v.6.0 Reference: Record Type 71 Field No. 4

Use the form name as shown in the example. If both the 485 and 486 forms are being sent,repeat the segment.Use the form name as shown in the example. If both the 485 and 486 forms are being sent,repeat the segment.



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey submittal of HCFA-485 and HCFA-486 data OR HCFA-486 data only.1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey submittal of HCFA-485 and HCFA-486 data OR HCFA-486 data only.

Example:Example:REF*DD*485~REF*DD*485~



REF Original Reference Number(ICN/DCN)






CodeList Summary (Total Codes: 1503, Included: 1)Code NameF8 Original Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Claim Original Reference NumberIndustry: Claim Original Reference NumberUB-92 Ref. [UB-Name]: 37 (A-C) [Internal Control Number (ICN)/ Document ControlNumber (DCN)]UB-92 Ref. [UB-Name]: 37 (A-C) [Internal Control Number (ICN)/ Document ControlNumber (DCN)]EMC v.6.0 Reference: Record Type 31 Field No. 14 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 14 (Sequence 01-03)



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey the control number assigned to the original bill by the payer to identify a uniqueclaim.

1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey the control number assigned to the original bill by the payer to identify a uniqueclaim.

Example:Example:REF*F8*1234636854~REF*F8*1234636854~



REF Investigational DeviceExemption Number






CodeList Summary (Total Codes: 1503, Included: 1)Code NameLX Qualified Products List


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Investigational Device Exemption IdentifierIndustry: Investigational Device Exemption IdentifierEMC v.6.0 Reference: Record Type 34 Field No. 5EMC v.6.0 Reference: Record Type 34 Field No. 5



Notes:Notes:1. Required only on claims involving an FDA assigned investigational device exemption (IDE) number. Only oneIDE per claim is to be reported.1. Required only on claims involving an FDA assigned investigational device exemption (IDE) number. Only oneIDE per claim is to be reported.

Example:Example:REF*LX*432907~REF*LX*432907~



REF Service AuthorizationException Code






CodeList Summary (Total Codes: 1503, Included: 1)Code Name4N Special Payment Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Service Authorization Exception CodeIndustry: Service Authorization Exception Code

CodeList Summary (Total Codes: 7, Included: 7)Code Name1 Immediate/Urgent Care2 Services Rendered in a Retroactive Period3 Emergency Care4 Client as Temporary Medicaid5 Request from Country for Second Option to Recipient can Work 6 Request for Override Pending7 Special Handling



Notes:Notes:1. Used only in claims where providers are required by state law (e.g., New York State Medicaid) to obtainauthorization for specific services but, for the reasons listed in REF02, performed the service without obtainingthe service authorization. Check with your state Medicaid to see if this applies in your state.

1. Used only in claims where providers are required by state law (e.g., New York State Medicaid) to obtainauthorization for specific services but, for the reasons listed in REF02, performed the service without obtainingthe service authorization. Check with your state Medicaid to see if this applies in your state.

Example:Example:REF*4N*1~REF*4N*1~



REF Peer Review Organization(PRO) Approval Number






CodeList Summary (Total Codes: 1503, Included: 1)Code NameG4 Peer Review Organization (PRO) Approval Number

Description: An authorization number for certain surgical procedures and for anassistant at cataract surgery


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Peer Review Authorization NumberIndustry: Peer Review Authorization Number



Notes:Notes:1. Required when an external Peer Review Organization assigns an Approval Number to services deemedmedically necessary by that organization.1. Required when an external Peer Review Organization assigns an Approval Number to services deemedmedically necessary by that organization.

Example:Example:REF*G4*284746~REF*G4*284746~



REF Prior Authorization orReferral Number






CodeList Summary (Total Codes: 1503, Included: 2)Code Name9F Referral NumberG1 Prior Authorization Number

Description: An authorization number acquired prior to the submission of a claim


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Prior Authorization NumberIndustry: Prior Authorization NumberUB-92 Ref. [UB-Name]: 63 (A-C) [Treatment Authorization Code]UB-92 Ref. [UB-Name]: 63 (A-C) [Treatment Authorization Code]EMC v.6.0 Reference: Record Type 40 Field No. 5, 6, 7 (Treatment Authorization Number)EMC v.6.0 Reference: Record Type 40 Field No. 5, 6, 7 (Treatment Authorization Number)



Notes:Notes:1. Required where services on this claim were preauthorized or where a referral is involved. Generally,preauthorization/referral numbers are those numbers assigned by the payer/UMO to authorize a service prior toits being performed. The UMO (Utilization Management Organization) is generally the entity empowered to makea decision regarding the outcome of a health services review or the owner of information. The referral or priorauthorization number carried in this REF is specific to the destination payer reported in the 2010BC loop. If otherpayers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payer’sinformation.

1. Required where services on this claim were preauthorized or where a referral is involved. Generally,preauthorization/referral numbers are those numbers assigned by the payer/UMO to authorize a service prior toits being performed. The UMO (Utilization Management Organization) is generally the entity empowered to makea decision regarding the outcome of a health services review or the owner of information. The referral or priorauthorization number carried in this REF is specific to the destination payer reported in the 2010BC loop. If otherpayers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payer’sinformation.




REF Medical Record Number Pos: 180 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1503, Included: 1)Code NameEA Medical Record Identification Number

Description: A unique number assigned to each patient by the provider of service(hospital) to assist in retrieval of medical records


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Medical Record NumberIndustry: Medical Record NumberEMC v.6.0 Reference: Record Type 20 Field No. 25 (Medical Record Number)EMC v.6.0 Reference: Record Type 20 Field No. 25 (Medical Record Number)



Notes:Notes:1. Required if provider needs to identify for future inquiries the actual medical record of the patient identified ineither Loop ID - 2010BA or 2010CA for this episode of care.2. Used if provider will utilize this information in a 276 - Claim Status Inquiry in order to receive and process a 277-Claim Status Response.

1. Required if provider needs to identify for future inquiries the actual medical record of the patient identified ineither Loop ID - 2010BA or 2010CA for this episode of care.2. Used if provider will utilize this information in a 276 - Claim Status Inquiry in order to receive and process a 277-Claim Status Response.

Example:Example:REF*EA*1230484376R~REF*EA*1230484376R~



REF Demonstration ProjectIdentifier






CodeList Summary (Total Codes: 1503, Included: 1)Code NameP4 Project Code


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Demonstration Project IdentifierIndustry: Demonstration Project Identifier



Notes:Notes:1. Required on claims/encounters where a demonstration project is being billed/reported. This information isspecific to the destination payer reported in the 2010BC loop. If other payers have a similar number, report thatinformation in the 2330 loop which holds that payer’s information.

1. Required on claims/encounters where a demonstration project is being billed/reported. This information isspecific to the destination payer reported in the 2010BC loop. If other payers have a similar number, report thatinformation in the 2330 loop which holds that payer’s information.

Example:Example:REF*P4*THJ1222~REF*P4*THJ1222~



K3 File Information Pos: 185 Max: 10Detail - Optional


User Option (Usage): SituationalPurpose: To transmit a fixed-format record or matrix contents

Element Summary: Ref Id Element Name Req Type Min/Max UsageK301 449 Fixed Format Information M AN 1/80 Required

Description: Data in fixed format agreed upon by sender and receiver

Semantics: 1. K303 identifies the value of the index.

Comments: 1. The default for K302 is content.

Notes:Notes:1. At the time of publication K3 segments have no specific use. However, they have been included in thisimplementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirementby a state regulatory authority.2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislativerequirement AND the administering state agency or other state organization has contacted the X12N workgroup,requested a review of the K3 data requirement to ensure there is not an existing method within theimplementation guide to meet this requirement, and X12N determines that there is no method to meet therequirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N willsubmit the necessary data maintenance and refer the request to the appropriate data content committee.

1. At the time of publication K3 segments have no specific use. However, they have been included in thisimplementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirementby a state regulatory authority.2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislativerequirement AND the administering state agency or other state organization has contacted the X12N workgroup,requested a review of the K3 data requirement to ensure there is not an existing method within theimplementation guide to meet this requirement, and X12N determines that there is no method to meet therequirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N willsubmit the necessary data maintenance and refer the request to the appropriate data content committee.



NTE Claim Note Pos: 190 Max: 10Detail - Optional


User Option (Usage): SituationalPurpose: To transmit information in a free-form format, if necessary, for comment or special instruction

Element Summary: Ref Id Element Name Req Type Min/Max UsageNTE01 363 Note Reference Code O ID 3/3 Required

Description: Code identifying the functional area or purpose for which the note appliesEMC v.6.0 Reference: Record Type 73 Field No. 5EMC v.6.0 Reference: Record Type 73 Field No. 5

CodeList Summary (Total Codes: 241, Included: 14)Code NameALG Allergies

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48517Record Type 73 Field No. 5 Code 48517

DCP Goals, Rehabilitation Potential, or Discharge PlansEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48522Record Type 73 Field No. 5 Code 48522

DGN Diagnosis DescriptionDescription: Verbal description of the condition involved

DME Durable Medical Equipment (DME) and SuppliesEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48514Record Type 73 Field No. 5 Code 48514

MED MedicationsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48510Record Type 73 Field No. 5 Code 48510

NTR Nutritional RequirementsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48516Record Type 73 Field No. 5 Code 48516

ODT Orders for Disciplines and TreatmentsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48521Record Type 73 Field No. 5 Code 48521

RHB Functional Limitations, Reason Homebound, or BothEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48617Record Type 73 Field No. 5 Code 48617

RLH Reasons Patient Leaves HomeEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48621Record Type 73 Field No. 5 Code 48621

RNH Times and Reasons Patient Not at HomeEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48620Record Type 73 Field No. 5 Code 48620

SET Unusual Home, Social Environment, or BothEMC v.6.0 Reference:EMC v.6.0 Reference:


Code Name


Record Type 73 Field No. 5 Code 48619Record Type 73 Field No. 5 Code 48619SFM Safety Measures


SPT Supplementary Plan of TreatmentEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48521Record Type 73 Field No. 5 Code 48521

UPI Updated InformationEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48616Record Type 73 Field No. 5 Code 48616

NTE02 352 Description M AN 1/80 Required

Description: A free-form description to clarify the related data elements and their contentIndustry: Claim Note TextIndustry: Claim Note TextUB-92 Ref. [UB-Name]: 84 [Remarks]UB-92 Ref. [UB-Name]: 84 [Remarks]EMC v.6.0 Reference: Record Type 73 Field No. 6EMC v.6.0 Reference: Record Type 73 Field No. 6

Comments: 1. The NTE segment permits free-form information/data which, under ANSI X12 standard implementations, is not

machine processable. The use of the NTE segment should therefore be avoided, if at all possible, in anautomated environment.

Notes:Notes:1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information inthe NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in LoopID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guidediscourage using narrative information within the 837. Trading partners who require narrative information withclaims are encouraged to codify that information within the X12 environment.2. Home Health Corresponding Data This segment is used to convey Home Health narrative information from theforms ‘‘Home Health Certification and Plan of Treatment’’ and ‘‘Medical Update and Patient Information.’’3. Required only when provider deems it necessary to transmit information not otherwise supported in thisimplementation.

1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information inthe NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in LoopID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guidediscourage using narrative information within the 837. Trading partners who require narrative information withclaims are encouraged to codify that information within the X12 environment.2. Home Health Corresponding Data This segment is used to convey Home Health narrative information from theforms ‘‘Home Health Certification and Plan of Treatment’’ and ‘‘Medical Update and Patient Information.’’3. Required only when provider deems it necessary to transmit information not otherwise supported in thisimplementation.

Example:Example:NTE*NTR*PATIENT REQUIRES TUBE FEEDING~NTE*NTR*PATIENT REQUIRES TUBE FEEDING~



NTE Billing Note Pos: 190 Max: 1Detail - Optional




Description: Code identifying the functional area or purpose for which the note applies

CodeList Summary (Total Codes: 241, Included: 1)Code NameADD Additional Information


Description: A free-form description to clarify the related data elements and their contentIndustry: Billing Note TextIndustry: Billing Note TextUB-92 Ref. [UB-Name]: 84 [Remarks]UB-92 Ref. [UB-Name]: 84 [Remarks]EMC v.6.0 Reference: Record Type 90 Field No. 4, 17EMC v.6.0 Reference: Record Type 90 Field No. 4, 17



Notes:Notes:1. This segment is used to convey additional information necessary to adjudicate the claim.2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) inthe opinion of the provider, the information is needed to substantiate the medical treatment and is not supportedelsewhere within the claim data set.

1. This segment is used to convey additional information necessary to adjudicate the claim.2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) inthe opinion of the provider, the information is needed to substantiate the medical treatment and is not supportedelsewhere within the claim data set.

Example:Example:NTE*ADD*NO LIABILITY, PATIENT FELL AT HOME~NTE*ADD*NO LIABILITY, PATIENT FELL AT HOME~



CR6 Home Health CareInformation



User Option (Usage): SituationalPurpose: To supply information related to the certification of a home health care patient

Element Summary: Ref Id Element Name Req Type Min/Max UsageCR601 923 Prognosis Code M ID 1/1 Required

Description: Code indicating physician's prognosis for the patientAlias: Prognosis IndicatorAlias: Prognosis IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 18EMC v.6.0 Reference: Record Type 71 Field No. 18

CodeList Summary (Total Codes: 8, Included: 8)Code Name1 Poor2 Guarded3 Fair4 Good5 Very Good6 Excellent7 Less than 6 Months to Live8 Terminal

CR602 373 Date M DT 8/8 Required

Description: Date expressed as CCYYMMDDIndustry: Service From DateIndustry: Service From DateAlias: SOC DateAlias: SOC DateEMC v.6.0 Reference: Record Type 71 Field No. 5 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 5 (MMDDYY)

CR603 1250 Date Time Period Format Qualifier C ID 2/3 Situational

Description: Code indicating the date format, time format, or date and time formatRequired on claims/encounters when a certification for Home Health Services waspreviously or is being submitted to the destination payer.Required on claims/encounters when a certification for Home Health Services waspreviously or is being submitted to the destination payer.

CodeList Summary (Total Codes: 39, Included: 1)Code NameRD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Description: A range of dates expressed in the format CCYYMMDD-CCYYMMDDwhere CCYY is the numerical expression of the century CC and year YY, MM is thenumerical expression of the month within the year, and DD is the numericalexpression of the day within the year; the first occurrence of CCYYMMDD is thebeginning date and the second occurrence is the ending date

CR604 1251 Date Time Period C AN 1/35 Situational

Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Home Health Certification PeriodIndustry: Home Health Certification PeriodAlias: Certification PeriodAlias: Certification Period




EMC v.6.0 Reference: Record Type 71 Field No. 6, 7EMC v.6.0 Reference: Record Type 71 Field No. 6, 7

Required on claims/encounters when a certification for Home Health Services waspreviously or is being submitted to the destination payer.Required on claims/encounters when a certification for Home Health Services waspreviously or is being submitted to the destination payer.

CR605 373 Date O DT 8/8 Required

Description: Date expressed as CCYYMMDDIndustry: Diagnosis DateIndustry: Diagnosis DateAlias: Date of Onset or Exacerbation of Principal DiagnosisAlias: Date of Onset or Exacerbation of Principal DiagnosisEMC v.6.0 Reference: Record Type 71 Field No. 8 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 8 (MMDDYY)

CR606 1073 Yes/No Condition or Response Code O ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Skilled Nursing Facility IndicatorIndustry: Skilled Nursing Facility IndicatorAlias: Patient Receiving Care in 1861 (j) (1) Facility IndicatorAlias: Patient Receiving Care in 1861 (j) (1) Facility IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 27EMC v.6.0 Reference: Record Type 71 Field No. 27

CodeList Summary (Total Codes: 4, Included: 3)Code NameN NoU UnknownY Yes

CR607 1073 Yes/No Condition or Response Code M ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Medicare Coverage IndicatorIndustry: Medicare Coverage IndicatorAlias: Medicare Covered IndicatorAlias: Medicare Covered IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 24EMC v.6.0 Reference: Record Type 71 Field No. 24


CR608 1322 Certification Type Code M ID 1/1 Required

Description: Code indicating the type of certificationAlias: Certification Type IndicatorAlias: Certification Type IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 28EMC v.6.0 Reference: Record Type 71 Field No. 28


CodeList Summary (Total Codes: 14, Included: 3)Code NameI InitialR RenewalS Revised

CR609 373 Date C DT 8/8 Situational

Description: Date expressed as CCYYMMDD




Industry: Surgery DateIndustry: Surgery DateAlias: Date Surgical Procedure PerformedAlias: Date Surgical Procedure PerformedEMC v.6.0 Reference: Record Type 71 Field No. 10 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 10 (MMDDYY)

This data element is required when a surgical procedure was performed on the patient.This data element is required when a surgical procedure was performed on the patient.

CR610 235 Product/Service ID Qualifier C ID 2/2 Situational

Description: Code identifying the type/source of the descriptive number used inProduct/Service ID (234)Industry: Product or Service ID QualifierIndustry: Product or Service ID Qualifier


CodeList Summary (Total Codes: 477, Included: 2)Code NameHC Health Care Financing Administration Common Procedural Coding System

(HCPCS) CodesDescription: HCFA coding scheme to group procedure(s) performed on anoutpatient basis for payment to hospital under Medicare; primarily used forambulatory surgical and other diagnostic departmentsThis code includes Current Procedural Terminology (CPT) and HCPCS coding.This code includes Current Procedural Terminology (CPT) and HCPCS coding.

CODE SOURCE:CODE SOURCE:130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding System

ID International Classification of Diseases Clinical Modification (ICD-9-CM) -ProcedureDescription: The International Classification of Diseases, Clinical Modification, isdesignated for the classification of morbidity and mortality information for statisticalpurposes and for the indexing of hospital records by disease and operations, fordata storage and retrieval; this is a procedure codeCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

CR611 1137 Medical Code Value C AN 1/15 Situational

Description: Code value for describing a medical condition or procedureIndustry: Surgical Procedure CodeIndustry: Surgical Procedure CodeEMC v.6.0 Reference: Record Type 71 Field No. 9EMC v.6.0 Reference: Record Type 71 Field No. 9


ExternalCodeList Name: 130 Description: Health Care Financing Administration Common Procedural Coding System ExternalCodeList Name: 131P Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

CR612 373 Date O DT 8/8 Situational

Description: Date expressed as CCYYMMDDIndustry: Physician Order DateIndustry: Physician Order DateAlias: Verbal SOC DateAlias: Verbal SOC DateEMC v.6.0 Reference: Record Type 71 Field No. 19 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 19 (MMDDYY)




This data element is required when the Provider has the Physician Order Date informationon file.This data element is required when the Provider has the Physician Order Date informationon file.


Description: Date expressed as CCYYMMDDIndustry: Last Visit DateIndustry: Last Visit DateAlias: Date Physician Last Saw PatientAlias: Date Physician Last Saw PatientEMC v.6.0 Reference: Record Type 71 Field No. 25 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 25 (MMDDYY)

This data element is required when the Provider has the Last Visit Date information on file.This data element is required when the Provider has the Last Visit Date information on file.


Description: Date expressed as CCYYMMDDIndustry: Physician Contact DateIndustry: Physician Contact DateAlias: Date Last Contacted PhysicianAlias: Date Last Contacted PhysicianEMC v.6.0 Reference: Record Type 71 Field No. 26 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 26 (MMDDYY)

This data element is required when the Provider has the Physician Contact Dateinformation on file.This data element is required when the Provider has the Physician Contact Dateinformation on file.


Description: Code indicating the date format, time format, or date and time formatThis data element is required when a hospital admission occurred to the patient.This data element is required when a hospital admission occurred to the patient.




Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Last Admission PeriodIndustry: Last Admission PeriodAlias: Admission Date and Discharge DateAlias: Admission Date and Discharge DateEMC v.6.0 Reference: Record Type 71 Field No. 29, 30 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 29, 30 (MMDDYY)

This data element is required when a hospital admission occurred to the patient.This data element is required when a hospital admission occurred to the patient.

CR617 1384 Patient Location Code C ID 1/1 Required

Description: Code identifying the location where patient is receiving medical treatmentIndustry: Patient Discharge Facility Type CodeIndustry: Patient Discharge Facility Type CodeAlias: Type of FacilityAlias: Type of FacilityEMC v.6.0 Reference: Record Type 71 Field No. 31EMC v.6.0 Reference: Record Type 71 Field No. 31

CodeList Summary (Total Codes: 15, Included: 14)Code NameA Acute Care FacilityB Boarding Home


Code Name


C HospiceD Intermediate Care FacilityE Long-term or Extended Care FacilityF Not SpecifiedG Nursing HomeH Sub-acute Care FacilityL Other LocationM Rehabilitation FacilityO Outpatient FacilityR Residential Treatment FacilityS Skilled Nursing HomeT Rest Home


Description: Date expressed as CCYYMMDDIndustry: Diagnosis DateIndustry: Diagnosis DateAlias: Date Secondary Diagnosis - 1Alias: Date Secondary Diagnosis - 1EMC v.6.0 Reference: Record Type 71 Field No. 11EMC v.6.0 Reference: Record Type 71 Field No. 11

This data element is required when a secondary diagnosis code is present on this claim.This data element is required when a secondary diagnosis code is present on this claim.



This data element is required when a second secondary diagnosis code is present on thisclaim.This data element is required when a second secondary diagnosis code is present on thisclaim.



This data element is required when a third secondary diagnosis code is present on thisclaim.This data element is required when a third secondary diagnosis code is present on thisclaim.



This data element is required when a fourth secondary diagnosis code is present on thisclaim.This data element is required when a fourth secondary diagnosis code is present on thisclaim.

Syntax Rules: 1. P0304 - If either CR603 or CR604 is present, then the other is required.2. P091011 - If either CR609, CR610 or CR611 are present, then the others are required.



3. P151617 - If either CR615, CR616 or CR617 are present, then the others are required.

Semantics: 1. CR602 is the date covered home health services began.2. CR604 is the certification period covered by this plan of treatment.3. CR605 is the date of onset or exacerbation of the principal diagnosis.4. A "Y" value indicates patient is receiving care in a 1861J1 (skilled nursing) facility. An "N" value indicates

patient is not receiving care in a 1861J1 facility. A "U" value indicates it is unknown whether or not the patientis receiving care in a 1861J1 facility.

5. CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered byMedicare; an "N" value indicates patient is not covered by Medicare.

6. CR609 is date that the surgery identified in CR614 was performed.7. CR610 qualifies CR611.8. CR611 is the surgical procedure most relevant to the care being rendered.9. CR612 is the date the agency received the verbal orders from the physician for start of care.

10. CR613 is the date that the patient was last seen by the physician.11. CR614 is the date of the home health agency's most recent contact with the physician.12. CR616 is the date range of the most recent inpatient stay.13. CR617 indicates the type of facility from which the patient was most recently discharged.14. CR618 is the date of onset or exacerbation of the first secondary diagnosis.15. CR619 is the date of onset or exacerbation of the second secondary diagnosis.16. CR620 is the date of onset or exacerbation of the third secondary diagnosis.17. CR621 is the date of onset or exacerbation of the fourth secondary diagnosis.

Notes:Notes:This segment is required for Home Health claims when applicable.This segment is required for Home Health claims when applicable.

Example:Example:CR6*4*941101*RD8*19941101- 19941231*941015*N*Y*I*****941101****A~CR6*4*941101*RD8*19941101- 19941231*941015*N*Y*I*****941101****A~



CRC Home Health FunctionalLimitations



User Option (Usage): SituationalPurpose: To supply information on conditions

Element Summary: Ref Id Element Name Req Type Min/Max UsageCRC01 1136 Code Category M ID 2/2 Required

Description: Specifies the situation or category to which the code applies

CodeList Summary (Total Codes: 341, Included: 1)Code Name75 Functional Limitations

CRC02 1073 Yes/No Condition or Response Code M ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Certification Condition IndicatorIndustry: Certification Condition Indicator


CRC03 1321 Condition Indicator M ID 2/2 Required

Description: Code indicating a conditionIndustry: Functional Limitation CodeIndustry: Functional Limitation CodeEMC v.6.0 Reference: Record Type 71 Field No. 15EMC v.6.0 Reference: Record Type 71 Field No. 15

The codes for CRC03 also can be used for CRC04 through CRC07.The codes for CRC03 also can be used for CRC04 through CRC07.

CodeList Summary (Total Codes: 1079, Included: 11)Code NameAA Amputation


AL Ambulation LimitationsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 7Record Type 71 Field No. 15 Code 7

BL Bowel Limitations, Bladder Limitations, or both (Incontinence)EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 2Record Type 71 Field No. 15 Code 2

CO ContractureEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 3Record Type 71 Field No. 15 Code 3

DY Dyspnea with Minimal ExertionEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code ARecord Type 71 Field No. 15 Code A


Code Name


EL Endurance LimitationsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 6Record Type 71 Field No. 15 Code 6

HL Hearing LimitationsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 4Record Type 71 Field No. 15 Code 4

LB Legally BlindEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 9Record Type 71 Field No. 15 Code 9

OL Other LimitationEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code BRecord Type 71 Field No. 15 Code B

PA ParalysisEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 5Record Type 71 Field No. 15 Code 5

SL Speech LimitationsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 15 Code 8Record Type 71 Field No. 15 Code 8

CRC04 1321 Condition Indicator O ID 2/2 Situational

Description: Code indicating a conditionIndustry: Functional Limitation CodeIndustry: Functional Limitation Code

See CRC03This data element is required when more than one Functional Limitation Code is applicableto the patient.










Code Name




















Code Name




















Code Name




















Code Name




Semantics: 1. CRC01 qualifies CRC03 through CRC07.2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03

through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.

Notes:Notes:1. The CRC segment in Loop ID-2300 applies to the entire claim unless it is overridden by a CRC segment at theservice line level in Loop ID-2400 with the same value in CRC01.2. This segment is required to convey Home Health Plan of Treatment information when applicable.

1. The CRC segment in Loop ID-2300 applies to the entire claim unless it is overridden by a CRC segment at theservice line level in Loop ID-2400 with the same value in CRC01.2. This segment is required to convey Home Health Plan of Treatment information when applicable.

Example:Example:CRC*75*Y*AL~CRC*75*Y*AL~



CRC Home Health ActivitiesPermitted





Description: Specifies the situation or category to which the code appliesIndustry: Certification Condition IndicatorIndustry: Certification Condition Indicator

CodeList Summary (Total Codes: 341, Included: 1)Code Name76 Activities Permitted


Description: Code indicating a Yes or No condition or responseIndustry: Functional Limitation CodeIndustry: Functional Limitation Code



Description: Code indicating a conditionIndustry: Activities Permitted CodeIndustry: Activities Permitted CodeEMC v.6.0 Reference: Record Type 71 Field No. 16EMC v.6.0 Reference: Record Type 71 Field No. 16


CodeList Summary (Total Codes: 1079, Included: 12)Code NameBR Bedrest BRP (Bathroom Privileges)


CA Cane RequiredEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code 9Record Type 71 Field No. 16 Code 9

CB Complete BedrestEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code 1Record Type 71 Field No. 16 Code 1

CR Crutches RequiredEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code 8Record Type 71 Field No. 16 Code 8

EP Exercises PrescribedEMC v.6.0 Reference:EMC v.6.0 Reference:


Code Name


Record Type 71 Field No. 16 Code 5Record Type 71 Field No. 16 Code 5IH Independent at Home


NR No RestrictionsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code C (This is the same qualifier used in CLP06 ofthe 835 Health Care Claim Payment.)Record Type 71 Field No. 16 Code C (This is the same qualifier used in CLP06 ofthe 835 Health Care Claim Payment.)

PW Partial Weight BearingEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code 6Record Type 71 Field No. 16 Code 6

TR Transfer to Bed, or Chair, or BothEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code 4Record Type 71 Field No. 16 Code 4

UT Up as ToleratedEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code 3Record Type 71 Field No. 16 Code 3

WA Walker RequiredEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code BRecord Type 71 Field No. 16 Code B

WR Wheelchair RequiredEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 16 Code ARecord Type 71 Field No. 16 Code A


Description: Code indicating a conditionIndustry: Activities Permitted CodeIndustry: Activities Permitted Code

This data element is required when more than one Activities Permitted Code is applicableto the patient.This data element is required when more than one Activities Permitted Code is applicableto the patient.








Code Name




















Code Name




















Code Name




















Code Name












Notes:Notes:1. This segment is required to convey Home Health Plan of Treatment information when applicable.1. This segment is required to convey Home Health Plan of Treatment information when applicable.

Example:Example:CRC*76*Y*CB~CRC*76*Y*CB~



CRC Home Health Mental Status Pos: 220 Max: 2Detail - Optional





CodeList Summary (Total Codes: 341, Included: 1)Code Name77 Mental Status





Description: Code indicating a conditionIndustry: Mental Status CodeIndustry: Mental Status CodeEMC v.6.0 Reference: Record Type 71 Field No. 17EMC v.6.0 Reference: Record Type 71 Field No. 17


CodeList Summary (Total Codes: 1079, Included: 8)Code NameAG Agitated


CM ComatoseEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 2Record Type 71 Field No. 17 Code 2

DI DisorientedEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 5Record Type 71 Field No. 17 Code 5

DP DepressedEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 4Record Type 71 Field No. 17 Code 4

FO ForgetfulEMC v.6.0 Reference:EMC v.6.0 Reference:


Code Name


Record Type 71 Field No. 17 Code 3Record Type 71 Field No. 17 Code 3LE Lethargic


MC Other Mental ConditionEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 8Record Type 71 Field No. 17 Code 8

OT OrientedEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 1Record Type 71 Field No. 17 Code 1


Description: Code indicating a condition






FO ForgetfulEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 3Record Type 71 Field No. 17 Code 3

LE LethargicEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 71 Field No. 17 Code 6Record Type 71 Field No. 17 Code 6








Code NameAG Agitated


















Code Name


















Notes:Notes:



1. This segment is required to convey Home Health Plan of Treatment information when applicable.1. This segment is required to convey Home Health Plan of Treatment information when applicable.

Example:Example:CRC*77*Y*DI~CRC*77*Y*DI~



HI Principal, Admitting, E-Codeand Patient Reason For VisitDiagnosis Information



User Option (Usage): SituationalPurpose: To supply information related to the delivery of health care

Element Summary: Ref Id Element Name Req Type Min/Max UsageHI01 C022 Health Care Code Information M Comp Required

Description: To send health care codes and their associated dates, amounts andquantities

HI01-01 1270 Code List Qualifier Code M ID 1/3 Required

Description: Code identifying a specific industry code list

CodeList Summary (Total Codes: 558, Included: 1)Code NameBK Principal Diagnosis

CODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

HI01-02 1271 Industry Code M AN 1/30 Required

Description: Code indicating a code from a specific industry code listUB-92 Ref. [UB-Name]: 67 [Principal Diagnosis Code]UB-92 Ref. [UB-Name]: 67 [Principal Diagnosis Code]EMC v.6.0 Reference: Record Type 70 Field No. 4EMC v.6.0 Reference: Record Type 70 Field No. 4

ExternalCodeList Name: 131D Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis

HI02 C022 Health Care Code Information O Comp Situational

Description: To send health care codes and their associated dates, amounts andquantitiesRequired for all unscheduled outpatient visits or upon the patient’s admission to thehosptial.Required for all unscheduled outpatient visits or upon the patient’s admission to thehosptial.


Description: Code identifying a specific industry code listZZ used to indicate the “Patient Reason For Visit.”ZZ used to indicate the “Patient Reason For Visit.”

CodeList Summary (Total Codes: 558, Included: 2)Code NameBJ Admitting Diagnosis


ZZ Mutually Defined


Code Name


ZZ used to indicate the “Patient Reason For Visit.” See Code Source 131.ZZ used to indicate the “Patient Reason For Visit.” See Code Source 131.


Description: Code indicating a code from a specific industry code listUB-92 Ref. [UB-Name]: 76 [Admitting Diagnosis/Patient’s Reason for Visit]UB-92 Ref. [UB-Name]: 76 [Admitting Diagnosis/Patient’s Reason for Visit]EMC v.6.0 Reference: Record Type 70 Field No. 25EMC v.6.0 Reference: Record Type 70 Field No. 25



Description: To send health care codes and their associated dates, amounts andquantitiesUsed when necessary to report multiple additional co-existing conditions.Used when necessary to report multiple additional co-existing conditions.



CodeList Summary (Total Codes: 558, Included: 1)Code NameBN United States Department of Health and Human Services, Office of Vital Statistics

E-codeCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure


Description: Code indicating a code from a specific industry code listUB-92 Ref. [UB-Name]: 77 [External Cause of Injury Code (E-code)]UB-92 Ref. [UB-Name]: 77 [External Cause of Injury Code (E-code)]EMC v.6.0 Reference: Record Type 70 Field No. 26EMC v.6.0 Reference: Record Type 70 Field No. 26


Notes:Notes:1. Required on all claims and encounters except claims for Religious Non-medical claims (Bill Types 4XX and5XX) and hospital other (Bill Types 14X).2. The Admitting Diagnosis is required on all inpatient admission claims and encounters.3. An E-Code diagnosis is required whenever a diagnosis is needed to describe an injury, poisoning or adverseeffect.4. The Patient Reason for Visit Diagnosis is required for all unscheduled outpatient visits.

1. Required on all claims and encounters except claims for Religious Non-medical claims (Bill Types 4XX and5XX) and hospital other (Bill Types 14X).2. The Admitting Diagnosis is required on all inpatient admission claims and encounters.3. An E-Code diagnosis is required whenever a diagnosis is needed to describe an injury, poisoning or adverseeffect.4. The Patient Reason for Visit Diagnosis is required for all unscheduled outpatient visits.

Example:Example:HI*BK:9976~HI*BK:9976~



HI Diagnosis Related Group(DRG) Information








CodeList Summary (Total Codes: 558, Included: 1)Code NameDR Diagnosis Related Group (DRG)

CODE SOURCE:CODE SOURCE:229: Diagnosis Related Group Number (DRG)229: Diagnosis Related Group Number (DRG)


Description: Code indicating a code from a specific industry code listIndustry: Diagnosis Related Group (DRG) CodeIndustry: Diagnosis Related Group (DRG) Code

ExternalCodeList Name: 229 Description: Diagnosis Related Group Number (DRG)

Notes:Notes:1. DRG Information is required when an inpatient hospital is under DRG contract with a payer and the contractrequires the provider to identify the DRG to the payer.1. DRG Information is required when an inpatient hospital is under DRG contract with a payer and the contractrequires the provider to identify the DRG to the payer.

Example:Example:HI*DR:123~HI*DR:123~



HI Other Diagnosis Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 1)Code NameBF Diagnosis



Description: Code indicating a code from a specific industry code listIndustry: Other DiagnosisIndustry: Other DiagnosisUB-92 Ref. [UB-Name]: 68 [Other Diagnoses Codes]

69 [Other Diagnoses Codes]







UB-92 Ref. [UB-Name]: 68 [Other Diagnoses Codes]







75 [Other Diagnoses Codes]EMC v.6.0 Reference: Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12EMC v.6.0 Reference: Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12




































Description: Code indicating a code from a specific industry code listIndustry: Other DiagnosisIndustry: Other DiagnosisUB-92 Ref. [UB-Name]: 68 [Other Diagnoses Codes]UB-92 Ref. [UB-Name]: 68 [Other Diagnoses Codes]











































































Code Name




























Description: Code indicating a code from a specific industry code listIndustry: Other DiagnosisIndustry: Other DiagnosisEMC v.6.0 Reference: 68 [Other Diagnoses Codes]




EMC v.6.0 Reference: 68 [Other Diagnoses Codes]














75 [Other Diagnoses Codes]Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12








































































































75 [Other Diagnoses Codes]75 [Other Diagnoses Codes]Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12


























Notes:Notes:1. Required when other condition(s) co-exists with the principal diagnosis, co-exists at the time of admission ordevelops subsequently during the patient’s treatment.1. Required when other condition(s) co-exists with the principal diagnosis, co-exists at the time of admission ordevelops subsequently during the patient’s treatment.

Example:Example:HI*BF:V9782~HI*BF:V9782~



HI Principal ProcedureInformation








CodeList Summary (Total Codes: 558, Included: 2)Code NameBP Health Care Financing Administration Common Procedural Coding System

Principal ProcedureCODE SOURCE:CODE SOURCE:130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding System

BR International Classification of Diseases Clinical Modification (ICD-9-CM) PrincipalProcedureCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure


Description: Code indicating a code from a specific industry code listIndustry: Principal Procedure CodeIndustry: Principal Procedure CodeUB-92 Ref. [UB-Name]: 80 [Principal Procedure Code and Date]UB-92 Ref. [UB-Name]: 80 [Principal Procedure Code and Date]EMC v.6.0 Reference: Record Type 70 Field No. 13EMC v.6.0 Reference: Record Type 70 Field No. 13


HI01-03 1250 Date Time Period Format Qualifier C ID 2/3 Situational



Use code D8 when the value in composite data element HI01-1 equals “BR”.Use code D8 when the value in composite data element HI01-1 equals “BR”.

HI01-04 1251 Date Time Period C AN 1/35 Situational




Description: Expression of a date, a time, or range of dates, times or dates and timesUB-92 Ref. [UB-Name]: 80, “DATE” field [Principal Procedure Code and Date]UB-92 Ref. [UB-Name]: 80, “DATE” field [Principal Procedure Code and Date]EMC v.6.0 Reference: Record Type 70 Field No. 14EMC v.6.0 Reference: Record Type 70 Field No. 14

Required when HI01-3 is used.Required when HI01-3 is used.

Notes:Notes:1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when a procedure was performed.

1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when a procedure was performed.

Example:Example:HI*BR:92795:D8:19980321~HI*BR:92795:D8:19980321~



HI Other Procedure Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 2)Code NameBO Health Care Financing Administration Common Procedural Coding System


BQ International Classification of Diseases Clinical Modification (ICD-9-CM) ProcedureCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure


Description: Code indicating a code from a specific industry code listIndustry: Procedure CodeIndustry: Procedure CodeUB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]EMC v.6.0 Reference: Record Type 70 Field No. 15, 17, 19, 21, 23EMC v.6.0 Reference: Record Type 70 Field No. 15, 17, 19, 21, 23



Description: Code indicating the date format, time format, or date and time formatRequired if the procedure code reported is ICD-9-CM in the preceding data element. Usedif needed to report a procedure date when the code reported is HCPCS. If used, theimmediatley following element is required.

Required if the procedure code reported is ICD-9-CM in the preceding data element. Usedif needed to report a procedure date when the code reported is HCPCS. If used, theimmediatley following element is required.






Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Procedure DateIndustry: Procedure DateUB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]EMC v.6.0 Reference: Record Type 70 Field No. 16, 18, 20, 22, 24EMC v.6.0 Reference: Record Type 70 Field No. 16, 18, 20, 22, 24
















Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Procedure DateIndustry: Procedure DateUB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]




EMC v.6.0 Reference: Record Type 70 Field No. 16, 18, 20, 22, 24EMC v.6.0 Reference: Record Type 70 Field No. 16, 18, 20, 22, 24









































Used when necessary to report multiple additional co-existing conditions.Used when necessary to report multiple additional co-existing conditions.









































Code NameBO Health Care Financing Administration Common Procedural Coding System



















Code Name


130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding SystemBQ International Classification of Diseases Clinical Modification (ICD-9-CM) Procedure

















BQ International Classification of Diseases Clinical Modification (ICD-9-CM) ProcedureCODE SOURCE:CODE SOURCE:


Code Name


131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure





































Description: Code indicating a code from a specific industry code listIndustry: Procedure CodeIndustry: Procedure Code




UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]EMC v.6.0 Reference: Record Type 70 Field No. 15, 17, 19, 21, 23EMC v.6.0 Reference: Record Type 70 Field No. 15, 17, 19, 21, 23


























Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Procedure DateIndustry: Procedure DateUB-92 Ref. [UB-Name]: Record Type 70 Field No. 16, 18, 20, 22, 24UB-92 Ref. [UB-Name]: Record Type 70 Field No. 16, 18, 20, 22, 24EMC v.6.0 Reference: 81 (A-E) [Other Procedure Codes and Dates]EMC v.6.0 Reference: 81 (A-E) [Other Procedure Codes and Dates]

Notes:Notes:1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when additional procedures must be reported.

1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when additional procedures must be reported.

Example:Example:HI*BQ:92795:D8:19980321~HI*BQ:92795:D8:19980321~



HI Occurrence Span Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 1)Code NameBI Occurrence Span

CODE SOURCE:CODE SOURCE:132: National Uniform Billing Committee (NUBC) Codes132: National Uniform Billing Committee (NUBC) Codes


Description: Code indicating a code from a specific industry code listIndustry: Occurrence Span CodeIndustry: Occurrence Span CodeUB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]UB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31

ExternalCodeList Name: 132 Description: National Uniform Billing Committee (NUBC) Codes

HI01-03 1250 Date Time Period Format Qualifier C ID 2/3 Required




HI01-04 1251 Date Time Period C AN 1/35 Required

Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Occurrence or Occurrence Span Code Associated DateIndustry: Occurrence or Occurrence Span Code Associated DateUB-92 Ref. [UB-Name]: 36 (a-b), “FROM” and “THROUGH” fields [Occurrence Span Codeand Dates]UB-92 Ref. [UB-Name]: 36 (a-b), “FROM” and “THROUGH” fields [Occurrence Span Codeand Dates]EMC v.6.0 Reference: Record Type 40 Field No. 29, 30, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 29, 30, 32, 33





























Description: Code indicating a code from a specific industry code listIndustry: Occurrence Span CodeIndustry: Occurrence Span CodeUB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]UB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33















Code Name


132: National Uniform Billing Committee (NUBC) Codes132: National Uniform Billing Committee (NUBC) Codes

















Description: Code indicating a code from a specific industry code listIndustry: Occurrence Span CodeIndustry: Occurrence Span CodeUB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]UB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]




EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33






































Description: A range of dates expressed in the format CCYYMMDD-CCYYMMDDwhere CCYY is the numerical expression of the century CC and year YY, MM is the


Code Name


numerical expression of the month within the year, and DD is the numericalexpression of the day within the year; the first occurrence of CCYYMMDD is thebeginning date and the second occurrence is the ending date

















Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Occurrence or Occurrence Span Code Associated DateIndustry: Occurrence or Occurrence Span Code Associated Date




UB-92 Ref. [UB-Name]: 36 (a-b), “FROM” and “THROUGH” fields [Occurrence Span Codeand Dates]UB-92 Ref. [UB-Name]: 36 (a-b), “FROM” and “THROUGH” fields [Occurrence Span Codeand Dates]EMC v.6.0 Reference: Record Type 40 Field No. 29, 30, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 29, 30, 32, 33










































Code NameBI Occurrence Span


















Description: Code indicating a code from a specific industry code list




Industry: Occurrence Span CodeIndustry: Occurrence Span CodeUB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]UB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33








Notes:Notes:1. Required when occurrence span information applies to the claim or encounter.1. Required when occurrence span information applies to the claim or encounter.

Example:Example:HI*BI:70:RD8:19981202-19981212~HI*BI:70:RD8:19981202-19981212~



HI Occurrence Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 1)Code NameBH Occurrence



Description: Code indicating a code from a specific industry code listIndustry: Occurrence CodeIndustry: Occurrence CodeUB-92 Ref. [UB-Name]: 32 (a-b) [Occurrence Codes and Dates]

33 (a-b) [Occurrence Codes and Dates]



UB-92 Ref. [UB-Name]: 32 (a-b) [Occurrence Codes and Dates]



35 (a-b) [Occurrence Codes and Dates]EMC v.6.0 Reference: Record Type 40 Field No. 8, 10, 12, 14, 16, 18, 20, 22, 24, 26EMC v.6.0 Reference: Record Type 40 Field No. 8, 10, 12, 14, 16, 18, 20, 22, 24, 26






Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Occurrence or Occurrence Span Code Associated

Date

Industry: Occurrence or Occurrence Span Code Associated

DateUB-92 Ref. [UB-Name]: 32 (a-b), “DATE” field [Occurrence Codes and Dates]UB-92 Ref. [UB-Name]: 32 (a-b), “DATE” field [Occurrence Codes and Dates]




33 (a-b), “DATE” field [Occurrence Codes and Dates]





35 (a-b), “DATE” field [Occurrence Codes and Dates]EMC v.6.0 Reference: Record Type 40 Field No. 9, 11, 13, 15, 17, 19, 21, 23, 25, 27EMC v.6.0 Reference: Record Type 40 Field No. 9, 11, 13, 15, 17, 19, 21, 23, 25, 27






















Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date












Notes:Notes:1. Required when occurrence information applies to the claim or encounter.1. Required when occurrence information applies to the claim or encounter.

Example:Example:HI*BH:42:D8:19981208~HI*BH:42:D8:19981208~



HI Value Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 1)Code NameBE Value



Description: Code indicating a code from a specific industry code listIndustry: Value CodeIndustry: Value CodeUB-92 Ref. [UB-Name]: 39 (a-d) [Value Codes and Amounts]

40 (a-d) [Value Codes and Amounts]


UB-92 Ref. [UB-Name]: 39 (a-d) [Value Codes and Amounts]


41 (a-d) [Value Codes and Amounts]EMC v.6.0 Reference: Record Type 41 Field No. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31, 32, 33, 34, 35, 35, 37, 38, 39EMC v.6.0 Reference: Record Type 41 Field No. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31, 32, 33, 34, 35, 35, 37, 38, 39


HI01-05 782 Monetary Amount O R 1/18 Required

Description: Monetary amountIndustry: Value Code Associated AmountIndustry: Value Code Associated Amount

This data element must contain the Value Code Amount when HIxx-1 value equals BE(Value Code).This data element must contain the Value Code Amount when HIxx-1 value equals BE(Value Code).












40 (a-d)0 [Value Codes and Amounts]

























EMC v.6.0 Reference: Record Type 41 Field No. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31, 32, 33, 34, 35, 35, 37, 38, 39EMC v.6.0 Reference: Record Type 41 Field No. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31, 32, 33, 34, 35, 35, 37, 38, 39


















































Description: Code indicating a code from a specific industry code listIndustry: Value CodeIndustry: Value CodeUB-92 Ref. [UB-Name]: 39 (a-d) [Value Codes and Amounts]UB-92 Ref. [UB-Name]: 39 (a-d) [Value Codes and Amounts]














































































































CodeList Summary (Total Codes: 558, Included: 1)Code Name


Code Name


BE ValueCODE SOURCE:CODE SOURCE:132: National Uniform Billing Committee (NUBC) Codes132: National Uniform Billing Committee (NUBC) Codes












Notes:Notes:1. Required when value information applies to the claim or encounter.1. Required when value information applies to the claim or encounter.

Example:Example:HI*BE:08:::1740~HI*BE:08:::1740~



HI Condition Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 1)Code NameBG Condition



Description: Code indicating a code from a specific industry code listIndustry: Condition CodeIndustry: Condition CodeUB-92 Ref. [UB-Name]: 24 [Condition Codes]

25 [Condition Codes]






UB-92 Ref. [UB-Name]: 24 [Condition Codes]






30 [Condition Codes]EMC v.6.0 Reference: Record Type 41 Field No. 4, 5, 6, 7, 8, 9, 10, 11, 12, 13EMC v.6.0 Reference: Record Type 41 Field No. 4, 5, 6, 7, 8, 9, 10, 11, 12, 13











































































































Description: Code indicating a code from a specific industry code listIndustry: Condition CodeIndustry: Condition CodeUB-92 Ref. [UB-Name]: 24 [Condition Codes]UB-92 Ref. [UB-Name]: 24 [Condition Codes]














































































































































Code Name



















Notes:Notes:1. Required when condition information applies to the claim or encounter.1. Required when condition information applies to the claim or encounter.

Example:Example:HI*BG:67~HI*BG:67~



HI Treatment Code Information Pos: 231 Max: 2Detail - Optional







CodeList Summary (Total Codes: 558, Included: 1)Code NameTC Treatment Codes

CODE SOURCE:CODE SOURCE:359: Treatment Codes359: Treatment Codes


Description: Code indicating a code from a specific industry code listIndustry: Treatment CodeIndustry: Treatment CodeEMC v.6.0 Reference: Record Type 72 Field No. 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42EMC v.6.0 Reference: Record Type 72 Field No. 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42

ExternalCodeList Name: 359 Description: Treatment Codes








Description: Code indicating a code from a specific industry code listIndustry: Treatment CodeIndustry: Treatment CodeEMC v.6.0 Reference: Record Type 72 Field No. 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,EMC v.6.0 Reference: Record Type 72 Field No. 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,




29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 4229, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42





























































Description: To send health care codes and their associated dates, amounts and




quantitiesUsed when necessary to report multiple additional co-existing conditions.Used when necessary to report multiple additional co-existing conditions.






































Notes:Notes:1. Required when Home Health Agencies need to report Plan of Treatment information under various payercontracts.1. Required when Home Health Agencies need to report Plan of Treatment information under various payercontracts.

Example:Example:HI*TC:A01~HI*TC:A01~



QTY Claim Quantity Pos: 240 Max: 4Detail - Optional


User Option (Usage): SituationalPurpose: To specify quantity information

Element Summary: Ref Id Element Name Req Type Min/Max UsageQTY01 673 Quantity Qualifier M ID 2/2 Required

Description: Code specifying the type of quantity

CodeList Summary (Total Codes: 832, Included: 4)Code NameCA Covered - Actual

Description: Days covered on this serviceUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:7 [Covered Days]7 [Covered Days]

EMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 20 (Sequence 01-03)Record Type 30 Field No. 20 (Sequence 01-03)

CD Co-insured - ActualUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:9 [Coinsurance Days]9 [Coinsurance Days]


LA Life-time Reserve - ActualDescription: Medicare hospital insurance includes extra hospital days to be used ifthe patient has a long illness and is required to stay in the hospital over a specifiednumber of days; this is the actual number of days in reserveUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:10 [Lifetime Reserve Days]10 [Lifetime Reserve Days]


NA Number of Non-covered DaysUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:8 [Non-Covered Days]8 [Non-Covered Days]


QTY02 380 Quantity C R 1/15 Required

Description: Numeric value of quantityIndustry: Claim Days CountIndustry: Claim Days Count

QTY03 C001 Composite Unit of Measure O Comp Required

Description: To identify a composite unit of measure(See Figures Appendix for examplesof use)

QTY03-01 355 Unit or Basis for Measurement Code M ID 2/2 Required




Description: Code specifying the units in which a value is being expressed, or manner inwhich a measurement has been taken

CodeList Summary (Total Codes: 794, Included: 1)Code NameDA Days

Syntax Rules: 1. R0204 - At least one of QTY02 or QTY04 is required.2. E0204 - Only one of QTY02 or QTY04 may be present.

Semantics: 1. QTY04 is used when the quantity is non-numeric.

Notes:Notes:1. Use the Quantity segment at the claim level Loop ID-2300 to transmit quantities that apply to the entire claim.2. Required on Inpatient claims or encounters when covered, co-insured, life-time reserved or non-covered daysare being reported.

1. Use the Quantity segment at the claim level Loop ID-2300 to transmit quantities that apply to the entire claim.2. Required on Inpatient claims or encounters when covered, co-insured, life-time reserved or non-covered daysare being reported.

Example:Example:QTY*LA*20*DA~QTY*LA*20*DA~



HCP Claim Pricing/RepricingInformation



User Option (Usage): SituationalPurpose: To specify pricing or repricing information about a health care claim or line item

Element Summary: Ref Id Element Name Req Type Min/Max UsageHCP01 1473 Pricing Methodology C ID 2/2 Required

Description: Code specifying pricing methodology at which the claim or line item has beenpriced or repricedAlias: Pricing MethodologyAlias: Pricing Methodology

Trading partners need to agree on which codes to use in this element. There do not appearto be standard definitions for the code elements.Trading partners need to agree on which codes to use in this element. There do not appearto be standard definitions for the code elements.

CodeList Summary (Total Codes: 15, Included: 15)Code Name00 Zero Pricing (Not Covered Under Contract)01 Priced as Billed at 100%02 Priced at the Standard Fee Schedule03 Priced at a Contractual Percentage04 Bundled Pricing05 Peer Review Pricing06 Per Diem Pricing07 Flat Rate Pricing08 Combination Pricing09 Maternity Pricing10 Other Pricing11 Lower of Cost12 Ratio of Cost13 Cost Reimbursed14 Adjustment Pricing

HCP02 782 Monetary Amount O R 1/18 Required

Description: Monetary amountIndustry: Repriced Allowed AmountIndustry: Repriced Allowed AmountAlias: Allowed AmountAlias: Allowed Amount

HCP03 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Repriced Saving AmountIndustry: Repriced Saving AmountAlias: Savings AmountAlias: Savings Amount

This data element is required when it is necessary to report Savings Amount on claimswhich has been priced or repriced.This data element is required when it is necessary to report Savings Amount on claimswhich has been priced or repriced.

HCP04 127 Reference Identification O AN 1/30 Situational

Description: Reference information as defined for a particular Transaction Set or as




specified by the Reference Identification QualifierIndustry: Repricing Organization IdentifierIndustry: Repricing Organization IdentifierAlias: Repricing Organization IDAlias: Repricing Organization ID

This data element is required when it is necessary to report Repricing Organization ID onclaims which has been priced or repriced.This data element is required when it is necessary to report Repricing Organization ID onclaims which has been priced or repriced.

HCP05 118 Rate O R 1/9 Situational

Description: Rate expressed in the standard monetary denomination for the currencyspecifiedIndustry: Repricing Per Diem or Flat Rate AmountIndustry: Repricing Per Diem or Flat Rate AmountAlias: Pricing RateAlias: Pricing Rate

This data element is required when it is necessary to report Pricing Rate on claims whichhas been priced or repriced.This data element is required when it is necessary to report Pricing Rate on claims whichhas been priced or repriced.


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Repriced Approved DRG CodeIndustry: Repriced Approved DRG CodeAlias: Approved DRG CodeAlias: Approved DRG Code

This data element is required when it is necessary to report Approved DRG Code on claimswhich has been priced or repriced.This data element is required when it is necessary to report Approved DRG Code on claimswhich has been priced or repriced.


Description: Monetary amountIndustry: Repriced Approved AmountIndustry: Repriced Approved AmountAlias: Approved DRG AmountAlias: Approved DRG Amount

This data element is required when it is necessary to report Approved DRG Amount onclaims which has been priced or repriced.This data element is required when it is necessary to report Approved DRG Amount onclaims which has been priced or repriced.

HCP08 234 Product/Service ID O AN 1/48 Situational

Description: Identifying number for a product or serviceIndustry: Repriced Approved Revenue CodeIndustry: Repriced Approved Revenue CodeAlias: Approved Revenue CodeAlias: Approved Revenue Code

This data element is required when it is necessary to report Approved Revenue Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Approved Revenue Code onclaims which has been priced or repriced.

HCP09 235 Product/Service ID Qualifier C ID 2/2 Situational


Required when HCP10 exists.Required when HCP10 exists.


(HCPCS) CodesDescription: HCFA coding scheme to group procedure(s) performed on anoutpatient basis for payment to hospital under Medicare; primarily used forambulatory surgical and other diagnostic departments


Code Name


This code includes Current Procedural Terminology (CPT) and HCPCS coding.This code includes Current Procedural Terminology (CPT) and HCPCS coding.CODE SOURCE:CODE SOURCE:130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding System

HCP10 234 Product/Service ID C AN 1/48 Situational

Description: Identifying number for a product or serviceIndustry: Repriced Approved HCPCS CodeIndustry: Repriced Approved HCPCS CodeAlias: Approved Procedure CodeAlias: Approved Procedure Code

This data element is required when it is necessary to report Approved HCPCS Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Approved HCPCS Code onclaims which has been priced or repriced.

ExternalCodeList Name: 130 Description: Health Care Financing Administration Common Procedural Coding System

HCP11 355 Unit or Basis for Measurement Code C ID 2/2 Situational

Description: Code specifying the units in which a value is being expressed, or manner inwhich a measurement has been takenRequired when HCP12 exists.Required when HCP12 exists.

CodeList Summary (Total Codes: 794, Included: 2)Code NameDA DaysUN Unit

HCP12 380 Quantity C R 1/15 Situational

Description: Numeric value of quantityIndustry: Repriced Approved Service Unit CountIndustry: Repriced Approved Service Unit CountAlias: Approved Service UnitsAlias: Approved Service Units

This data element is required when it is necessary to report Approved Service Unit Counton claims which has been priced or repriced.This data element is required when it is necessary to report Approved Service Unit Counton claims which has been priced or repriced.

HCP13 901 Reject Reason Code C ID 2/2 Situational

Description: Code assigned by issuer to identify reason for rejectionAlias: Rejection MessageAlias: Rejection Message

This data element is required when it is necessary to report Rejection Message on claimswhich has been priced or repriced.This data element is required when it is necessary to report Rejection Message on claimswhich has been priced or repriced.

CodeList Summary (Total Codes: 181, Included: 6)Code NameT1 Cannot Identify Provider as TPO (Third Party Organization) ParticipantT2 Cannot Identify Payer as TPO (Third Party Organization) ParticipantT3 Cannot Identify Insured as TPO (Third Party Organization) ParticipantT4 Payer Name or Identifier MissingT5 Certification Information MissingT6 Claim does not contain enough information for re-pricing

HCP14 1526 Policy Compliance Code O ID 1/2 Situational

Description: Code specifying policy compliance




Alias: Policy Compliance CodeAlias: Policy Compliance Code

This data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.

CodeList Summary (Total Codes: 5, Included: 5)Code Name1 Procedure Followed (Compliance)2 Not Followed - Call Not Made (Non-Compliance Call Not Made)3 Not Medically Necessary (Non-Compliance Non-Medically Necessary)4 Not Followed Other (Non-Compliance Other)5 Emergency Admit to Non-Network Hospital

HCP15 1527 Exception Code O ID 1/2 Situational

Description: Code specifying the exception reason for consideration of out-of-networkhealth care servicesAlias: Exception Reason CodeAlias: Exception Reason Code

This data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.This data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.

CodeList Summary (Total Codes: 6, Included: 6)Code Name1 Non-Network Professional Provider in Network Hospital2 Emergency Care3 Services or Specialist not in Network4 Out-of-Service Area5 State Mandates6 Other

Syntax Rules: 1. R0113 - At least one of HCP01 or HCP13 is required.2. P0910 - If either HCP09 or HCP10 is present, then the other is required.3. P1112 - If either HCP11 or HCP12 is present, then the other is required.

Semantics: 1. HCP02 is the allowed amount.2. HCP03 is the savings amount.3. HCP04 is the repricing organization identification number.4. HCP05 is the pricing rate associated with per diem or flat rate repricing.5. HCP06 is the approved DRG code.6. HCP07 is the approved DRG amount.7. HCP08 is the approved revenue code.8. HCP10 is the approved procedure code.9. HCP12 is the approved service units or inpatient days.

10. HCP13 is the rejection message returned from the third party organization.11. HCP15 is the exception reason generated by a third party organization.

Comments: 1. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original

submitted values.



Notes:Notes:1. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualifyother information within the claim.2. This segment is used when the sender is required to provide the receiver with pricing or repricing informationnecessary to process the claim or encounter.

1. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualifyother information within the claim.2. This segment is used when the sender is required to provide the receiver with pricing or repricing informationnecessary to process the claim or encounter.

Example:Example:HCP*03*100*10*RPO12345~HCP*03*100*10*RPO12345~



Loop Home Health Care PlanInformation



User Option (Usage): SituationalPurpose: To supply information related to the home health care plan of treatment and services

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage242 CR7 Home Health Care Plan Information O 1 Situational243 HSD Health Care Services Delivery O 12 Situational

Semantics: 1. CR702 is the total visits on this bill rendered prior to the recertification "to" date.2. CR703 is the total visits projected during this certification period.

Notes:Notes:1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. This segment is required to convey Home Health Plan of Treatment information for this claim when applicable.

1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. This segment is required to convey Home Health Plan of Treatment information for this claim when applicable.

Example:Example:CR7*PT*4*12~CR7*PT*4*12~



CR7 Home Health Care PlanInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageCR701 921 Discipline Type Code M ID 2/2 Required

Description: Code indicating disciplines ordered by a physicianAlias: Disipline Type CodeAlias: Disipline Type CodeEMC v.6.0 Reference: Record Type 72 Field No. 4EMC v.6.0 Reference: Record Type 72 Field No. 4

CodeList Summary (Total Codes: 6, Included: 6)Code NameAI Home Health AideMS Medical Social WorkerOT Occupational TherapyPT Physical TherapySN Skilled NursingST Speech Therapy

CR702 1470 Number M N0 1/9 Required

Description: A generic numberIndustry: Visits Prior to Recertification Date CountIndustry: Visits Prior to Recertification Date CountAlias: Total Visits Prior to Recertification DateAlias: Total Visits Prior to Recertification DateEMC v.6.0 Reference: Record Type 72 Field No. 5EMC v.6.0 Reference: Record Type 72 Field No. 5


Description: A generic numberIndustry: Total Visits Projected This Certification CountIndustry: Total Visits Projected This Certification CountAlias: Total Visits Projected During Certification PeriodAlias: Total Visits Projected During Certification PeriodEMC v.6.0 Reference: Record Type 72 Field No. 43EMC v.6.0 Reference: Record Type 72 Field No. 43







HSD Health Care ServicesDelivery



User Option (Usage): SituationalPurpose: To specify the delivery pattern of health care services

Element Summary: Ref Id Element Name Req Type Min/Max UsageHSD01 673 Quantity Qualifier C ID 2/2 Situational

Description: Code specifying the type of quantityIndustry: VisitsIndustry: VisitsAlias: Quantity QualifierAlias: Quantity Qualifier

Required if the physician’s order or prescription for the service contains the data.Required if the physician’s order or prescription for the service contains the data.

CodeList Summary (Total Codes: 832, Included: 1)Code NameVS Visits

HSD02 380 Quantity C R 1/15 Situational

Description: Numeric value of quantityIndustry: Number of VisitsIndustry: Number of VisitsAlias: Frequency Number - 1Alias: Frequency Number - 1EMC v.6.0 Reference: Record Type 72 Field No. 6 (position 1)EMC v.6.0 Reference: Record Type 72 Field No. 6 (position 1)


HSD03 355 Unit or Basis for Measurement Code O ID 2/2 Situational

Description: Code specifying the units in which a value is being expressed, or manner inwhich a measurement has been takenIndustry: Frequency PeriodIndustry: Frequency PeriodAlias: Frequency Period - 1Alias: Frequency Period - 1EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 2-3)EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 2-3)


CodeList Summary (Total Codes: 794, Included: 4)Code NameDA DaysMO MonthsQ1 Quarter (Time)WK Week

HSD04 1167 Sample Selection Modulus O R 1/6 Situational

Description: To specify the sampling frequency in terms of a modulus of the Unit ofMeasure, e.g., every fifth bag, every 1.5 minutesIndustry: Frequency CountIndustry: Frequency Count


HSD05 615 Time Period Qualifier C ID 1/2 Situational




Description: Code defining periodsIndustry: Duration of Visits UnitsIndustry: Duration of Visits UnitsAlias: Frequency Time PeriodAlias: Frequency Time Period

Absence of data indicates PRN orders.Required if the physician’s order or prescription for the service contains the data.Absence of data indicates PRN orders.Required if the physician’s order or prescription for the service contains the data.

CodeList Summary (Total Codes: 36, Included: 2)Code Name7 Day35 Week

HSD06 616 Number of Periods O N0 1/3 Situational

Description: Total number of periodsIndustry: Duration of Visits, Number of UnitsIndustry: Duration of Visits, Number of UnitsAlias: Duration - 1Alias: Duration - 1EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 4-6)EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 4-6)


HSD07 678 Ship/Delivery or Calendar Pattern Code O ID 1/2 Situational

Description: Code which specifies the routine shipments, deliveries, or calendar patternIndustry: Ship, Delivery or Calendar Pattern CodeIndustry: Ship, Delivery or Calendar Pattern Code


CodeList Summary (Total Codes: 44, Included: 34)Code Name1 1st Week of the Month2 2nd Week of the Month3 3rd Week of the Month4 4th Week of the Month5 5th Week of the Month6 1st & 3rd Weeks of the Month7 2nd & 4th Weeks of the Month8 1st Working Day of Period9 Last Working Day of PeriodA Monday through FridayB Monday through SaturdayC Monday through SundayD MondayE TuesdayF WednesdayG ThursdayH FridayJ SaturdayK SundayL Monday through ThursdayN As DirectedO Daily Mon. through Fri.


Code Name


S Once Anytime Mon. through Fri.W Whenever NecessarySA Sunday, Monday, Thursday, Friday, SaturdaySB Tuesday through SaturdaySC Sunday, Wednesday, Thursday, Friday, SaturdaySD Monday, Wednesday, Thursday, Friday, SaturdaySG Tuesday through FridaySL Monday, Tuesday and ThursdaySP Monday, Tuesday and FridaySX Wednesday and ThursdaySY Monday, Wednesday and ThursdaySZ Tuesday, Thursday and Friday

HSD08 679 Ship/Delivery Pattern Time Code O ID 1/1 Situational

Description: Code which specifies the time for routine shipments or deliveriesIndustry: Delivery Pattern Time CodeIndustry: Delivery Pattern Time Code


CodeList Summary (Total Codes: 9, Included: 3)Code NameD A.M.E P.M.F As Directed

Syntax Rules: 1. P0102 - If either HSD01 or HSD02 is present, then the other is required.2. C0605 - If HSD06 is present, then HSD05 is required.

Notes:Notes:1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearlysubstantiate medical treatment.2. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.Between HDS02 and HSD03 verbally insert a “per every.” HSD03 qualifies HSD04: If the value in HSD04=3 andthe value in HSD03=DA (Day), this means “three days.” Between HSD04 and HSD05 verbally insert a “for.”HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.” Thetotal message reads: HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”3. Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.4. An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means“1 visit on Wednesday and Thursday morning.”

1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearlysubstantiate medical treatment.2. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.Between HDS02 and HSD03 verbally insert a “per every.” HSD03 qualifies HSD04: If the value in HSD04=3 andthe value in HSD03=DA (Day), this means “three days.” Between HSD04 and HSD05 verbally insert a “for.”HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.” Thetotal message reads: HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”3. Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.4. An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means“1 visit on Wednesday and Thursday morning.”

Example:Example:HSD*VS*1*DA**7*10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days.")HSD*VS*1*DA~ (This indicates one visit per day.)HSD*VS*1*DA**7*10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days.")HSD*VS*1*DA~ (This indicates one visit per day.)



Loop Attending Physician Name Pos: 250 Repeat: 1Optional

Loop:2310A

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage250 NM1 Attending Physician Name O 1 Situational255 PRV Attending Physician Specialty Information O 1 Situational271 REF Attending Physician Secondary




Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required on all inpatient claims or encounters.4. Required to indicate the Primary Physician responsible on a Home Health Agency Plan of Treatment.

1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required on all inpatient claims or encounters.4. Required to indicate the Primary Physician responsible on a Home Health Agency Plan of Treatment.

Example:Example:NM1*71*1*JONES*JOHN****XX*12345678~NM1*71*1*JONES*JOHN****XX*12345678~



NM1 Attending Physician Name Pos: 250 Max: 1Detail - Optional

Loop:2310A

Elements: 8



Description: Code identifying an organizational entity, a physical location, property or anindividualThe entity identifier in NM101 applies to all segments in Loop ID-2310.The entity identifier in NM101 applies to all segments in Loop ID-2310.

CodeList Summary (Total Codes: 1312, Included: 1)Code Name71 Attending Physician

Description: Physician present when medical services are performed





Description: Individual last name or organizational nameIndustry: Attending Physician Last NameIndustry: Attending Physician Last NameUB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]UB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 91-106 (Also maps toRecord Type 71 Field No. 20 if you are creating this attachment)EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 91-106 (Also maps toRecord Type 71 Field No. 20 if you are creating this attachment)


Description: Individual first nameIndustry: Attending Physician First NameIndustry: Attending Physician First NameUB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]UB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 107-114 (Also maps to EMCv.4.1 Record Type 71 Field No. 21 if you are creating this attachment)EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 107-114 (Also maps to EMCv.4.1 Record Type 71 Field No. 21 if you are creating this attachment)Required if NM102=1 (person).Required if NM102=1 (person).


Description: Individual middle name or initialIndustry: Attending Physician Middle NameIndustry: Attending Physician Middle Name






Description: Suffix to individual nameIndustry: Attending Physician Name SuffixIndustry: Attending Physician Name Suffix



Description: Code designating the system/method of code structure used for IdentificationCode (67)EMC v.6.0 Reference: Record Type 80 Field No. 4 (The National Registry for Medicareassigns the UPIN to the provider for identification purposes.)EMC v.6.0 Reference: Record Type 80 Field No. 4 (The National Registry for Medicareassigns the UPIN to the provider for identification purposes.)




Description: Code identifying a party or other codeIndustry: Attending Physician Primary IdentifierIndustry: Attending Physician Primary IdentifierUB-92 Ref. [UB-Name]: 82, Line a [Attending Physician ID]UB-92 Ref. [UB-Name]: 82, Line a [Attending Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 5EMC v.6.0 Reference: Record Type 80 Field No. 5










PRV Attending PhysicianSpecialty Information


Loop:2310A

Elements: 3



Description: Code identifying the type of provider

CodeList Summary (Total Codes: 26, Included: 2)Code NameAT AttendingSU Supervising





Provider Taxonomy CodeProvider Taxonomy Code


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Provider Taxonomy CodeIndustry: Provider Taxonomy CodeAlias: Provider Specialty CodeAlias: Provider Specialty Code


Notes:Notes:1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by thepresence of a PRV segment with the same value in PRV01.2. Use code value AT to report the specialty of the attending physician. Use code value SU when the physician isresponsible for the patient’s Home Health Plan of Treatment. 3. PRV02 qualifies PRV03.4. Required when the billing provider is a billing service and taxonomy is know to impact the adjudication of theclaim.

1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by thepresence of a PRV segment with the same value in PRV01.2. Use code value AT to report the specialty of the attending physician. Use code value SU when the physician isresponsible for the patient’s Home Health Plan of Treatment. 3. PRV02 qualifies PRV03.4. Required when the billing provider is a billing service and taxonomy is know to impact the adjudication of theclaim.

Example:Example:PRV*AT*ZZ*363LP0200N~PRV*AT*ZZ*363LP0200N~



REF Attending PhysicianSecondary Identification


Loop:2310A

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 13)Code Name0B State License Number1A Blue Cross Provider Number1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider Number1G Provider UPIN Number1H CHAMPUS Identification NumberEI Employer's Identification NumberG2 Provider Commercial Number

Description: A unique number assigned to a provider by a commercial insurerLU Location NumberN5 Provider Plan Network Identification Number

Description: A number assigned to identify a specific provider in a health care plannetwork

SY Social Security NumberThe social security number may not be used for Medicare.The social security number may not be used for Medicare.



Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Attending Physician Secondary IdentifierIndustry: Attending Physician Secondary Identifier



Notes:Notes:1. Use this REF only when a second number is necessary to identify the provider. The primary identification mustbe contained in NM109.1. Use this REF only when a second number is necessary to identify the provider. The primary identification mustbe contained in NM109.

Example:Example:



REF*1G*A12345~REF*1G*A12345~



Loop Operating Physician Name Pos: 250 Repeat: 1Optional

Loop:2310B

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage250 NM1 Operating Physician Name O 1 Situational271 REF Operating Physician Secondary




Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. This segment is required when any surgical procedure code is listed on this claim.3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.

1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. This segment is required when any surgical procedure code is listed on this claim.3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.

Example:Example:NM1*72*1*MEYERS*JANE****XX*12345678~NM1*72*1*MEYERS*JANE****XX*12345678~



NM1 Operating Physician Name Pos: 250 Max: 1Detail - Optional

Loop:2310B

Elements: 8




CodeList Summary (Total Codes: 1312, Included: 1)Code Name72 Operating Physician

Description: Doctor who performs a surgical procedure



CodeList Summary (Total Codes: 14, Included: 1)Code Name1 Person


Description: Individual last name or organizational nameIndustry: Operating Physician Last NameIndustry: Operating Physician Last NameUB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 10, Positions 116-131.EMC v.6.0 Reference: Record Type 80 Field No. 10, Positions 116-131.

NM104 1036 Name First O AN 1/25 Required

Description: Individual first nameIndustry: Operating Physician First NameIndustry: Operating Physician First NameUB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 10, Position 132-139EMC v.6.0 Reference: Record Type 80 Field No. 10, Position 132-139


Description: Individual middle name or initialIndustry: Operating Physican Middle NameIndustry: Operating Physican Middle Name

This data element is required when NM102 equals one (1) and the Middle Name or Initialof the person is known by the provider.This data element is required when NM102 equals one (1) and the Middle Name or Initialof the person is known by the provider.


Description: Suffix to individual nameIndustry: Operating Physician Name SuffixIndustry: Operating Physician Name Suffix










Description: Code identifying a party or other codeIndustry: Operating Physician Primary IdentifierIndustry: Operating Physician Primary IdentifierUB-92 Ref. [UB-Name]: 83A, Line a [Other Physician ID]UB-92 Ref. [UB-Name]: 83A, Line a [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 6EMC v.6.0 Reference: Record Type 80 Field No. 6










REF Operating PhysicianSecondary Identification


Loop:2310B

Elements: 2










Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Operating Physician Secondary IdentifierIndustry: Operating Physician Secondary Identifier




Example:Example:



REF*1G*A12345~REF*1G*A12345~



Loop Other Provider Name Pos: 250 Repeat: 1Optional

Loop:2310C

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage250 NM1 Other Provider Name O 1 Situational271 REF Other Provider Secondary Identification O 5 Situational



Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required when the claim/encounter involves an other provider such as, but not limited to: Referring Provider,Ordering Provider, Assisting Provider, etc.

1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required when the claim/encounter involves an other provider such as, but not limited to: Referring Provider,Ordering Provider, Assisting Provider, etc.

Example:Example:NM1*73*1*DOE*JOHN*A***34*201749586~NM1*73*1*DOE*JOHN*A***34*201749586~



NM1 Other Provider Name Pos: 250 Max: 1Detail - Optional

Loop:2310C

Elements: 8




CodeList Summary (Total Codes: 1312, Included: 1)Code Name73 Other Physician

Description: Physician not one of the other specified choices





Description: Individual last name or organizational nameIndustry: Other Physician Last NameIndustry: Other Physician Last NameUB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 11, 12EMC v.6.0 Reference: Record Type 80 Field No. 11, 12


Description: Individual first nameIndustry: Other Physician First NameIndustry: Other Physician First NameUB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 11, 12EMC v.6.0 Reference: Record Type 80 Field No. 11, 12



Description: Individual middle name or initialIndustry: Other Provider Middle NameIndustry: Other Provider Middle Name

Required when NM102=1-Person and the Middle Name or Initial of the person is known bythe provider.Required when NM102=1-Person and the Middle Name or Initial of the person is known bythe provider.


Description: Suffix to individual name




Industry: Other Provider Name SuffixIndustry: Other Provider Name Suffix

Other Provider GenerationRequired if known.Other Provider GenerationRequired if known.






Description: Code identifying a party or other codeIndustry: Other Physician IdentifierIndustry: Other Physician IdentifierAlias: Other Physician Primary IDAlias: Other Physician Primary IDUB-92 Ref. [UB-Name]: 83B, Line a [Other Physician ID]UB-92 Ref. [UB-Name]: 83B, Line a [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 7


EMC v.6.0 Reference: Record Type 80 Field No. 7






Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2410 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required on all outpatient and home health claims/encounters to indicate the person or organization (HomeHealth Agency) who rendered the care. In the case where a subsitute provider (locum tenans) was used, thatperson should be entered here. Required when the Other Provider NM1 information is different than that carriedin either the Billing Provider NM1 or the Pay-to Provider in the 2010AA/AB loops.4. Required on non-outpatient (e.g inpatient, SNF, ICF etc.) claims or encounters to indicate the physician whorendered service for the principal procedure if other than the operating physician reported in Loop 2310B. Notrequired on non-outpatient claims or ncounters if no principal procedure was performed.

1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2410 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required on all outpatient and home health claims/encounters to indicate the person or organization (HomeHealth Agency) who rendered the care. In the case where a subsitute provider (locum tenans) was used, thatperson should be entered here. Required when the Other Provider NM1 information is different than that carriedin either the Billing Provider NM1 or the Pay-to Provider in the 2010AA/AB loops.4. Required on non-outpatient (e.g inpatient, SNF, ICF etc.) claims or encounters to indicate the physician whorendered service for the principal procedure if other than the operating physician reported in Loop 2310B. Notrequired on non-outpatient claims or ncounters if no principal procedure was performed.






REF Other Provider SecondaryIdentification


Loop:2310C

Elements: 2










Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Provider Secondary IdentifierIndustry: Other Provider Secondary Identifier




Example:Example:



REF*1G*A12345~REF*1G*A12345~



Loop Service Facility Name Pos: 250 Repeat: 1Optional

Loop:2310E

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage250 NM1 Service Facility Name O 1 Situational265 N3 Service Facility Address O 1 Required270 N4 Service Facility City/State/Zip Code O 1 Required271 REF Service Facility Secondary Identification O 5 Situational



Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence ofLoop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. This loop is required when the location of health care service is different than that carried in the 2010AA (BillingProvider) or 2010AB (Pay-to Provider) loops.

1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence ofLoop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. This loop is required when the location of health care service is different than that carried in the 2010AA (BillingProvider) or 2010AB (Pay-to Provider) loops.

Example:Example:NM1*FA*2*Rehab Facility*****XX*12345678~NM1*FA*2*Rehab Facility*****XX*12345678~



NM1 Service Facility Name Pos: 250 Max: 1Detail - Optional

Loop:2310E

Elements: 5




CodeList Summary (Total Codes: 1312, Included: 1)Code NameFA Facility





Description: Individual last name or organizational nameIndustry: Laboratory or Facility NameIndustry: Laboratory or Facility NameAlias: Laboratory/Facility NameAlias: Laboratory/Facility Name


Description: Code designating the system/method of code structure used for IdentificationCode (67)Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.




Description: Code identifying a party or other codeIndustry: Laboratory or Facility Primary IdentifierIndustry: Laboratory or Facility Primary IdentifierAlias: Laboratory/Facility Primary IdentifierAlias: Laboratory/Facility Primary Identifier

Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.













N3 Service Facility Address Pos: 265 Max: 1Detail - Optional

Loop:2310E

Elements: 2



Description: Address informationIndustry: Laboratory or Facility Address LineIndustry: Laboratory or Facility Address LineAlias: Laboratory/Facility Address 1Alias: Laboratory/Facility Address 1


Description: Address informationIndustry: Laboratory or Facility Address LineIndustry: Laboratory or Facility Address Line





N4 Service Facility City/State/ZipCode


Loop:2310E

Elements: 4



Description: Free-form text for city nameIndustry: Laboratory or Facility City NameIndustry: Laboratory or Facility City NameAlias: Laboratory/Facility CityAlias: Laboratory/Facility City


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Laboratory or Facility State or Province CodeIndustry: Laboratory or Facility State or Province CodeAlias: Laboratory/Facility StateAlias: Laboratory/Facility State



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Laboratory or Facility Postal Zone or ZIP CodeIndustry: Laboratory or Facility Postal Zone or ZIP CodeAlias: Laboratory/Facility Zip CodeAlias: Laboratory/Facility Zip Code



Description: Code identifying the countryAlias: Laboratory/Facility Country CodeAlias: Laboratory/Facility Country Code

Required if the address is out of the U.S.Required if the address is out of the U.S.






Example:Example:N4*ANY TOWN*TX*75123~N4*ANY TOWN*TX*75123~



REF Service Facility SecondaryIdentification


Loop:2310E

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 15)Code Name0B State License Number1A Blue Cross Provider Number1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider Number1G Provider UPIN Number1H CHAMPUS Identification Number1J Facility ID NumberEI Employer's Identification NumberFH Clinic Number


Description: A unique number assigned to a provider by a commercial insurerG5 Provider Site NumberLU Location NumberN5 Provider Plan Network Identification Number




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Laboratory or Facility Secondary IdentifierIndustry: Laboratory or Facility Secondary Identifier






Example:Example:REF*1G*A12345~REF*1G*A12345~



Loop Other Subscriber Information Pos: 290 Repeat: 10Optional


User Option (Usage): SituationalPurpose: To record information specific to the primary insured and the insurance carrier for that insured

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage290 SBR Other Subscriber Information O 1 Situational295 CAS Claim Level Adjustment O 5 Situational300 AMT Payer Prior Payment O 1 Situational300 AMT Coordination of Benefits (COB) Total

Allowed AmountO 1 Situational

300 AMT Coordination of Benefits (COB) TotalSubmitted Charges

O 1 Situational

300 AMT Diagnostic Related Group (DRG) OutlierAmount

O 1 Situational

300 AMT Coordination of Benefits (COB) TotalMedicare Paid Amount

O 1 Situational

300 AMT Medicare Paid Amount - 100% O 1 Situational300 AMT Medicare Paid Amount - 80% O 1 Situational300 AMT Coordination of Benefits (COB) Medicare A

Trust Fund Paid AmountO 1 Situational

300 AMT Coordination of Benefits (COB) Medicare BTrust Fund Paid Amount

O 1 Situational

300 AMT Coordination of Benefits (COB) TotalNon-covered Amount

O 1 Situational

300 AMT Coordination of Benefits (COB) TotalDenied Amount

O 1 Situational

305 DMG Other Subscriber Demographic Information O 1 Situational310 OI Other Insurance Coverage Information O 1 Required315 MIA Medicare Inpatient Adjudication


320 MOA Medicare Outpatient AdjudicationInformation

O 1 Situational

325 Loop 2330A O 1 Required325 Loop 2330B O 1 Required325 Loop 2330C O 1 Situational325 Loop 2330D O 1 Situational325 Loop 2330E O 1 Situational325 Loop 2330F O 1 Situational325 Loop 2330H O 1 Situational





Notes:Notes:1. Required if other payers are known to potentially be involved in paying on this claim.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. All information contained in the 2320 Loop applies only to the payer who is identified in the 2330B Loop of thisiteration of the 2320 Loop. It is specific only to that payer. If information on additional payers is needed to becarried, run the 2320 Loop again with it’s respective 2330 Loops.

1. Required if other payers are known to potentially be involved in paying on this claim.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. All information contained in the 2320 Loop applies only to the payer who is identified in the 2330B Loop of thisiteration of the 2320 Loop. It is specific only to that payer. If information on additional payers is needed to becarried, run the 2320 Loop again with it’s respective 2330 Loops.

Example:Example:SBR*S*01*GR00786**MC****OF~SBR*S*01*GR00786**MC****OF~



SBR Other SubscriberInformation













































Code Name



Used to indicate “payer of last resort”.Used to indicate “payer of last resort”.

SBR02 1069 Individual Relationship Code O ID 2/2 Required

Description: Code indicating the relationship between two individuals or entitiesUB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]UB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)

Use this code to specify the patient’s relationship to the person insured.Use this code to specify the patient’s relationship to the person insured.

CodeList Summary (Total Codes: 153, Included: 24)Code Name01 Spouse

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 02 [Spouse]59 Code 02 [Spouse]

04 Grandfather or GrandmotherUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 19 [Grandparent]59 Code 19 [Grandparent]

05 Grandson or GranddaughterUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 13 [Grandchild]59 Code 13 [Grandchild]

07 Nephew or NieceUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 14 [Niece/Nephew]59 Code 14 [Niece/Nephew]

10 Foster ChildUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 06 [Foster Child]59 Code 06 [Foster Child]

15 WardUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 07 [Ward of the Court]59 Code 07 [Ward of the Court]

17 Stepson or StepdaughterUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 05 [Step Child]59 Code 05 [Step Child]

18 SelfUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 01 [Patient Is Insured]59 Code 01 [Patient Is Insured]

19 ChildDescription: Dependent between the ages of 0 and 19; age qualifications mayvary depending on policyUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 03 [Natural Child/Insured Financial Responsibility]59 Code 03 [Natural Child/Insured Financial Responsibility]

20 EmployeeUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 08 [Employee]59 Code 08 [Employee]

21 UnknownUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:


Code Name


59 Code 09 [Unknown]59 Code 09 [Unknown]22 Handicapped Dependent

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 10 [Handicapped Dependent]59 Code 10 [Handicapped Dependent]

23 Sponsored DependentDescription: Dependents between the ages of 19 and 25 not attending school; agequalifications may vary depending on policyUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 16 [Sponsored Dependent]59 Code 16 [Sponsored Dependent]

24 Dependent of a Minor DependentDescription: A child not legally of age who has been granted adult statusUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 17 [Minor Dependent of a Minor Dependent]59 Code 17 [Minor Dependent of a Minor Dependent]

29 Significant Other32 Mother33 Father36 Emancipated Minor

Description: A person who has been judged by a court of competent jurisdiction tobe allowed to act in his or her own interest; no adult is legally responsible for thisminor; this may be declared as a result of marriage

39 Organ DonorDescription: Individual receiving medical service in order to donate organs for atransplantUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 11 [Organ Donor]59 Code 11 [Organ Donor]

40 Cadaver DonorDescription: Deceased individual donating body to be used for research ortransplantsUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 12 [Cadaver Donor]59 Code 12 [Cadaver Donor]

41 Injured PlaintiffUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 15 [Injured Plaintiff]59 Code 15 [Injured Plaintiff]

43 Child Where Insured Has No Financial ResponsibilityDescription: Child is covered by the insured but the insured is not the legalguardianUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 04 [Natural Child/Insured Does not Have Financial Responsibility]59 Code 04 [Natural Child/Insured Does not Have Financial Responsibility]

53 Life PartnerUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 20 [Life Partner]59 Code 20 [Life Partner]

G8 Other Relationship


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Insured Group or Policy NumberIndustry: Insured Group or Policy Number




UB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number]UB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number]EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03) Insurance GroupNo.EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03) Insurance GroupNo.Use this element to carry the subscriber’s group number but not the number that uniquelyidentifies the subscriber. The subscriber’s number should be carried in NM109. Using codeIL in NM101 identifies the number in NM109 as the insured’s Identification Number.



Description: Free-form nameIndustry: Other Insured Group NameIndustry: Other Insured Group NameUB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name]UB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name]EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03)

Plan Name (Group Name)This data element is required when the Provider has the Plan Name (Group Name) withintheir files.



Description: Code identifying type of claimEMC v.6.0 Reference: Record Type 30 Field No. 4 (Sequence 01-03. See SBR09 inLOOP 2000B for EMC code translation.)EMC v.6.0 Reference: Record Type 30 Field No. 4 (Sequence 01-03. See SBR09 inLOOP 2000B for EMC code translation.)Required prior to mandated used of PlanID. Not used after PlanID is mandated.Required prior to mandated used of PlanID. Not used after PlanID is mandated.

CodeList Summary (Total Codes: 45, Included: 24)Code Name09 Self-pay10 Central Certification11 Other Non-Federal Programs12 Preferred Provider Organization (PPO)13 Point of Service (POS)14 Exclusive Provider Organization (EPO)15 Indemnity Insurance16 Health Maintenance Organization (HMO) Medicare RiskAM Automobile MedicalBL Blue Cross/Blue ShieldCH ChampusCI Commercial Insurance Co.DS DisabilityHM Health Maintenance OrganizationLI LiabilityLM Liability MedicalMA Medicare Part AMB Medicare Part BMC MedicaidOF Other Federal ProgramTV Title VVA Veteran Administration Plan

Refers to Veterans Affairs Plan.Refers to Veterans Affairs Plan.WC Workers' Compensation Health Claim


Code Name


ZZ Mutually DefinedUnknownUnknown








CAS Claim Level Adjustment Pos: 295 Max: 5Detail - Optional


User Option (Usage): SituationalPurpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a particular servicewithin the claim being paid

Element Summary: Ref Id Element Name Req Type Min/Max UsageCAS01 1033 Claim Adjustment Group Code M ID 1/2 Required

Description: Code identifying the general category of payment adjustmentEMC v.6.0 Reference: Record Type 42 Field No. 5EMC v.6.0 Reference: Record Type 42 Field No. 5

CodeList Summary (Total Codes: 8, Included: 5)Code NameCO Contractual ObligationsCR Correction and ReversalsOA Other adjustmentsPI Payor Initiated ReductionsPR Patient Responsibility

CAS02 1034 Claim Adjustment Reason Code M ID 1/5 Required

Description: Code identifying the detailed reason the adjustment was madeIndustry: Adjustment Reason CodeIndustry: Adjustment Reason CodeEMC v.6.0 Reference: Record Type 42 Field No. 6EMC v.6.0 Reference: Record Type 42 Field No. 6

ExternalCodeList Name: 139 Description: Claim Adjustment Reason Code

CAS03 782 Monetary Amount M R 1/18 Required

Description: Monetary amountIndustry: Adjustment AmountIndustry: Adjustment AmountEMC v.6.0 Reference: Record Type 42 Field No. 7EMC v.6.0 Reference: Record Type 42 Field No. 7

CAS04 380 Quantity O R 1/15 Situational

Description: Numeric value of quantityIndustry: Adjustment QuantityIndustry: Adjustment QuantityEMC v.6.0 Reference: Record Type 42 Field No. 8EMC v.6.0 Reference: Record Type 42 Field No. 8

Use this number for the units of service being adjusted.Use this number for the units of service being adjusted.

CAS05 1034 Claim Adjustment Reason Code C ID 1/5 Situational


Used when additional adjustment information applies to claim.Used when additional adjustment information applies to claim.

ExternalCodeList



Name: 139 Description: Claim Adjustment Reason Code

CAS06 782 Monetary Amount C R 1/18 Situational



CAS07 380 Quantity C R 1/15 Situational

















































Syntax Rules: 1. L050607 - If CAS05 is present, then at least one of CAS06 or CAS07 is required.2. C0605 - If CAS06 is present, then CAS05 is required.3. C0705 - If CAS07 is present, then CAS05 is required.4. L080910 - If CAS08 is present, then at least one of CAS09 or CAS10 is required.5. C0908 - If CAS09 is present, then CAS08 is required.6. C1008 - If CAS10 is present, then CAS08 is required.7. L111213 - If CAS11 is present, then at least one of CAS12 or CAS13 is required.8. C1211 - If CAS12 is present, then CAS11 is required.9. C1311 - If CAS13 is present, then CAS11 is required.

10. L141516 - If CAS14 is present, then at least one of CAS15 or CAS16 is required.11. C1514 - If CAS15 is present, then CAS14 is required.12. C1614 - If CAS16 is present, then CAS14 is required.13. L171819 - If CAS17 is present, then at least one of CAS18 or CAS19 is required.14. C1817 - If CAS18 is present, then CAS17 is required.15. C1917 - If CAS19 is present, then CAS17 is required.

Semantics: 1. CAS03 is the amount of adjustment.2. CAS04 is the units of service being adjusted.3. CAS06 is the amount of the adjustment.4. CAS07 is the units of service being adjusted.5. CAS09 is the amount of the adjustment.6. CAS10 is the units of service being adjusted.7. CAS12 is the amount of the adjustment.8. CAS13 is the units of service being adjusted.9. CAS15 is the amount of the adjustment.

10. CAS16 is the units of service being adjusted.11. CAS18 is the amount of the adjustment.12. CAS19 is the units of service being adjusted.

Comments: 1. Adjustment information is intended to help the provider balance the remittance information. Adjustment

amounts should fully explain the difference between submitted charges and the amount paid.2. When the submitted charges are paid in full, the value for CAS03 should be zero.

Notes:Notes:1. Submitter should use this CAS segment to report prior payers claim level adjustments that cause the amountpaid to differ from the amount originally charged.2. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim

1. Submitter should use this CAS segment to report prior payers claim level adjustments that cause the amountpaid to differ from the amount originally charged.2. 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 again.3. Codes and associated amount should come from 835 (Remittance Advice) received on the claim. If noprevious payments have been made, omit this segment. See the 835 for definitions of the Group Codes (CAS01).4. Required if claim has been adjudicated by payer identified in this loop and has claim level adjustmentinformation.5. To locate the claim adjustment reason codes that are used in CAS02, 05, 08, 11, 14, and 17 see theWashington Publishing Company web site: http://www.wpc-edi.com. Follow the buttons to Code Lists - ClaimAdjustment Reason Codes.


Example:Example:CAS*CO*96*555.52~CAS*CO*96*555.52~



AMT Payer Prior Payment Pos: 300 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameC4 Prior Payment - Actual

Description: Amount paid in reality at an earlier time


Description: Monetary amountIndustry: Other Payer Patient Paid AmountIndustry: Other Payer Patient Paid AmountUB-92 Ref. [UB-Name]: 54 (A-C) [Prior Payments - Payers and Patient]UB-92 Ref. [UB-Name]: 54 (A-C) [Prior Payments - Payers and Patient]EMC v.6.0 Reference: Record Type 30 Field No. 25 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 25 (Sequence 01-03)

Notes:Notes:1. The amount this payer has paid to the provider towards this bill.2. This segment is required when the present payer has paid an amount to the provider towards this bill.1. The amount this payer has paid to the provider towards this bill.2. This segment is required when the present payer has paid an amount to the provider towards this bill.

Example:Example:AMT*C4*150~AMT*C4*150~



AMT Coordination of Benefits(COB) Total AllowedAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameB6 Allowed - Actual

Description: Amount considered for payment under the provisions of the contract


Description: Monetary amountIndustry: Allowed AmountIndustry: Allowed AmountEMC v.6.0 Reference: Record Type 92 Field No. 8 (For COB use. Use this amount for thetotal claim level charges allowed.)EMC v.6.0 Reference: Record Type 92 Field No. 8 (For COB use. Use this amount for thetotal claim level charges allowed.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Allowed Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Allowed Amount applicable to this claim when known.

Example:Example:AMT*B6*3794.82~AMT*B6*3794.82~



AMT Coordination of Benefits(COB) Total SubmittedCharges






CodeList Summary (Total Codes: 1473, Included: 1)Code NameT3 Total Submitted Charges


Description: Monetary amountIndustry: Coordination of Benefits Total Submitted Charge AmountIndustry: Coordination of Benefits Total Submitted Charge AmountEMC v.6.0 Reference: Record Type 92 Field No. 6 (For COB use. Use this amount for thetotal claim level submitted charges.)EMC v.6.0 Reference: Record Type 92 Field No. 6 (For COB use. Use this amount for thetotal claim level submitted charges.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Submitted Charges applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Submitted Charges applicable to this claim when known.

Example:Example:AMT*T3*7490.7~AMT*T3*7490.7~



AMT Diagnostic Related Group(DRG) Outlier Amount





Description: Code to qualify amountUse this qualifier until a more suitable one is developed. At this time, the qualifierrepresents what the amount is being used for (see monetary amount description).Use this qualifier until a more suitable one is developed. At this time, the qualifierrepresents what the amount is being used for (see monetary amount description).



Description: Monetary amountIndustry: Claim DRG Outlier AmountIndustry: Claim DRG Outlier Amount

Record Type 92 Field No. 15 (For COB use [temporary qualifier]. Use this amount for theDRG outlier amount.)Record Type 92 Field No. 15 (For COB use [temporary qualifier]. Use this amount for theDRG outlier amount.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the DRG Outlier Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the DRG Outlier Amount applicable to this claim when known.

Example:Example:AMT*ZZ*9034.7~AMT*ZZ*9034.7~



AMT Coordination of Benefits(COB) Total Medicare PaidAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameN1 Net Worth


Description: Monetary amountIndustry: Total Medicare Paid AmountIndustry: Total Medicare Paid Amount

Record Type 92 Field No. 9 (For COB use [temporary qualifier]. Use this amount for thetotal Medicare reimbursement.)Record Type 92 Field No. 9 (For COB use [temporary qualifier]. Use this amount for thetotal Medicare reimbursement.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Medicare Paid Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Medicare Paid Amount applicable to this claim when known.

Example:Example:AMT*N1*873.4~AMT*N1*873.4~



AMT Medicare Paid Amount -100%






CodeList Summary (Total Codes: 1473, Included: 1)Code NameKF Net Paid Amount


Description: Monetary amountIndustry: Medicare Paid at 100% AmountIndustry: Medicare Paid at 100% Amount

Record Type 93 Field No. 4 (For COB use [temporary qualifier]. Use this amount for theclaim level allowed charges Medicare paid at 100%.)Record Type 93 Field No. 4 (For COB use [temporary qualifier]. Use this amount for theclaim level allowed charges Medicare paid at 100%.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount -100% applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount -100% applicable to this claim when known.

Example:Example:AMT*KF*73.01~AMT*KF*73.01~



AMT Medicare Paid Amount - 80% Pos: 300 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NamePG Payoff




Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount - 80% applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount - 80% applicable to this claim when known.

Example:Example:AMT*PG*639.4~AMT*PG*639.4~



AMT Coordination of Benefits(COB) Medicare A TrustFund Paid Amount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameAA Allocated


Description: Monetary amountIndustry: Paid From Part A Medicare Trust Fund AmountIndustry: Paid From Part A Medicare Trust Fund Amount

Record Type 93 Field No. 6 (For COB use [temporary qualifier]. Use this amount for theamount paid from the Medicare A trust fund.)Record Type 93 Field No. 6 (For COB use [temporary qualifier]. Use this amount for theamount paid from the Medicare A trust fund.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare A Trust Fund Paid Amount applicable to this claim whenknown.

1. This segment is for COB use.2. This segment is used to convey the COB Medicare A Trust Fund Paid Amount applicable to this claim whenknown.

Example:Example:AMT*AA*4394.7~AMT*AA*4394.7~



AMT Coordination of Benefits(COB) Medicare B TrustFund Paid Amount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameB1 Benefit Amount

Use this qualifier until a more suitable one is developed. At this time, B1represents the Paid From Medicare B Trust Fund Amount.Use this qualifier until a more suitable one is developed. At this time, B1represents the Paid From Medicare B Trust Fund Amount.


Description: Monetary amountIndustry: Paid From Part B Medicare Trust Fund AmountIndustry: Paid From Part B Medicare Trust Fund AmountEMC v.6.0 Reference: Record Type 93 Field No. 7 (For COB use [temporary qualifier].Use this amount for the amount paid from the Medicare B trust fund.)EMC v.6.0 Reference: Record Type 93 Field No. 7 (For COB use [temporary qualifier].Use this amount for the amount paid from the Medicare B trust fund.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare B Trust Fund Paid Amount applicable to this claim whenknown.

1. This segment is for COB use.2. This segment is used to convey the COB Medicare B Trust Fund Paid Amount applicable to this claim whenknown.

Example:Example:AMT*B1*150~AMT*B1*150~



AMT Coordination of Benefits(COB) Total Non-coveredAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameA8 Noncovered Charges - Actual

Description: Calculated value not covered by the benefit plan


Description: Monetary amountIndustry: Non-Covered Charge AmountIndustry: Non-Covered Charge AmountEMC v.6.0 Reference: Record Type 92 Field No. 7 (For COB use [temporary qualifier].Use this amount for the total of non-covered claim level charges.)EMC v.6.0 Reference: Record Type 92 Field No. 7 (For COB use [temporary qualifier].Use this amount for the total of non-covered claim level charges.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Non-Covered Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Non-Covered Amount applicable to this claim when known.

Example:Example:AMT*A8*273~AMT*A8*273~



AMT Coordination of Benefits(COB) Total Denied Amount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameYT Denied


Description: Monetary amountIndustry: Claim Total Denied Charge AmountIndustry: Claim Total Denied Charge AmountEMC v.6.0 Reference: Record Type 92 Field No. 16 (For COB use. Use this amount forthe total claim level denied charges.)EMC v.6.0 Reference: Record Type 92 Field No. 16 (For COB use. Use this amount forthe total claim level denied charges.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Denied Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Denied Amount applicable to this claim when known.

Example:Example:AMT*YT*32~AMT*YT*32~



DMG Other SubscriberDemographic Information








Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Other Insured Birth DateIndustry: Other Insured Birth Date


Description: Code indicating the sex of the individualIndustry: Other Insured Gender CodeIndustry: Other Insured Gender CodeEMC v.6.0 Reference: Record Type 30 Field No. 15EMC v.6.0 Reference: Record Type 30 Field No. 15




Notes:Notes:1. Required when 2330A - Other Subscriber Name NM102 = 1 (Person).1. Required when 2330A - Other Subscriber Name NM102 = 1 (Person).

Example:Example:DMG***F~DMG***F~



OI Other Insurance CoverageInformation



User Option (Usage): RequiredPurpose: To specify information associated with other health insurance coverage

Element Summary: Ref Id Element Name Req Type Min/Max UsageOI03 1073 Yes/No Condition or Response Code O ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Benefits Assignment Certification IndicatorIndustry: Benefits Assignment Certification IndicatorEMC v.6.0 Reference: Record Type 30 Field No. 17EMC v.6.0 Reference: Record Type 30 Field No. 17

Assignment of Benefits IndicatorAssignment of Benefits Indicator


OI06 1363 Release of Information Code O ID 1/1 Required

Description: Code indicating whether the provider has on file a signed statement by thepatient authorizing the release of medical data to other organizationsEMC v.6.0 Reference: Record Type 30 Field No. 16EMC v.6.0 Reference: Record Type 30 Field No. 16





N No, Provider is Not Allowed to Release DataEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 16 Code NRecord Type 30 Field No. 16 Code N


Related to a ClaimEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 16 Code YRecord Type 30 Field No. 16 Code Y

Semantics: 1. OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes


Notes:Notes:



1. All information contained in the OI segment applies only to the payer who is identified in the 2330B loop of thisiteration of the 2320 loop. It is specific only to that payer.1. All information contained in the OI segment applies only to the payer who is identified in the 2330B loop of thisiteration of the 2320 loop. It is specific only to that payer.

Example:Example:OI***Y***Y~OI***Y***Y~



MIA Medicare InpatientAdjudication Information



User Option (Usage): SituationalPurpose: To provide claim-level data related to the adjudication of Medicare inpatient claims

Element Summary: Ref Id Element Name Req Type Min/Max UsageMIA01 380 Quantity M R 1/15 Required

Description: Numeric value of quantityIndustry: Covered Days or Visits CountIndustry: Covered Days or Visits Count

MIA02 380 Quantity O R 1/15 Situational

Description: Numeric value of quantityIndustry: Lifetime Reserve Days CountIndustry: Lifetime Reserve Days Count

Use this quantity to indicate the lifetime reserve days.Use this quantity to indicate the lifetime reserve days.


Description: Numeric value of quantityIndustry: Lifetime Psychiatric Days CountIndustry: Lifetime Psychiatric Days CountEMC v.6.0 Reference: Record Type 92 Field No. 18EMC v.6.0 Reference: Record Type 92 Field No. 18

MIA04 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Claim DRG AmountIndustry: Claim DRG AmountEMC v.6.0 Reference: Record Type 92 Field No. 14EMC v.6.0 Reference: Record Type 92 Field No. 14

Use this amount to indicate the Diagnosis Related Group (DRG) amount.Use this amount to indicate the Diagnosis Related Group (DRG) amount.

MIA05 127 Reference Identification O AN 1/30 Situational

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Remark CodeIndustry: Remark CodeEMC v.6.0 Reference: Record Type 42 Field No. 24EMC v.6.0 Reference: Record Type 42 Field No. 24

Use this reference identification for the Health Care Financing Administration claimpayment remark code.Use this reference identification for the Health Care Financing Administration claimpayment remark code.

ExternalCodeList Name: 411 Description: Remittance Remark Codes


Description: Monetary amountIndustry: Claim Disproportionate Share AmountIndustry: Claim Disproportionate Share Amount

Use this amount to indicate the disproportionate share amount.Use this amount to indicate the disproportionate share amount.


Description: Monetary amount




Industry: Claim MSP Pass-through AmountIndustry: Claim MSP Pass-through Amount

Use this amount to indicate the Medicare Secondary Payer (MSP) pass-through amount.Use this amount to indicate the Medicare Secondary Payer (MSP) pass-through amount.


Description: Monetary amountIndustry: Claim PPS Capital AmountIndustry: Claim PPS Capital Amount

Use this amount to indicate the Total Prospective Payment System (PPS) capital amount.Use this amount to indicate the Total Prospective Payment System (PPS) capital amount.


Description: Monetary amountIndustry: PPS-Capital FSP DRG AmountIndustry: PPS-Capital FSP DRG Amount

Use this amount to indicate the Prospective Payment System (PPS) capital,federal-specific portion, Diagnosis Related Group (DRG) amount.Use this amount to indicate the Prospective Payment System (PPS) capital,federal-specific portion, Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: PPS-Capital HSP DRG AmountIndustry: PPS-Capital HSP DRG Amount

Use this amount to indicate the Prospective Payment System (PPS) capital,hospital-specific portion, Diagnosis Related Group (DRG) amount.Use this amount to indicate the Prospective Payment System (PPS) capital,hospital-specific portion, Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: PPS-Capital DSH DRG AmountIndustry: PPS-Capital DSH DRG Amount

Use this amount to indicate the Prospective Payment System (PPS) capital,disproportionate share, hospital Diagnosis Related Group (DRG) amount.Use this amount to indicate the Prospective Payment System (PPS) capital,disproportionate share, hospital Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: Old Capital AmountIndustry: Old Capital Amount

Use this amount to indicate the old capital amount.Use this amount to indicate the old capital amount.


Description: Monetary amountIndustry: PPS-Capital IME amountIndustry: PPS-Capital IME amount

Use this amount to indicate the Prospective Payment System (PPS) capital indirectmedical education claim amount.Use this amount to indicate the Prospective Payment System (PPS) capital indirectmedical education claim amount.


Description: Monetary amountIndustry: PPS-Operating Hospital Specific DRG AmountIndustry: PPS-Operating Hospital Specific DRG Amount

Use this amount to indicate the hospital-specific, Diagnosis Related Group (DRG) amount.Use this amount to indicate the hospital-specific, Diagnosis Related Group (DRG) amount.


Description: Numeric value of quantityIndustry: Cost Report Day CountIndustry: Cost Report Day CountEMC v.6.0 Reference: Record Type 92 Field No. 17EMC v.6.0 Reference: Record Type 92 Field No. 17





Description: Monetary amountIndustry: PPS-Operating Federal Specific DRG AmountIndustry: PPS-Operating Federal Specific DRG Amount

Use this amount to indicate the federal-specific, Diagnosis Related Group (DRG) amount.Use this amount to indicate the federal-specific, Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: Claim PPS Capital Outlier AmountIndustry: Claim PPS Capital Outlier Amount

Use this amount to indicate the Prospective Payment System (PPS) Capital Outlier amount.Use this amount to indicate the Prospective Payment System (PPS) Capital Outlier amount.


Description: Monetary amountIndustry: Claim Indirect Teaching AmountIndustry: Claim Indirect Teaching Amount

Use this amount to indicate the indirect teaching amount.Use this amount to indicate the indirect teaching amount.


Description: Monetary amountIndustry: Nonpayable Professional Component AmountIndustry: Nonpayable Professional Component Amount

Use this amount to indicate the professional component amount billed but not payable.Use this amount to indicate the professional component amount billed but not payable.











Use this reference identification for the Health Care Financing Administration claim Use this reference identification for the Health Care Financing Administration claim




payment remark code.payment remark code.







Description: Monetary amountIndustry: PPS-Capital Exception AmountIndustry: PPS-Capital Exception Amount

Use this amount to indicate the capital exception amount.Use this amount to indicate the capital exception amount.

Semantics: 1. MIA01 is the covered days.2. MIA02 is the lifetime reserve days.3. MIA03 is the lifetime psychiatric days.4. MIA04 is the Diagnosis Related Group (DRG) amount.5. MIA05 is the Claim Payment Remark Code. See Code Source 411.6. MIA06 is the disproportionate share amount.7. MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.8. MIA08 is the total Prospective Payment System (PPS) capital amount.9. MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group

(DRG) amount.10. MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group

(DRG), amount.11. MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related

Group (DRG) amount.12. MIA12 is the old capital amount.13. MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.14. MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.15. MIA15 is the cost report days.16. MIA16 is the federal specific Diagnosis Related Group (DRG) amount.17. MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.18. MIA18 is the indirect teaching amount.19. MIA19 is the professional component amount billed but not payable.20. MIA20 is the Claim Payment Remark Code. See Code Source 411.21. MIA21 is the Claim Payment Remark Code. See Code Source 411.22. MIA22 is the Claim Payment Remark Code. See Code Source 411.



23. MIA23 is the Claim Payment Remark Code. See Code Source 411.24. MIA24 is the capital exception amount.

Notes:Notes:1. This segment is used to convey the Medicare Inpatient Adjudication Information if returned in the 835.1. This segment is used to convey the Medicare Inpatient Adjudication Information if returned in the 835.

Example:Example:MIA*1***3568.98*MAO***************21***MA25~MIA*1***3568.98*MAO***************21***MA25~



MOA Medicare OutpatientAdjudication Information



User Option (Usage): SituationalPurpose: To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Element Summary: Ref Id Element Name Req Type Min/Max UsageMOA01 954 Percent O R 1/10 Situational

Description: Percentage expressed as a decimalIndustry: Reimbursement RateIndustry: Reimbursement RateEMC v.6.0 Reference: Record Type 92 Field No. 20EMC v.6.0 Reference: Record Type 92 Field No. 20

Required if returned on the Electronic Remittance Advice (835).Required if returned on the Electronic Remittance Advice (835).

MOA02 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Claim HCPCS Payable AmountIndustry: Claim HCPCS Payable Amount

Use this amount to indicate the Claim Health Care Financing Administration CommonProcedural Coding System (HCPCS) payable amount.Required if returned on the Electronic Remittance Advice (835).


MOA03 127 Reference Identification O AN 1/30 Situational

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierUse this amount to indicate the Claim Health Care Financing Administration CommonProcedural Coding System (HCPCS) payable amount.Required if returned on the Electronic Remittance Advice (835).





Use this reference identification for the Health Care Financing Administration claimpayment remark code. Required if returned on the Electronic Remittance Advice (835).




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Remark CodeIndustry: Remark Code




EMC v.6.0 Reference: Record Type 42 Field No. 25EMC v.6.0 Reference: Record Type 42 Field No. 25

Use this reference identification for the Health Care FinancingAdministration claim payment remark code.Required if returned on the Electronic Remittance Advice (835).





Use this reference identification for the Health Care Financing Administration claimpayment remark code.Required if returned on the Electronic Remittance Advice (835).









Description: Monetary amountIndustry: Remark CodeIndustry: Remark CodeEMC v.6.0 Reference: Record Type 42 Field No. 28EMC v.6.0 Reference: Record Type 42 Field No. 28





Use this amount to indicate the professional component amount billed but not payable.Required if returned on the Electronic Remittance Advice (835).Use this amount to indicate the professional component amount billed but not payable.Required if returned on the Electronic Remittance Advice (835).

Semantics:



1. MOA01 is the reimbursement rate.2. MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS)

payable amount.3. MOA03 is the Claim Payment Remark Code. See Code Source 411.4. MOA04 is the Claim Payment Remark Code. See Code Source 411.5. MOA05 is the Claim Payment Remark Code. See Code Source 411.6. MOA06 is the Claim Payment Remark Code. See Code Source 411.7. MOA07 is the Claim Payment Remark Code. See Code Source 411.8. MOA08 is the End Stage Renal Disease (ESRD) payment amount.9. MOA09 is the professional component amount billed but not payable.

Notes:Notes:1. Required to convey the Medicare Outpatient Adjudication Information if returned in the Electronic RemittanceAdvice (835).1. Required to convey the Medicare Outpatient Adjudication Information if returned in the Electronic RemittanceAdvice (835).

Example:Example:MOA*12.5**MAO1~MOA*12.5**MAO1~



Loop Other Subscriber Name Pos: 325 Repeat: 1Optional

Loop:2330A

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Subscriber Name O 1 Required332 N3 Other Subscriber Address O 1 Situational340 N4 Other Subscriber City/State/ZIP Code O 1 Situational355 REF Other Subscriber Secondary Information O 3 Situational



Notes:Notes:1. Submitters are required to send information on all known other subscribers in Loop ID 2330.2. The 2330A Loop is required when Loop ID 2320 - Other Subscriber Information is used. Otherwise, this loop isnot used.

1. Submitters are required to send information on all known other subscribers in Loop ID 2330.2. The 2330A Loop is required when Loop ID 2320 - Other Subscriber Information is used. Otherwise, this loop isnot used.

Example:Example:NM1*IL*1*DOE*JOHN*T***34*123456789~NM1*IL*1*DOE*JOHN*T***34*123456789~



NM1 Other Subscriber Name Pos: 325 Max: 1Detail - Optional

Loop:2330A

Elements: 8









Description: Individual last name or organizational nameIndustry: Other Insured Last NameIndustry: Other Insured Last NameAlias: Subscriber’s Last NameAlias: Subscriber’s Last NameUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 12 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 12 (Sequence 01-03)


Description: Individual first nameIndustry: Other Insured First NameIndustry: Other Insured First NameAlias: Subscriber’s First NameAlias: Subscriber’s First NameUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 13 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 13 (Sequence 01-03)



Description: Individual middle name or initialIndustry: Other Insured Middle NameIndustry: Other Insured Middle NameAlias: Subscriber’s Middle InitialAlias: Subscriber’s Middle InitialUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 14 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 14 (Sequence 01-03)






Description: Suffix to individual nameIndustry: Other Insured Name SuffixIndustry: Other Insured Name Suffix

Examples: I, II, III, IV, Jr, SrRequired if known.Examples: I, II, III, IV, Jr, SrRequired if known.






ZZ Mutually DefinedThe value ’ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.

The value ’ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.


Description: Code identifying a party or other codeIndustry: Other Insured IdentifierIndustry: Other Insured IdentifierAlias: Subscriber Primary IDAlias: Subscriber Primary IDUB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]UB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)









N3 Other Subscriber Address Pos: 332 Max: 1Detail - Optional

Loop:2330A

Elements: 2



Description: Address informationIndustry: Other Insured Address LineIndustry: Other Insured Address LineAlias: Subscriber’s Address 1Alias: Subscriber’s Address 1UB-92 Ref. [UB-Name]: 84, Line b [Remarks]UB-92 Ref. [UB-Name]: 84, Line b [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 4 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 4 (Sequence 01-03)


Description: Address informationIndustry: Other Insured Address LineIndustry: Other Insured Address LineAlias: Subscriber Address 2Alias: Subscriber Address 2EMC v.6.0 Reference: Record Type 31 Field No. 5 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 5 (Sequence 01-03)


Notes:Notes:1. This segment is required when the Provider has the Other Subscriber Address information on file.1. This segment is required when the Provider has the Other Subscriber Address information on file.

Example:Example:N3*4320 WASHINGTON ST SUITE 100~N3*4320 WASHINGTON ST SUITE 100~



N4 Other SubscriberCity/State/ZIP Code


Loop:2330A

Elements: 4



Description: Free-form text for city nameIndustry: Other Insured City NameIndustry: Other Insured City NameAlias: Subscriber’s CityAlias: Subscriber’s CityUB-92 Ref. [UB-Name]: 84, Line c [Remarks]UB-92 Ref. [UB-Name]: 84, Line c [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 6 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 6 (Sequence 01-03)


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Other Insured State CodeIndustry: Other Insured State CodeAlias: Subscriber’s StateAlias: Subscriber’s StateUB-92 Ref. [UB-Name]: 84, Line c [Remarks]UB-92 Ref. [UB-Name]: 84, Line c [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 7 (Sequence 01-03)



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Other Insured Postal Zone or ZIP CodeIndustry: Other Insured Postal Zone or ZIP CodeAlias: Subscriber’s ZIP CodeAlias: Subscriber’s ZIP CodeUB-92 Ref. [UB-Name]: 84, Line d [Remarks]UB-92 Ref. [UB-Name]: 84, Line d [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 8 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 8 (Sequence 01-03)



Description: Code identifying the countryAlias: Subscriber Country CodeAlias: Subscriber Country Code







Notes:Notes:1. This segment is required when the associated N3 segment is present.1. This segment is required when the associated N3 segment is present.

Example:Example:N4*PALISADES*OR*23119~N4*PALISADES*OR*23119~



REF Other Subscriber SecondaryInformation


Loop:2330A

Elements: 2






This code is intended to be used only in claims submitted to the Indian HealthServices (IHS/CHS) Fiscal Intermediary for the purpose of reporting the HealthRecord Number.





Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Insured Additional IdentifierIndustry: Other Insured Additional IdentifierUB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]UB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)



Notes:Notes:1. This segment is required when additional identification numbers are required.1. This segment is required when additional identification numbers are required.




Loop Other Payer Name Pos: 325 Repeat: 1Optional

Loop:2330B

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Name O 1 Required332 N3 Other Payer Address O 1 Situational340 N4 Other Payer City/State/ZIP Code O 1 Situational350 DTP Claim Adjudication Date O 1 Situational355 REF Other Payer Secondary Identification and

Reference NumberO 2 Situational

355 REF Other Payer Prior Authorization or ReferralNumber

O 1 Situational



Notes:Notes:1. Submitters are required to send all known information on other payers in this Loop ID - 2330.1. Submitters are required to send all known information on other payers in this Loop ID - 2330.




NM1 Other Payer Name Pos: 325 Max: 1Detail - Optional

Loop:2330B

Elements: 5









Description: Individual last name or organizational nameIndustry: Other Payer Last or Organization NameIndustry: Other Payer Last or Organization NameAlias: Payer NameAlias: Payer NameUB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]UB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]EMC v.6.0 Reference: Record Type 30 Field No. 8b (Sequence 01-03)







(PAYERID)Description: Required if the National PlanID is mandated for use. Otherwise, oneof the other listed codes may be used.CODE SOURCE:CODE SOURCE:540: Health Care Financing Administration National PlanID540: Health Care Financing Administration National PlanID





Description: Code identifying a party or other codeIndustry: Other Payer Primary IdentifierIndustry: Other Payer Primary IdentifierAlias: Payer Primary IDAlias: Payer Primary ID

This number must be identical to SVD01 (L00p ID - 2430) for COB.This number must be identical to SVD01 (L00p ID - 2430) for COB.









N3 Other Payer Address Pos: 332 Max: 1Detail - Optional

Loop:2330B

Elements: 2



Description: Address informationIndustry: Other Payer Address LineIndustry: Other Payer Address LineAlias: Payer’s Address 1Alias: Payer’s Address 1EMC v.6.0 Reference: Record Type 32 Field No. 5 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 5 (Sequence 01-03)




Notes:Notes:1. This segment is only to be used when the Provider needs to identify the address for paper claim printingpurposes.1. This segment is only to be used when the Provider needs to identify the address for paper claim printingpurposes.




N4 Other Payer City/State/ZIPCode


Loop:2330B

Elements: 4



Description: Free-form text for city nameIndustry: Other Payer City NameIndustry: Other Payer City NameAlias: Payer City NameAlias: Payer City NameEMC v.6.0 Reference: Record Type 32 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 7 (Sequence 01-03)


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Other Payer State CodeIndustry: Other Payer State CodeAlias: Payer State CodeAlias: Payer State CodeEMC v.6.0 Reference: Record Type 32 Field No. 8 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 8 (Sequence 01-03)



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Other Payer Postal Zone or ZIP CodeIndustry: Other Payer Postal Zone or ZIP CodeAlias: Payer Postal CodeAlias: Payer Postal CodeEMC v.6.0 Reference: Record Type 32 Field No. 9 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 9 (Sequence 01-03)














DTP Claim Adjudication Date Pos: 350 Max: 1Detail - Optional

Loop:2330B

Elements: 3




CodeList Summary (Total Codes: 1112, Included: 1)Code Name573 Date Claim Paid





Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Adjudication or Payment DateIndustry: Adjudication or Payment Date


Notes:Notes:1. This segment is required when Loop-ID 2430 (Line Adjudication Date) is not used and this payer hasadjudicated the claim.1. This segment is required when Loop-ID 2430 (Line Adjudication Date) is not used and this payer hasadjudicated the claim.

Example:Example:DTP*573*D8*19981226~DTP*573*D8*19981226~



REF Other Payer SecondaryIdentification and ReferenceNumber


Loop:2330B

Elements: 2



Description: Code qualifying the Reference IdentificationUse code F8 to indicate the payer’s claim number assigned to this claim by the payerreferenced in this interation of Loop ID - 2330B.Use code F8 to indicate the payer’s claim number assigned to this claim by the payerreferenced in this interation of Loop ID - 2330B.

CodeList Summary (Total Codes: 1503, Included: 5)Code Name2U Payer Identification NumberF8 Original Reference Number

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:37 (A-C) [Internal Control Number (ICN)/ Document Control Number (DCN)]37 (A-C) [Internal Control Number (ICN)/ Document Control Number (DCN)]



NF National Association of Insurance Commissioners (NAIC) CodeDescription: A unique number assigned to each insurance companyCODE SOURCE:CODE SOURCE:245: National Association of Insurance Commissioners (NAIC) Code245: National Association of Insurance Commissioners (NAIC) Code



Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Secondary IdentifierIndustry: Other Payer Secondary Identifier




Notes:Notes:



1. This segment is required when a secondary number is needed to identify the payer.2. Used when it is necessary to identify the ’other’ payer’s claim number in a payer-to-payer COB situation (usecode F8).


Example:Example:REF*FY*465980789~REF*FY*465980789~



REF Other Payer PriorAuthorization or ReferralNumber


Loop:2330B

Elements: 2







Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Prior Authorization or Referral NumberIndustry: Other Payer Prior Authorization or Referral Number



Notes:Notes:1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. Thiselement is primalrily used in payer-to-payer COB situations.2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.

1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. Thiselement is primalrily used in payer-to-payer COB situations.2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.

Example:Example:REF*G1*AB333-Y5~REF*G1*AB333-Y5~



Loop Other Payer PatientInformation


Loop:2330C

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Patient Information O 1 Situational355 REF Other Payer Patient Identification Number O 3 Situational



Notes:Notes:1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identificationnumbers. The patient identification number(s) carried in this iteration of the 2330C loop are those patient ID’swhich belong to non-destination (COB) payers. The patients ID(s) for the destination payer are carried in the2010CA loop NM1 and REF segments.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.

1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identificationnumbers. The patient identification number(s) carried in this iteration of the 2330C loop are those patient ID’swhich belong to non-destination (COB) payers. The patients ID(s) for the destination payer are carried in the2010CA loop NM1 and REF segments.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.

Example:Example:NM1*QC*1******EI*128848726~NM1*QC*1******EI*128848726~



NM1 Other Payer PatientInformation


Loop:2330C

Elements: 4




CodeList Summary (Total Codes: 1312, Included: 1)Code NameQC Patient

Description: Individual receiving medical care






CodeList Summary (Total Codes: 215, Included: 2)Code NameEI Employee Identification NumberMI Member Identification Number




Description: Code identifying a party or other codeIndustry: Other Payer Patient Primary IdentifierIndustry: Other Payer Patient Primary IdentifierAlias: Patient’s Other Payer Primary Identification NumberAlias: Patient’s Other Payer Primary Identification Number


Semantics:



1. NM102 qualifies NM103.







REF Other Payer PatientIdentification Number


Loop:2330C

Elements: 2





If NM108 = MI, this qualifier cannot be used.If NM108 = MI, this qualifier cannot be used.IG Insurance Policy NumberSY Social Security Number

Do not use this code for Medicare.Do not use this code for Medicare.


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Patient Secondary IdentifierIndustry: Other Payer Patient Secondary Identifier



Notes:Notes:1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers forthis claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop.1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers forthis claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop.

Example:Example:REF*AZ*B333-Y5~REF*AZ*B333-Y5~



Loop Other Payer AttendingProvider


Loop:2330D

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Attending Provider O 1 Situational355 REF Other Payer Attending Provider

IdentificationO 3 Required



Notes:Notes:1. Used when it is necessary to send an additional payer-specific provider identification number fornon-destination (COB) payers.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.

1. Used when it is necessary to send an additional payer-specific provider identification number fornon-destination (COB) payers.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.

Example:Example:NM1*71*1~NM1*71*1~



NM1 Other Payer AttendingProvider


Loop:2330D

Elements: 2

















REF Other Payer AttendingProvider Identification


Loop:2330D

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 10)Code Name1A Blue Cross Provider Number1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider Number1G Provider UPIN Number1H CHAMPUS Identification NumberEI Employer's Identification NumberG2 Provider Commercial Number




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Attending Provider IdentifierIndustry: Other Payer Attending Provider Identifier



Notes:Notes:1. Non-destination (COB) payers’ provider identification number(s).1. Non-destination (COB) payers’ provider identification number(s).

Example:Example:REF*N5*RF446~REF*N5*RF446~



Loop Other Payer OperatingProvider


Loop:2330E

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Operating Provider O 1 Situational355 REF Other Payer Operating Provider









NM1 Other Payer OperatingProvider


Loop:2330E

Elements: 2

















REF Other Payer OperatingProvider Identification


Loop:2330E

Elements: 2








Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Operating Provider IdentifierIndustry: Other Payer Operating Provider Identifier






Loop Other Payer Other Provider Pos: 325 Repeat: 1Optional

Loop:2330F

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Other Provider O 1 Situational355 REF Other Payer Other Provider Identification O 3 Required








NM1 Other Payer Other Provider Pos: 325 Max: 1Detail - Optional

Loop:2330F

Elements: 2

















REF Other Payer Other ProviderIdentification


Loop:2330F

Elements: 2









Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Other Provider IdentifierIndustry: Other Payer Other Provider Identifier







Loop Other Payer Service FacilityProvider


Loop:2330H

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Service Facility Provider O 1 Situational355 REF Other Payer Service Facility Provider






Example:Example:NM1*FA*1~NM1*FA*1~



NM1 Other Payer Service FacilityProvider


Loop:2330H

Elements: 2
















REF Other Payer Service FacilityProvider Identification


Loop:2330H

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 7)Code Name1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider NumberEI Employer's Identification NumberG2 Provider Commercial Number




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Service Facility Provider IdentifierIndustry: Other Payer Service Facility Provider Identifier







Loop Service Line Number Pos: 365 Repeat: 999Optional


User Option (Usage): RequiredPurpose: To reference a line number in a transaction set

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage365 LX Service Line Number O 1 Required375 SV2 Institutional Service Line O 1 Required420 PWK Line Supplemental Information O 5 Situational455 DTP Service Line Date O 1 Situational455 DTP Assessment Date O 1 Situational475 AMT Service Tax Amount O 1 Situational475 AMT Facility Tax Amount O 1 Situational492 HCP Line Pricing/Repricing Information O 1 Situational494 Loop 2410 O 25 Situational500 Loop 2420A O 1 Situational500 Loop 2420B O 1 Situational500 Loop 2420C O 1 Situational540 Loop 2430 O 25 Situational

Notes:Notes:1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of aclaim. The LX functions as a line counter.2. The data in the LX is not returned in the 835 (Remittance Advice) transaction. It is used to indicatebundling/unbundling in SVC06.3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of aclaim. The LX functions as a line counter.2. The data in the LX is not returned in the 835 (Remittance Advice) transaction. It is used to indicatebundling/unbundling in SVC06.3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12nomenclature.

Example:Example:LX*1~LX*1~



LX Service Line Number Pos: 365 Max: 1Detail - Optional



Element Summary: Ref Id Element Name Req Type Min/Max UsageLX01 554 Assigned Number M N0 1/6 Required

Description: Number assigned for differentiation within a transaction setThis is the service line number. Begin with 1 and increment by 1 for each new LX segmentwithin a claim.This is the service line number. Begin with 1 and increment by 1 for each new LX segmentwithin a claim.






SV2 Institutional Service Line Pos: 375 Max: 1Detail - Optional


User Option (Usage): RequiredPurpose: To specify the claim service detail for a Health Care institution

Element Summary: Ref Id Element Name Req Type Min/Max UsageSV201 234 Product/Service ID C AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Service Line Revenue CodeIndustry: Service Line Revenue CodeUB-92 Ref. [UB-Name]: 42 [Revenue Code]UB-92 Ref. [UB-Name]: 42 [Revenue Code]EMC v.6.0 Reference: Record Type 50 Field No. 4, 11, 12, 13



EMC v.6.0 Reference: Record Type 50 Field No. 4, 11, 12, 13


Record Type 61 Field No. 4, 14, 15See Code Source 132: National Uniform Billing Committee (NUBC) Codes.See Code Source 132: National Uniform Billing Committee (NUBC) Codes.


SV202 C003 Composite Medical ProcedureIdentifier

C Comp Situational

Description: To identify a medical procedure by its standardized codes and applicablemodifiersAlias: Service Line Procedure CodeAlias: Service Line Procedure CodeUB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]

This data element required for outpatient claims when an appropriate HCPCS exists for theservice line item.This data element required for outpatient claims when an appropriate HCPCS exists for theservice line item.

SV202-01 235 Product/Service ID Qualifier M ID 2/2 Required


The NDC number is used for reporting prescribed drugs and biologics when required bygovernment regulation, or as deemed by the provider to enhance claimreporting/adjudication processes. The NDC number is reported in the LIN segment of LoopID-2410.



(HCPCS) CodesDescription: HCFA coding scheme to group procedure(s) performed on anoutpatient basis for payment to hospital under Medicare; primarily used forambulatory surgical and other diagnostic departmentsBecause the AMA’s CPT codes are also level 1 HCPCS codes, they are reportedunder HC.Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reportedunder HC.


Code Name



IV Home Infusion EDI Coalition (HIEC) Product/Service CodeThis code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code setunder HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.

This code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code setunder HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.

CODE SOURCE:CODE SOURCE:513: Home Infusion EDI Coalition (HIEC) Product/Service Code List513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

ZZ Mutually DefinedUse code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code. This code list is available from:Division of Institutional CareHealth Care Financing Administration S1-03-067500 Security Boulevard Baltimore, MD 21244-1850

Use code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code. This code list is available from:Division of Institutional CareHealth Care Financing Administration S1-03-067500 Security Boulevard Baltimore, MD 21244-1850

SV202-02 234 Product/Service ID M AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Procedure CodeIndustry: Procedure CodeAlias: HCPCS Procedure CodeAlias: HCPCS Procedure CodeUB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]EMC v.6.0 Reference: Record Type 60 Field No. 5, 13, 14


EMC v.6.0 Reference: Record Type 60 Field No. 5, 13, 14


ExternalCodeList Name: 130 Description: Health Care Financing Administration Common Procedural Coding System ExternalCodeList Name: 513 Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List ExternalCodeList Name: SNFR Description: Skilled Nursing Facility Rate Code

SV202-03 1339 Procedure Modifier O AN 2/2 Situational

Description: This identifies special circumstances related to the performance of theservice, as defined by trading partnersAlias: HCPCS Modifier 1Alias: HCPCS Modifier 1UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]EMC v.6.0 Reference: Record Type 60 Field No. 9, 13, 14



Record Type 61 Field No. 10, 14, 15Use this modifier for the first procedure code modifier.This data element is required when the Provider needs to convey additional clarification forthe associated procedure code.

Use this modifier for the first procedure code modifier.This data element is required when the Provider needs to convey additional clarification forthe associated procedure code.




ExternalCodeList Name: 513 Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List





Record Type 61 Field No. 7, 14, 15Use this modifier for the second procedure code modifier.See SV202-3Use this modifier for the second procedure code modifier.See SV202-3

ExternalCodeList Name: 130 Description: Health Care Financing Administration Common Procedural Coding System ExternalCodeList Name: 513 Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List


Description: This identifies special circumstances related to the performance of theservice, as defined by trading partnersAlias: HCPCS Modifier 3Alias: HCPCS Modifier 3UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]

See SV202-3See SV202-3








SV203 782 Monetary Amount O R 1/18 Required

Description: Monetary amountIndustry: Line Item Charge AmountIndustry: Line Item Charge AmountAlias: Service Line Charge AmountAlias: Service Line Charge AmountUB-92 Ref. [UB-Name]: 47 [Total Charges (by Revenue Code Category)]UB-92 Ref. [UB-Name]: 47 [Total Charges (by Revenue Code Category)]EMC v.6.0 Reference: Record Type 50 Field No. 7, 11, 12, 13





Record Type 61 Field No. 10, 14, 15Use this amount to indicate the submitted charge amount.Use this amount to indicate the submitted charge amount.

SV204 355 Unit or Basis for Measurement Code C ID 2/2 Required


CodeList Summary (Total Codes: 794, Included: 3)Code NameDA DaysF2 International Unit

Description: A unit accepted by an international agency; potency of a drug/vitaminbased on a specific weight of that drug/vitaminDosage amount is only used for drug claims when the dosage of the drug isvariable within a single NDC number (e.g. blood factors).Dosage amount is only used for drug claims when the dosage of the drug isvariable within a single NDC number (e.g. blood factors).

UN Unit

SV205 380 Quantity C R 1/15 Required

Description: Numeric value of quantityIndustry: Service Unit CountIndustry: Service Unit CountAlias: Service Line UnitsAlias: Service Line UnitsUB-92 Ref. [UB-Name]: 46 [Units of Service]UB-92 Ref. [UB-Name]: 46 [Units of Service]EMC v.6.0 Reference: Record Type 50 Field No. 6, 11, 12, 13






SV206 1371 Unit Rate O R 1/10 Situational

Description: The rate per unit of associate revenue for hospital accommodationIndustry: Service Line RateIndustry: Service Line RateAlias: Service Line Rate AmountAlias: Service Line Rate AmountUB-92 Ref. [UB-Name]: 44 (“RATES”) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (“RATES”) [HCPCS/Rates/HIPPS Rate Codes]EMC v.6.0 Reference: Record Type 50 Field No. 5, 11, 12, 13EMC v.6.0 Reference: Record Type 50 Field No. 5, 11, 12, 13

This data element is required when the associated revenue code is 100-219.This data element is required when the associated revenue code is 100-219.

SV207 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Line Item Denied Charge or Non-Covered Charge AmountIndustry: Line Item Denied Charge or Non-Covered Charge AmountAlias: Service Line Non-Covered Charge AmountAlias: Service Line Non-Covered Charge Amount




UB-92 Ref. [UB-Name]: 48 [Non-Covered Charges]UB-92 Ref. [UB-Name]: 48 [Non-Covered Charges]EMC v.6.0 Reference: Record Type 50 Field No. 8, 11, 12, 13





Record Type 61 Field No. 11, 14, 15Use this amount if needed to report line specific non-covered charge amount.Use this amount if needed to report line specific non-covered charge amount.

Syntax Rules: 1. R0102 - At least one of SV201 or SV202 is required.2. P0405 - If either SV204 or SV205 is present, then the other is required.

Semantics: 1. SV201 is the revenue code.2. SV203 is a submitted charge amount.3. SV207 is a noncovered charge amount.4. SV208 is the detail service line indicator. A "Y" value indicates a detail service line; an "N" value indicates a

summary service line.

Notes:Notes:1. This segment is required for inpatient claims or outpatient or other claims that require procedure or druginformation to be reported for claim adjudication.1. This segment is required for inpatient claims or outpatient or other claims that require procedure or druginformation to be reported for claim adjudication.

Example:Example:SV2*300*HC:80019*73.42*UN*1~SV2*120**1500*DA*5*300~SV2*300*HC:80019*73.42*UN*1~SV2*120**1500*DA*5*300~



PWK Line SupplementalInformation




















Code Name






Codes AB, AD, AF and AG are not in the ASC X12 004-010 Data Dictionary but areincluded in this guide to provide a standard way to report Home Infusion services untilthese codes are added to a later version of the 837. A Data Maintenance request for thesecodes is in the ASC X12 process. It is recommended that entities who have a need tosubmit or receive Home Infusion Services customize their 004-010 translator map to allowthese exception codes.





AB Previously Submitted to PayerAD Certification Included in this ClaimAF Narrative Segment Included in this ClaimAG No Documentation is RequiredBM By MailEL Electronically OnlyEM E-MailFX By Fax


Description: Code designating the system/method of code structure used for IdentificationCode (67)Required if PWK02 = “BM”, “EL”, “EM” or “FX”Required if PWK02 = “BM”, “EL”, “EM” or “FX”





Required if PWK02 = “BM”, “EL”, “EM” or “FX”Required if PWK02 = “BM”, “EL”, “EM” or “FX”


Comments:



1. PWK05 and PWK06 may be used to identify the addressee by a code number.2. PWK07 may be used to indicate special information to be shown on the specified report.3. PWK08 may be used to indicate action pertaining to a report.

Notes:Notes:1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope unless reportingHome Infusion (see codes AD & AF in PWK02).2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope unless reportingHome Infusion (see codes AD & AF in PWK02).2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

Example:Example:PWK*B2*AA***AC*29438476~PWK*B2*AA***AC*29438476~



DTP Service Line Date Pos: 455 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name472 Service

Use RD8 in DTP02 to indicate begin/end or from/to dates.Use RD8 in DTP02 to indicate begin/end or from/to dates.






Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Service DateIndustry: Service DateUB-92 Ref. [UB-Name]: 45 [Service Date]UB-92 Ref. [UB-Name]: 45 [Service Date]EMC v.6.0 Reference: Record Type 60 Field No. 12, 13, 14





Notes:Notes:1. Required on outpatient claims when revenue, procedure, HIEC or drug codes are reported in the SV2 segment.2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate therange of dates through which the drug will be used by the patient. Use RD8 for this purpose.3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date theprescription was written (or otherwise communicated by the prescriber if not written).4. Assessment Date DTP is not used when this segment is present.

1. Required on outpatient claims when revenue, procedure, HIEC or drug codes are reported in the SV2 segment.2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate therange of dates through which the drug will be used by the patient. Use RD8 for this purpose.3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date theprescription was written (or otherwise communicated by the prescriber if not written).4. Assessment Date DTP is not used when this segment is present.






DTP Assessment Date Pos: 455 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name866 Examination





Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Assessment DateIndustry: Assessment DateUB-92 Ref. [UB-Name]: 45 [Service Date]UB-92 Ref. [UB-Name]: 45 [Service Date]EMC v.6.0 Reference: Record Type 60 Field No. 13EMC v.6.0 Reference: Record Type 60 Field No. 13


Notes:Notes:1. Required when an assessment date is necessary (i.e. Medicare PPS processing).2. Refer to Code Source 132 National Uniform Billing Committee (NUBC) Codes for instructions on the use of thisdate.3. Service date DTP is not used when this segment is present.

1. Required when an assessment date is necessary (i.e. Medicare PPS processing).2. Refer to Code Source 132 National Uniform Billing Committee (NUBC) Codes for instructions on the use of thisdate.3. Service date DTP is not used when this segment is present.

Example:Example:DTP*866*19981210~DTP*866*19981210~



AMT Service Tax Amount Pos: 475 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameGT Goods and Services Tax

Description: Canadian value-added tax


Description: Monetary amountIndustry: Service Tax AmountIndustry: Service Tax Amount

Notes:Notes:1. Required when a service tax/surcharge applies to the service being reported in SV201.1. Required when a service tax/surcharge applies to the service being reported in SV201.

Example:Example:AMT*GT*15~AMT*GT*15~



AMT Facility Tax Amount Pos: 475 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameN8 Miscellaneous Taxes


Description: Monetary amountIndustry: Facility Tax AmountIndustry: Facility Tax Amount


Example:Example:AMT*N8*22~AMT*N8*22~



HCP Line Pricing/RepricingInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageHCP01 1473 Pricing Methodology X ID 2/2 Situational

Description: Code specifying pricing methodology at which the claim or line item has beenpriced or repricedAlias: Pricing/Repricing MethodologyAlias: Pricing/Repricing Methodology

Trading partners need to agree on which codes to use in this data element. There do notappear to be standard definitions for the code elements.Trading partners need to agree on which codes to use in this data element. There do notappear to be standard definitions for the code elements.



Description: Monetary amountIndustry: Repriced Allowed AmountIndustry: Repriced Allowed AmountAlias: Pricing/Repricing Allowed AmountAlias: Pricing/Repricing Allowed Amount


Description: Monetary amountIndustry: Repriced Saving AmountIndustry: Repriced Saving AmountAlias: Pricing/Repricing Saving AmountAlias: Pricing/Repricing Saving Amount







specified by the Reference Identification QualifierIndustry: Repriced Organizational IdentifierIndustry: Repriced Organizational IdentifierAlias: Pricing/Repricing Organizational IdentifierAlias: Pricing/Repricing Organizational Identifier



Description: Rate expressed in the standard monetary denomination for the currencyspecifiedIndustry: Repricing Per Diem or Flat Rate AmountIndustry: Repricing Per Diem or Flat Rate AmountAlias: Pricing/Repricing RateAlias: Pricing/Repricing Rate



Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Repriced Approved Ambulatory Patient Group CodeIndustry: Repriced Approved Ambulatory Patient Group CodeAlias: Approved APG Code, PricingAlias: Approved APG Code, Pricing



Description: Monetary amountIndustry: Repriced Approved Ambulatory Patient Group AmountIndustry: Repriced Approved Ambulatory Patient Group AmountAlias: Approved APG Amount, PricingAlias: Approved APG Amount, Pricing

This data element is required when it is necessary to reort Approved DRG Amount onclaims which has been priced or repriced.This data element is required when it is necessary to reort Approved DRG Amount onclaims which has been priced or repriced.




HCP09 235 Product/Service ID Qualifier X ID 2/2 Situational

Description: Code identifying the type/source of the descriptive number used inProduct/Service ID (234)Required when HCP10 exists.Required when HCP10 exists.




Code Name



HCP10 234 Product/Service ID X AN 1/48 Situational

Description: Identifying number for a product or serviceIndustry: Procedure CodeIndustry: Procedure CodeAlias: Pricing/Repricing Approved Procedure CodeAlias: Pricing/Repricing Approved Procedure Code

This data element is required when it is necessary to reort Approved HCPCS Code onclaims which has been priced or repriced.This data element is required when it is necessary to reort Approved HCPCS Code onclaims which has been priced or repriced.


HCP11 355 Unit or Basis for Measurement Code X ID 2/2 Situational



HCP12 380 Quantity X R 1/15 Situational

Description: Numeric value of quantityIndustry: Repricing Approved Service Unit CountIndustry: Repricing Approved Service Unit CountAlias: Pricing/Repricing Approved Units or Inpatient DaysAlias: Pricing/Repricing Approved Units or Inpatient Days


HCP13 901 Reject Reason Code X ID 2/2 Situational

Description: Code assigned by issuer to identify reason for rejectionAlias: Reject Reason CodeAlias: Reject Reason Code




Description: Code specifying policy complianceThis data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.






Description: Code specifying the exception reason for consideration of out-of-networkhealth care servicesThis data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.This data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.






submitted values.

Notes:Notes:1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BBloop.1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BBloop.






Loop Drug Identification Pos: 494 Repeat: 25Optional


User Option (Usage): SituationalPurpose: To specify basic item identification data

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage494 LIN Drug Identification O 1 Situational495 CTP Drug Pricing O 1 Situational496 REF Prescription Number O 1 Situational

Notes:Notes:1. The NDC number is used for reporting prescribed drugs and biologics when required by government regulation,or as deemed by the provider to enhance claim reporting/adjudication processes. The NDC number is reported inthe LIN segment of Loop ID-2410.2. Use Loop ID 2410 to specify billing/reporting for drugs provided that may be part of the service(s) described inSV2.

1. The NDC number is used for reporting prescribed drugs and biologics when required by government regulation,or as deemed by the provider to enhance claim reporting/adjudication processes. The NDC number is reported inthe LIN segment of Loop ID-2410.2. Use Loop ID 2410 to specify billing/reporting for drugs provided that may be part of the service(s) described inSV2.

Example:Example:LIN*N4*12345123412~LIN*N4*12345123412~



LIN Drug Identification Pos: 494 Max: 1Detail - Optional



Element Summary: Ref Id Element Name Req Type Min/Max UsageLIN02 235 Product/Service ID Qualifier M ID 2/2 Required

Description: Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

CodeList Summary (Total Codes: 477, Included: 1)Code NameN4 National Drug Code in 5-4-2 Format

Description: 5-digit manufacturer ID, 4-digit product ID, 2-digit trade package sizeCODE SOURCE:CODE SOURCE:240: National Drug Code by Format240: National Drug Code by Format

LIN03 234 Product/Service ID M AN 1/48 Required

Description: Identifying number for a product or serviceAlias: National Drug CodeAlias: National Drug Code

ExternalCodeList Name: 240 Description: National Drug Code by Format

Syntax Rules: 1. P0405 - If either LIN04 or LIN05 is present, then the other is required.2. P0607 - If either LIN06 or LIN07 is present, then the other is required.3. P0809 - If either LIN08 or LIN09 is present, then the other is required.4. P1011 - If either LIN10 or LIN11 is present, then the other is required.5. P1213 - If either LIN12 or LIN13 is present, then the other is required.6. P1415 - If either LIN14 or LIN15 is present, then the other is required.7. P1617 - If either LIN16 or LIN17 is present, then the other is required.8. P1819 - If either LIN18 or LIN19 is present, then the other is required.9. P2021 - If either LIN20 or LIN21 is present, then the other is required.

10. P2223 - If either LIN22 or LIN23 is present, then the other is required.11. P2425 - If either LIN24 or LIN25 is present, then the other is required.12. P2627 - If either LIN26 or LIN27 is present, then the other is required.13. P2829 - If either LIN28 or LIN29 is present, then the other is required.14. P3031 - If either LIN30 or LIN31 is present, then the other is required.

Semantics: 1. LIN01 is the line item identification

Comments: 1. See the Data Dictionary for a complete list of IDs.



2. LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color,Drawing No., U.P.C. No., ISBN No., Model No., or SKU.






CTP Drug Pricing Pos: 495 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To specify pricing information

Element Summary: Ref Id Element Name Req Type Min/Max UsageCTP03 212 Unit Price X R 1/17 Required

Description: Price per unit of product, service, commodity, etc.Alias: Drug Unit PriceAlias: Drug Unit Price

CTP04 380 Quantity X R 1/15 Required

Description: Numeric value of quantityAlias: National Drug Unit CountAlias: National Drug Unit Count

CTP05 C001 Composite Unit of Measure O Comp Required

Description: To identify a composite unit of measure(See Figures Appendix for examplesof use)Alias: Unit/Basis of MeasurementAlias: Unit/Basis of Measurement

CTP05-01 355 Unit or Basis for Measurement Code M ID 2/2 Required


CodeList Summary (Total Codes: 794, Included: 4)Code NameF2 International Unit

Description: A unit accepted by an international agency; potency of a drug/vitaminbased on a specific weight of that drug/vitamin

GR GramML MilliliterUN Unit

Syntax Rules: 1. P0405 - If either CTP04 or CTP05 is present, then the other is required.2. C0607 - If CTP06 is present, then CTP07 is required.3. C0902 - If CTP09 is present, then CTP02 is required.4. C1002 - If CTP10 is present, then CTP02 is required.5. C1103 - If CTP11 is present, then CTP03 is required.

Semantics: 1. CTP07 is a multiplier factor to arrive at a final discounted price. A multiplier of .90 would be the factor if a 10%

discount is given.2. CTP08 is the rebate amount.

Comments: 1. See Figures Appendix for an example detailing the use of CTP03 and CTP04.2. See Figures Appendix for an example detailing the use of CTP03, CTP04 and CTP07.



Notes:Notes:1. Required when it is necessary to provide a price specific to the NDC provided in LIN03 that is different than theprice reported in SV203.1. Required when it is necessary to provide a price specific to the NDC provided in LIN03 that is different than theprice reported in SV203.

Example:Example:CTP***1.15*2*UN~CTP***1.15*2*UN~



REF Prescription Number Pos: 496 Max: 1Detail - Optional




Description: Code qualifying the Reference IdentificationAlias: Code QualifierAlias: Code Qualifier

CodeList Summary (Total Codes: 1503, Included: 1)Code NameXZ Pharmacy Prescription Number

REF02 127 Reference Identification X AN 1/30 Required

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierAlias: Prescription NumberAlias: Prescription Number



Notes:Notes:1. Required if dispense of the drug has been done with an assigned Rx number.2. In cases where a compound drug is being billed, the components of the compound will all have the sameprescription number. Payers receiving the claim can relate all the components by matching the prescriptionnumber.

1. Required if dispense of the drug has been done with an assigned Rx number.2. In cases where a compound drug is being billed, the components of the compound will all have the sameprescription number. Payers receiving the claim can relate all the components by matching the prescriptionnumber.

Example:Example:REF*XZ*123456~REF*XZ*123456~




Loop:2420A

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage500 NM1 Attending Physician Name O 1 Situational525 REF Attending Physician Secondary




Notes:Notes:1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. Required when line level provider information is known to impact adjudication.

1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. Required when line level provider information is known to impact adjudication.

Example:Example:NM1*71*1*JONES*JOHN***SR.*24*123456789~NM1*71*1*JONES*JOHN***SR.*24*123456789~




Loop:2420A

Elements: 8



Description: Code identifying an organizational entity, a physical location, property or anindividualThe identifier in NM101 applies to all segments in this iteration of Loop ID-2420.The identifier in NM101 applies to all segments in this iteration of Loop ID-2420.







Description: Individual last name or organizational nameIndustry: Attending Physician Last NameIndustry: Attending Physician Last Name

Attending Provider Last NameAttending Provider Last Name


Description: Individual first nameIndustry: Attending Physician First NameIndustry: Attending Physician First Name






Description: Suffix to individual nameIndustry: Attending Physician Name SuffixIndustry: Attending Physician Name SuffixAlias: Attending Provider GenerationAlias: Attending Provider Generation










Description: Code identifying a party or other codeIndustry: Attending Physician Primary IdentifierIndustry: Attending Physician Primary Identifier

Attending Provider Primary IdentifierAttending Provider Primary Identifier












Loop:2420A

Elements: 2













Notes:Notes:1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109 in this loop.1. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109 in this loop.

Example:Example:



REF*1D*AC12345H~REF*1D*AC12345H~




Loop:2420B

Elements: N/A








Example:Example:NM1*72*1*MEYERS*JANE*I***34*129847263~NM1*72*1*MEYERS*JANE*I***34*129847263~




Loop:2420B

Elements: 8










Description: Individual last name or organizational nameIndustry: Operating Physician Last NameIndustry: Operating Physician Last Name


Description: Individual first nameIndustry: Operating Physician First NameIndustry: Operating Physician First Name



Required when the middle name/initial of the person is known.Required when the middle name/initial of the person is known.


Description: Suffix to individual nameIndustry: Operating Physician Name SuffixIndustry: Operating Physician Name SuffixAlias: Operating Physician GenerationAlias: Operating Physician Generation







Code Name24 Employer's Identification Number34 Social Security Number

Social Security Number cannot be used for Medicare claims.Social Security Number cannot be used for Medicare claims.XX Health Care Financing Administration National Provider Identifier



Description: Code identifying a party or other codeIndustry: Operating Physician Primary IdentifierIndustry: Operating Physician Primary IdentifierAlias: Operating Physician Primary Identifier.Alias: Operating Physician Primary Identifier.












Loop:2420B

Elements: 2














Example:Example:







Loop:2420C

Elements: N/A





Notes:Notes:1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. Required when line level provider information is known to impact adjudication.3. Required when the claim/encounter involves an other provider such as, but not limited to: Referring Provider,Ordering Provider, Assisting Provider, etc.

1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.2. Required when line level provider information is known to impact adjudication.3. Required when the claim/encounter involves an other provider such as, but not limited to: Referring Provider,Ordering Provider, Assisting Provider, etc.





Loop:2420C

Elements: 8










Description: Individual last name or organizational nameIndustry: Other Physician Last NameIndustry: Other Physician Last NameAlias: Other Provider Last NameAlias: Other Provider Last Name


Description: Individual first nameIndustry: Other Physician First NameIndustry: Other Physician First Name






Description: Suffix to individual nameIndustry: Other Provider Name SuffixIndustry: Other Provider Name SuffixAlias: Other Provider GenerationAlias: Other Provider Generation








Social Security Number cannot be used forMedicare claims.Social Security Number cannot be used forMedicare claims.

XX Health Care Financing Administration National Provider IdentifierDescription: Required value if the National Provider ID is mandated for use.Otherwise, one of the other listed codes may be used.


Description: Code identifying a party or other codeIndustry: Other Provider IdentifierIndustry: Other Provider IdentifierAlias: Other Provider Primary IdentifierAlias: Other Provider Primary Identifier












Loop:2420C

Elements: 2













Notes:Notes:1. Use this REF segment only if a second number is necessary to identify the provider. The primary identificationnumber should be contained in NM109.2. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.

1. Use this REF segment only if a second number is necessary to identify the provider. The primary identificationnumber should be contained in NM109.2. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.






Loop Service Line AdjudicationInformation



User Option (Usage): SituationalPurpose: To convey service line adjudication information for coordination of benefits between the initial payers of ahealth care claim and all subsequent payers

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage540 SVD Service Line Adjudication Information O 1 Situational545 CAS Service Line Adjustment O 99 Situational550 DTP Service Adjudication Date O 1 Situational

Semantics: 1. SVD01 is the payer identification code.2. SVD02 is the amount paid for this service line.3. SVD04 is the revenue code.4. SVD05 is the paid units of service.

Comments: 1. SVD03 represents the medical procedure code upon which adjudication of this service line was based. This

may be different than the submitted medical procedure code.2. SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into

which this service line was bundled.

Notes:Notes:1. Required if claim has been previously adjudicated by payer identified in Loop 2330B and service line hasadjustments applied to it.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. To show unbundled lines: if in the original claim, line 3 is unbundled into lines numbers 8 and 9, then in thesecondary claim, LX08 would show 3 in SVD06 and LX09 would also show 3 in SVD06. This indicates that line 3was unbundled into lines 8 and 9.4. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for examples) 2 additional lines, thenthe SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for theadditional unbundled lines. If a line item control number (REF01 = 6R) exists for the line, that number may beused in SVD06 instead of the LX number when a line is unbundled.

1. Required if claim has been previously adjudicated by payer identified in Loop 2330B and service line hasadjustments applied to it.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. To show unbundled lines: if in the original claim, line 3 is unbundled into lines numbers 8 and 9, then in thesecondary claim, LX08 would show 3 in SVD06 and LX09 would also show 3 in SVD06. This indicates that line 3was unbundled into lines 8 and 9.4. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for examples) 2 additional lines, thenthe SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for theadditional unbundled lines. If a line item control number (REF01 = 6R) exists for the line, that number may beused in SVD06 instead of the LX number when a line is unbundled.

Example:Example:SVD*NR002*50.5**0305*1~SVD*NR002*50.5**0305*1~



SVD Service Line AdjudicationInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageSVD01 67 Identification Code M AN 2/80 Required

Description: Code identifying a party or other codeIndustry: Payer IdentifierIndustry: Payer IdentifierEMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (This must match one of thecorresponding loops: 2010BC - Payer Name, or 2330B - Other Payer Name.)EMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (This must match one of thecorresponding loops: 2010BC - Payer Name, or 2330B - Other Payer Name.)

SVD02 782 Monetary Amount M R 1/18 Required

Description: Monetary amountIndustry: Service Line Paid AmountIndustry: Service Line Paid AmountAlias: Service Line Amount PaidAlias: Service Line Amount Paid

SVD03 C003 Composite Medical ProcedureIdentifier

O Comp Situational

Description: To identify a medical procedure by its standardized codes and applicablemodifiersRequired when returned on an 835 payment for this claim or when needed to identify theservice line adjudicated.Required when returned on an 835 payment for this claim or when needed to identify theservice line adjudicated.

SVD03-01 235 Product/Service ID Qualifier M ID 2/2 Required







IV Home Infusion EDI Coalition (HIEC) Product/Service CodeThis code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code set This code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code set


Code Name


under HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.under HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.


ZZ Mutually DefinedUse code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code.Use code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code.

SVD03-02 234 Product/Service ID M AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Procedure CodeIndustry: Procedure Code

This code list is available from:Division of Institutional Care Health Care Financing Administration S1-03-06 7500 SecurityBoulevard Baltimore, MD 21244-1850



SVD03-03 1339 Procedure Modifier O AN 2/2 Situational

Description: This identifies special circumstances related to the performance of theservice, as defined by trading partnersRequired when a modifier clarifies/improves the reporting accuracy of the associatedprocedure code.Required when a modifier clarifies/improves the reporting accuracy of the associatedprocedure code.




ExternalCodeList Name: 130 Description: Health Care Financing Administration Common Procedural Coding System ExternalCodeList Name: 513



Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List







SVD03-07 352 Description O AN 1/80 Situational

Description: A free-form description to clarify the related data elements and their contentIndustry: Procedure Code DescriptionIndustry: Procedure Code Description

Required if SVC01-7 was returned in the 835 transaction.Required if SVC01-7 was returned in the 835 transaction.

SVD04 234 Product/Service ID O AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Service Line Revenue CodeIndustry: Service Line Revenue CodeEMC v.6.0 Reference: Record Type 52 Field No. 5







SVD05 380 Quantity O R 1/15 Required

Description: Numeric value of quantityIndustry: Adjustment QuantityIndustry: Adjustment QuantityAlias: Paid Units of ServiceAlias: Paid Units of Service

Crosswalk from SVC05 in 835 or, if not present in 835, use original billed units.Crosswalk from SVC05 in 835 or, if not present in 835, use original billed units.




SVD06 554 Assigned Number O N0 1/6 Situational

Description: Number assigned for differentiation within a transaction setIndustry: Bundled or Unbundled Line NumberIndustry: Bundled or Unbundled Line Number

Use the LX from this transaction which points to the bundled/unbundled line.Required if payer bundled/unbundled this service line.Use the LX from this transaction which points to the bundled/unbundled line.Required if payer bundled/unbundled this service line.










CAS Service Line Adjustment Pos: 545 Max: 99Detail - Optional




Description: Code identifying the general category of payment adjustmentEMC v.6.0 Reference: Record Type 52 Field No. 6






Description: Code identifying the detailed reason the adjustment was madeIndustry: Adjustment Reason CodeIndustry: Adjustment Reason CodeEMC v.6.0 Reference: Record Type 52 Field No. 7






Description: Monetary amountIndustry: Adjustment AmountIndustry: Adjustment AmountEMC v.6.0 Reference: Record Type 52 Field No. 8



Record Type 63 Field No. 8Use this amount for the amount of adjustment.Use this amount for the charges applied to the preceding reason code.Use this amount for the amount of adjustment.Use this amount for the charges applied to the preceding reason code.


Description: Numeric value of quantityIndustry: Adjustment QuantityIndustry: Adjustment QuantityEMC v.6.0 Reference: Record Type 52 Field No. 9







Use this value for the quantity applied to the preceding reason code.Use this value for the quantity applied to the preceding reason code.





Record Type 63 Field No. 10See CAS02See CAS02






Record Type 63 Field No. 11Use this amount for the charges applied to the preceding reason code.See CAS03Use this amount for the charges applied to the preceding reason code.See CAS03





Record Type 63 Field No. 12Use this value for the quantity applied to the preceding reason code.See CAS04Use this value for the quantity applied to the preceding reason code.See CAS04















Use this amount for the charges applied to the preceding reason code.See CAS03Use this amount for the charges applied to the preceding reason code.See CAS03

































































Notes:Notes:1. Inpatient or Outpatient - Service Line Adjustments2. Submitters should use this CAS segment to report line level adjustments from prior payments which cause theamount paid to differ from the amount originally charged.3. The Claim Adjustment Reason codes are located on the Washington Publishing Company web sitehttp://www.wpc-edi.com.4. Required when the prior payment had service line adjustments reported on a remittance.

1. Inpatient or Outpatient - Service Line Adjustments2. Submitters should use this CAS segment to report line level adjustments from prior payments which cause theamount paid to differ from the amount originally charged.3. The Claim Adjustment Reason codes are located on the Washington Publishing Company web sitehttp://www.wpc-edi.com.4. Required when the prior payment had service line adjustments reported on a remittance.

Example:Example:CAS*CO*A1*25~CAS*CO*A1*25~



DTP Service Adjudication Date Pos: 550 Max: 1Detail - Optional










Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Service Adjudication or Payment DateIndustry: Service Adjudication or Payment Date


Notes:Notes:1. This segment is required when Service line adjudication has been performed.1. This segment is required when Service line adjudication has been performed.




Loop Patient Hierarchical Level Pos: 001 Repeat: >1Optional

Loop:2000C

Elements: N/A

User Option (Usage): SituationalPurpose: To identify dependencies among and the content of hierarchically related groups of data segments

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage001 HL Patient Hierarchical Level O 1 Situational007 PAT Patient Information O 1 Required015 Loop 2010CA O 1 Required130 Loop 2300 O 100 Required







Notes:Notes:1. This HL is required when the patient is a different person than the subscriber. There are no HL’s subordinate tothe Patient HL.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Patient Hierarchical Level loops, there is an implied maximum of 5000.

1. This HL is required when the patient is a different person than the subscriber. There are no HL’s subordinate tothe Patient HL.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Patient Hierarchical Level loops, there is an implied maximum of 5000.




HL Patient Hierarchical Level Pos: 001 Max: 1Detail - Optional

Loop:2000C

Elements: 4

User Option (Usage): SituationalPurpose: To identify dependencies among and the content of hierarchically related groups of data segments


Description: A unique number assigned by the sender to identify a particular datasegment in a hierarchical structure

HL02 734 Hierarchical Parent ID Number O AN 1/12 Required

Description: Identification number of the next higher hierarchical data segment that thedata segment being described is subordinate to



CodeList Summary (Total Codes: 170, Included: 1)Code Name23 Dependent

Description: Identifies the individual who is affiliated with the subscriber, such asspouse, child, etc., and therefore may be entitled to benefits


Description: Code indicating if there are hierarchical child data segments subordinate tothe level being describedThe claim loop (Loop ID-2300) can be used only when HL04 has no subordinate levels(HL04 = 0).The claim loop (Loop ID-2300) can be used only when HL04 has no subordinate levels(HL04 = 0).

CodeList Summary (Total Codes: 2, Included: 1)Code Name0 No Subordinate HL Segment in This Hierarchical Structure.









Notes:Notes:1. This HL is required when the patient is a different person than the subscriber. There are no HL’s subordinate tothe Patient HL.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Patient Hierarchical Level loops, there is an implied maximum of 5000.

1. This HL is required when the patient is a different person than the subscriber. There are no HL’s subordinate tothe Patient HL.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.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. While the implementation guide sets no specific limit tothe number of Patient Hierarchical Level loops, there is an implied maximum of 5000.




PAT Patient Information Pos: 007 Max: 1Detail - Optional

Loop:2000C

Elements: 1

User Option (Usage): RequiredPurpose: To supply patient information

Element Summary: Ref Id Element Name Req Type Min/Max UsagePAT01 1069 Individual Relationship Code O ID 2/2 Required

Description: Code indicating the relationship between two individuals or entitiesAlias: Patients Relationship to InsuredAlias: Patients Relationship to InsuredUB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]UB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)








15 WardWard of the Court. This code indicates that the patient is a ward of the insured asa result of a court order.Ward of the Court. This code indicates that the patient is a ward of the insured asa result of a court order.

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 07 [Ward of the Court]59 Code 07 [Ward of the Court]




Code Name



21 UnknownUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 09 [Unknown]59 Code 09 [Unknown]

22 Handicapped DependentUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 10 [Handicapped Dependent]59 Code 10 [Handicapped Dependent]











Code Name



Syntax Rules: 1. P0506 - If either PAT05 or PAT06 is present, then the other is required.2. P0708 - If either PAT07 or PAT08 is present, then the other is required.

Semantics: 1. PAT06 is the date of death.2. PAT08 is the patient's weight.3. PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant;

code "N" indicates the patient is not pregnant.

Example:Example:PAT*19******01*145~PAT*19******01*145~



Loop Patient Name Pos: 015 Repeat: 1Optional

Loop:2010CA

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage015 NM1 Patient Name O 1 Required025 N3 Patient Address O 1 Required030 N4 Patient City/State/ZIP Code O 1 Required032 DMG Patient Demographic Information O 1 Required035 REF Patient Secondary Identification Number O 5 Situational035 REF Property and Casualty Claim Number O 1 Situational



Example:Example:NM1*QC*1*DOE*SALLY****34*123456789~NM1*QC*1*DOE*SALLY****34*123456789~



NM1 Patient Name Pos: 015 Max: 1Detail - Optional

Loop:2010CA

Elements: 8










Description: Individual last name or organizational nameIndustry: Patient Last NameIndustry: Patient Last NameUB-92 Ref. [UB-Name]: 12 [Patient Name]UB-92 Ref. [UB-Name]: 12 [Patient Name]EMC v.6.0 Reference: Record Type 20 Field No. 4EMC v.6.0 Reference: Record Type 20 Field No. 4


Description: Individual first nameIndustry: Patient First NameIndustry: Patient First NameUB-92 Ref. [UB-Name]: 12 [Patient Name]UB-92 Ref. [UB-Name]: 12 [Patient Name]EMC v.6.0 Reference: Record Type 20 Field No. 5EMC v.6.0 Reference: Record Type 20 Field No. 5


Description: Individual middle name or initialIndustry: Patient Middle NameIndustry: Patient Middle NameUB-92 Ref. [UB-Name]: 12 [Patient Name]UB-92 Ref. [UB-Name]: 12 [Patient Name]EMC v.6.0 Reference: Record Type 20 Field No. 6EMC v.6.0 Reference: Record Type 20 Field No. 6



Description: Suffix to individual nameIndustry: Patient Name SuffixIndustry: Patient Name Suffix




Alias: Patient’s GenerationAlias: Patient’s Generation



Description: Code designating the system/method of code structure used for IdentificationCode (67)This data element is required when the Patient’s Identifier is different from the Subscriber’sIdentifier.This data element is required when the Patient’s Identifier is different from the Subscriber’sIdentifier.




ZZ Mutually DefinedThe value ‘ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.

The value ‘ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.


Description: Code identifying a party or other codeIndustry: Patient Primary IdentifierIndustry: Patient Primary IdentifierUB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]UB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]EMC v.6.0 Reference: Record Type 30 Field No. 7EMC v.6.0 Reference: Record Type 30 Field No. 7

This data element is required when the Patients ID is different from the Subscribers ID.This data element is required when the Patients ID is different from the Subscribers ID.




Example:Example:NM1*QC*1*DOE*SALLY****34*123456789~NM1*QC*1*DOE*SALLY****34*123456789~



N3 Patient Address Pos: 025 Max: 1Detail - Optional

Loop:2010CA

Elements: 2



Description: Address informationIndustry: Patient Address LineIndustry: Patient Address LineUB-92 Ref. [UB-Name]: 13 [Patient Address]UB-92 Ref. [UB-Name]: 13 [Patient Address]EMC v.6.0 Reference: Record Type 20 Field No. 12EMC v.6.0 Reference: Record Type 20 Field No. 12


Description: Address informationIndustry: Patient Address LineIndustry: Patient Address LineUB-92 Ref. [UB-Name]: 13 [Patient Address]UB-92 Ref. [UB-Name]: 13 [Patient Address]EMC v.6.0 Reference: Record Type 20 Field No. 13EMC v.6.0 Reference: Record Type 20 Field No. 13


Example:Example:N3*RFD 10*100 COUNTRY LANE~N3*RFD 10*100 COUNTRY LANE~



N4 Patient City/State/ZIP Code Pos: 030 Max: 1Detail - Optional

Loop:2010CA

Elements: 4



Description: Free-form text for city nameIndustry: Patient City NameIndustry: Patient City NameUB-92 Ref. [UB-Name]: 13 [Patient Address]UB-92 Ref. [UB-Name]: 13 [Patient Address]EMC v.6.0 Reference: Record Type 20 Field No. 14EMC v.6.0 Reference: Record Type 20 Field No. 14


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Patient State CodeIndustry: Patient State CodeUB-92 Ref. [UB-Name]: 13 [Patient Address]UB-92 Ref. [UB-Name]: 13 [Patient Address]EMC v.6.0 Reference: Record Type 20 Field No. 15EMC v.6.0 Reference: Record Type 20 Field No. 15



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Patient Postal Zone or ZIP CodeIndustry: Patient Postal Zone or ZIP CodeUB-92 Ref. [UB-Name]: 13 [Patient Address]UB-92 Ref. [UB-Name]: 13 [Patient Address]EMC v.6.0 Reference: Record Type 20 Field No. 16EMC v.6.0 Reference: Record Type 20 Field No. 16



Description: Code identifying the countryThis data element is required when the address is outside of the U.S.This data element is required when the address is outside of the U.S.



Comments:



1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.2. N402 is required only if city name (N401) is in the U.S. or Canada.

Example:Example:N4*CORNFIELD TOWNSHIP*IA*99999~N4*CORNFIELD TOWNSHIP*IA*99999~



DMG Patient DemographicInformation


Loop:2010CA

Elements: 3

User Option (Usage): RequiredPurpose: To supply demographic information





Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Patient Birth DateIndustry: Patient Birth DateAlias: Patient’s Date of BirthAlias: Patient’s Date of BirthUB-92 Ref. [UB-Name]: 14 [Patient Birthdate]UB-92 Ref. [UB-Name]: 14 [Patient Birthdate]EMC v.6.0 Reference: Record Type 20 Field No. 8 (MMDDCCYY)EMC v.6.0 Reference: Record Type 20 Field No. 8 (MMDDCCYY)


Description: Code indicating the sex of the individualIndustry: Patient Gender CodeIndustry: Patient Gender CodeUB-92 Ref. [UB-Name]: 15 [Patient Sex]UB-92 Ref. [UB-Name]: 15 [Patient Sex]EMC v.6.0 Reference: Record Type 20 Field No. 7EMC v.6.0 Reference: Record Type 20 Field No. 7




Example:Example:DMG*D8*19530101*F~DMG*D8*19530101*F~



REF Patient SecondaryIdentification Number


Loop:2010CA

Elements: 2











Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Patient Secondary IdentifierIndustry: Patient Secondary Identifier



Notes:Notes:1. This segment is required when an additional identification number is needed.1. This segment is required when an additional identification number is needed.

Example:Example:REF*A6*030385074~REF*A6*030385074~



REF Property and Casualty ClaimNumber


Loop:2010CA

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 1)Code NameY4 Agency Claim Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Property Casualty Claim NumberIndustry: Property Casualty Claim Number



Notes:Notes:1. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims.Providers receive this number from the property and casualty payer during eligibility determinations or some othercommunication with that payer. See Section 4.2, Property and Casualty, for additional information about propertyand casualty claims.2. In the case where the patient is the same person as the subscriber, the property and casualty claim number isplaced in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number isplaced in Loop ID-2010CA. This number should be transmitted in only one place.

1. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims.Providers receive this number from the property and casualty payer during eligibility determinations or some othercommunication with that payer. See Section 4.2, Property and Casualty, for additional information about propertyand casualty claims.2. In the case where the patient is the same person as the subscriber, the property and casualty claim number isplaced in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number isplaced in Loop ID-2010CA. This number should be transmitted in only one place.

Example:Example:REF*Y4*4445555~REF*Y4*4445555~



Loop Claim information Pos: 130 Repeat: 100Optional



Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage130 CLM Claim information O 1 Required135 DTP Discharge Hour O 1 Situational135 DTP Statement Dates O 1 Required135 DTP Admission Date/Hour O 1 Situational140 CL1 Institutional Claim Code O 1 Situational155 PWK Claim Supplemental Information O 10 Situational160 CN1 Contract Information O 1 Situational175 AMT Payer Estimated Amount Due O 1 Situational175 AMT Patient Estimated Amount Due O 1 Situational175 AMT Patient Paid Amount O 1 Situational175 AMT Credit/Debit Card Maximum Amount O 1 Situational180 REF Adjusted Repriced Claim Number O 1 Situational180 REF Repriced Claim Number O 1 Situational180 REF Claim Identification Number For

Clearinghouses and Other TransmissionIntermediaries

O 1 Situational

180 REF Document Identification Code O 2 Situational180 REF Original Reference Number (ICN/DCN) O 1 Situational180 REF Investigational Device Exemption Number O 1 Situational180 REF Service Authorization Exception Code O 1 Situational180 REF Peer Review Organization (PRO) Approval

NumberO 1 Situational

180 REF Prior Authorization or Referral Number O 2 Situational180 REF Medical Record Number O 1 Situational180 REF Demonstration Project Identifier O 1 Situational185 K3 File Information O 10 Situational190 NTE Claim Note O 10 Situational190 NTE Billing Note O 1 Situational216 CR6 Home Health Care Information O 1 Situational220 CRC Home Health Functional Limitations O 3 Situational220 CRC Home Health Activities Permitted O 3 Situational220 CRC Home Health Mental Status O 2 Situational231 HI Principal, Admitting, E-Code and Patient

Reason For Visit Diagnosis InformationO 1 Situational

231 HI Diagnosis Related Group (DRG)Information

O 1 Situational

231 HI Other Diagnosis Information O 2 Situational231 HI Principal Procedure Information O 1 Situational231 HI Other Procedure Information O 2 Situational231 HI Occurrence Span Information O 2 Situational


Pos Id Segment Name Req Max Use Repeat Usage


231 HI Occurrence Information O 2 Situational231 HI Value Information O 2 Situational231 HI Condition Information O 2 Situational231 HI Treatment Code Information O 2 Situational240 QTY Claim Quantity O 4 Situational241 HCP Claim Pricing/Repricing Information O 1 Situational242 Loop 2305 O 6 Situational250 Loop 2310A O 1 Situational250 Loop 2310B O 1 Situational250 Loop 2310C O 1 Situational250 Loop 2310E O 1 Situational290 Loop 2320 O 10 Situational365 Loop 2400 O 999 Required







Notes:Notes:1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is thesubscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.

1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is thesubscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.




CLM Claim information Pos: 130 Max: 1Detail - Optional



Element Summary: Ref Id Element Name Req Type Min/Max UsageCLM01 1028 Claim Submitter's Identifier M AN 1/38 Required

Description: Identifier used to track a claim from creation by the health care providerthrough paymentIndustry: Patient Account NumberIndustry: Patient Account NumberAlias: Patient Control NumberAlias: Patient Control NumberUB-92 Ref. [UB-Name]: 3 [Patient Control Number]UB-92 Ref. [UB-Name]: 3 [Patient Control Number]EMC v.6.0 Reference: Record Type 20 Field No. 3EMC v.6.0 Reference: Record Type 20 Field No. 3



CLM02 782 Monetary Amount O R 1/18 Required

Description: Monetary amountIndustry: Total Claim Charge AmountIndustry: Total Claim Charge AmountAlias: Total Claim ChargesAlias: Total Claim ChargesUB-92 Ref. [UB-Name]: 47 (Revenue Code 001) This amount is the total of the SV2segments, with the exception of Revenue Code 001. [Total Charges (by Revenue CodeCategory)]

UB-92 Ref. [UB-Name]: 47 (Revenue Code 001) This amount is the total of the SV2segments, with the exception of Revenue Code 001. [Total Charges (by Revenue CodeCategory)]EMC v.6.0 Reference: Record Type 90 Field No. 13 (Total of Field No. 13 and Field No.15. This amount is the total of the SV2 segments, with the exception of Revenue Code001.)

EMC v.6.0 Reference: Record Type 90 Field No. 13 (Total of Field No. 13 and Field No.15. This amount is the total of the SV2 segments, with the exception of Revenue Code001.)Use this element to indicate the total amount of all submitted charges of service segmentsfor this claim.Zero may be a valid amount.

Use this element to indicate the total amount of all submitted charges of service segmentsfor this claim.Zero may be a valid amount.

CLM05 C023 Health Care Service LocationInformation

O Comp Required

Description: To provide information that identifies the place of service or the type of billrelated to the location at which a health care service was renderedAlias: Type of BillAlias: Type of Bill

CLM05-01 1331 Facility Code Value M AN 1/2 Required

Description: Code identifying the type of facility where services were performed; the firstand second positions of the Uniform Bill Type code or the Place of Service code from theElectronic Media Claims National Standard FormatIndustry: Facility Type CodeIndustry: Facility Type Code




UB-92 Ref. [UB-Name]: 4, Positions 1-2 [Type of Bill]UB-92 Ref. [UB-Name]: 4, Positions 1-2 [Type of Bill]EMC v.6.0 Reference: Record Type 40 Field No. 4, Positions 1-2



EMC v.6.0 Reference: Record Type 40 Field No. 4, Positions 1-2



ExternalCodeList Name: 236 Description: Uniform Billing Claim Form Bill Type

CLM05-02 1332 Facility Code Qualifier O ID 1/2 Required

Description: Code identifying the type of facility referenced

CodeList Summary (Total Codes: 2, Included: 1)Code NameA Uniform Billing Claim Form Bill Type

CODE SOURCE:CODE SOURCE:236: Uniform Billing Claim Form Bill Type236: Uniform Billing Claim Form Bill Type

CLM05-03 1325 Claim Frequency Type Code O ID 1/1 Required

Description: Code specifying the frequency of the claim; this is the third position of theUniform Billing Claim Form Bill TypeIndustry: Claim Frequency CodeIndustry: Claim Frequency CodeUB-92 Ref. [UB-Name]: 4, Position 3 [Type of Bill]UB-92 Ref. [UB-Name]: 4, Position 3 [Type of Bill]EMC v.6.0 Reference: Record Type 40 Field No. 4, Position 3



EMC v.6.0 Reference: Record Type 40 Field No. 4, Position 3


Record Type 95 Field No. 5, Position 3 (Batch Control)User Note 6: Use 1 for all original submissions. All other values will be treated as adjustments.User Note 6: Use 1 for all original submissions. All other values will be treated as adjustments.

ExternalCodeList Name: 235 Description: Claim Frequency Type Code


Description: Code indicating a Yes or No condition or responseIndustry: Provider or Supplier Signature IndicatorIndustry: Provider or Supplier Signature IndicatorAlias: Provider Signature on FileAlias: Provider Signature on File


CLM07 1359 Provider Accept Assignment Code O ID 1/1 Situational

Description: Code indicating whether the provider accepts assignmentIndustry: Medicare Assignment CodeIndustry: Medicare Assignment Code




CLM07 indicates whether the provider accepts Medicare assignment.CLM07 indicates whether the provider accepts Medicare assignment.

CodeList Summary (Total Codes: 4, Included: 2)Code NameA AssignedC Not Assigned


Description: Code indicating a Yes or No condition or responseIndustry: Benefits Assignment Certification IndicatorIndustry: Benefits Assignment Certification IndicatorAlias: Assignment of Benefits IndicatorAlias: Assignment of Benefits IndicatorUB-92 Ref. [UB-Name]: 53 (A-C) [Assignment of Benefits Certification Indicator]UB-92 Ref. [UB-Name]: 53 (A-C) [Assignment of Benefits Certification Indicator]EMC v.6.0 Reference: Record Type 30 Field No. 17 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 17 (Sequence 01-03)




CLM09 1363 Release of Information Code O ID 1/1 Required

Description: Code indicating whether the provider has on file a signed statement by thepatient authorizing the release of medical data to other organizationsUB-92 Ref. [UB-Name]: 52 (A-C) [Release of Information Certification Indicator]UB-92 Ref. [UB-Name]: 52 (A-C) [Release of Information Certification Indicator]EMC v.6.0 Reference: Record Type 30 Field No. 16 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 16 (Sequence 01-03)




UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:52 Code R [Restricted or Modified Release]52 Code R [Restricted or Modified Release]


N No, Provider is Not Allowed to Release DataUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:52 Code N [No Release]52 Code N [No Release]


Related to a ClaimUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:52 Code Y [Yes]52 Code Y [Yes]





Description: Code indicating a Yes or No condition or responseIndustry: Explanation of Benefits IndicatorIndustry: Explanation of Benefits IndicatorAlias: Explanation of Benefits (EOB) IndicatorAlias: Explanation of Benefits (EOB) Indicator


CLM20 1514 Delay Reason Code O ID 1/2 Situational

Description: Code indicating the reason why a request was delayedDelay Reason CodeThis element may be used if a particular claim is being transmitted in response to a requestfor information (e.g., a 277), and the response has been delayed.Required when claim is submitted late (past contracted date of filing limitations) and any ofthe codes below apply.

Delay Reason CodeThis element may be used if a particular claim is being transmitted in response to a requestfor information (e.g., a 277), and the response has been delayed.Required when claim is submitted late (past contracted date of filing limitations) and any ofthe codes below apply.

CodeList Summary (Total Codes: 14, Included: 11)Code Name1 Proof of Eligibility Unknown or Unavailable2 Litigation3 Authorization Delays4 Delay in Certifying Provider5 Delay in Supplying Billing Forms6 Delay in Delivery of Custom-made Appliances7 Third Party Processing Delay8 Delay in Eligibility Determination9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing

Limitation Rules10 Administration Delay in the Prior Approval Process11 Other







Notes:Notes:1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. For purposes of this documentation, the claim detail information is presented only in the dependent level.

1. 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-SEtransactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.2. 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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is thesubscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.

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 hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is thesubscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of thesubscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.




DTP Discharge Hour Pos: 135 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name096 Discharge



CodeList Summary (Total Codes: 39, Included: 1)Code NameTM Time Expressed in Format HHMM

Description: Time expressed in the format HHMM where HH is the numericalexpression of hours in the day based on a twenty-four hour clock and MM is thenumerical expression of minutes within an hour


Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Discharge HourIndustry: Discharge HourUB-92 Ref. [UB-Name]: 21 [Discharge Hour]UB-92 Ref. [UB-Name]: 21 [Discharge Hour]EMC v.6.0 Reference: Record Type 20 Field No. 22EMC v.6.0 Reference: Record Type 20 Field No. 22


Notes:Notes:1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all final inpatient claims/encounters.

1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all final inpatient claims/encounters.

Example:Example:DTP*096*TM*1130~DTP*096*TM*1130~



DTP Statement Dates Pos: 135 Max: 1Detail - Optional


User Option (Usage): RequiredPurpose: To specify any or all of a date, a time, or a time period



CodeList Summary (Total Codes: 1112, Included: 1)Code Name434 Statement

Description: Date on which billing document was created




Description: A range of dates expressed in the format CCYYMMDD-CCYYMMDDwhere CCYY is the numerical expression of the century CC and year YY, MM is thenumerical expression of the month within the year, and DD is the numericalexpression of the day within the year; the first occurrence of CCYYMMDD is thebeginning date and the second occurrence is the ending dateUse RD8 in DTP02 if it is necessary to indicate begin/end for from/to statementdates.Use RD8 in DTP02 if it is necessary to indicate begin/end for from/to statementdates.


Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Statement From or To DateIndustry: Statement From or To DateUB-92 Ref. [UB-Name]: 6 (From) and (Through) [Statement Covers Period]UB-92 Ref. [UB-Name]: 6 (From) and (Through) [Statement Covers Period]EMC v.6.0 Reference: Record Type 20 Field No. 19, 20EMC v.6.0 Reference: Record Type 20 Field No. 19, 20


Example:Example:DTP*434*RD8*19981209-19981214~DTP*434*RD8*19981209-19981214~



DTP Admission Date/Hour Pos: 135 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name435 Admission

Description: Date of entrance to a health care establishment



CodeList Summary (Total Codes: 39, Included: 1)Code NameDT Date and Time Expressed in Format CCYYMMDDHHMM


Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Admission Date and HourIndustry: Admission Date and HourUB-92 Ref. [UB-Name]: 17 [Admission/Start of Care Date]

18 [Admission Hour]

UB-92 Ref. [UB-Name]: 17 [Admission/Start of Care Date]

18 [Admission Hour]EMC v.6.0 Reference: Record Type 20 Field No. 17 (Admission Date)


EMC v.6.0 Reference: Record Type 20 Field No. 17 (Admission Date)



Notes:Notes:1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all Inpatient claims.

1. The dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in LoopID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300for that service line only.2. This segment is required on all Inpatient claims.

Example:Example:DTP*435*DT*199610131242~DTP*435*DT*199610131242~



CL1 Institutional Claim Code Pos: 140 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To supply information specific to hospital claims

Element Summary: Ref Id Element Name Req Type Min/Max UsageCL101 1315 Admission Type Code O ID 1/1 Situational

Description: Code indicating the priority of this admissionUB-92 Ref. [UB-Name]: 19 [Type of Admission]UB-92 Ref. [UB-Name]: 19 [Type of Admission]EMC v.6.0 Reference: Record Type 20 Field No. 10EMC v.6.0 Reference: Record Type 20 Field No. 10

Required when patient is being admitted to the hospital for inpatient services.Required when patient is being admitted to the hospital for inpatient services.

ExternalCodeList Name: 231 Description: Admission Type Code

CL102 1314 Admission Source Code O ID 1/1 Situational

Description: Code indicating the source of this admissionUB-92 Ref. [UB-Name]: 20 [Source of Admission]UB-92 Ref. [UB-Name]: 20 [Source of Admission]EMC v.6.0 Reference: Record Type 20 Field No. 11EMC v.6.0 Reference: Record Type 20 Field No. 11

Required for all inpatient admissions. Required on Medicare outpatient registrations fordiagnostic testing services.Required for all inpatient admissions. Required on Medicare outpatient registrations fordiagnostic testing services.

ExternalCodeList Name: 230 Description: Admission Source Code

CL103 1352 Patient Status Code O ID 1/2 Situational

Description: Code indicating patient status as of the "statement covers through date"UB-92 Ref. [UB-Name]: 22 [Patient Status]UB-92 Ref. [UB-Name]: 22 [Patient Status]EMC v.6.0 Reference: Record Type 20 Field No. 21EMC v.6.0 Reference: Record Type 20 Field No. 21

This element is required for inpatient claims/encounters.This element is required for inpatient claims/encounters.

ExternalCodeList Name: 239 Description: Patient Status Code

Notes:Notes:1. This segment is required when reporting hospital based admission and Medicare outpatient registrations onclaims/encounters. It may be used when provider wishes to communicate this information on non-Medicareoutpatient claims/encounters.

1. This segment is required when reporting hospital based admission and Medicare outpatient registrations onclaims/encounters. It may be used when provider wishes to communicate this information on non-Medicareoutpatient claims/encounters.

Example:Example:CL1*1*7*30~CL1*1*7*30~



PWK Claim SupplementalInformation




















Code Name









BM By MailEL Electronically OnlyEM E-MailFX By Fax


Description: Code designating the system/method of code structure used for IdentificationCode (67)This data element is required when PWK02 DOES NOT equal ’AA’. Can be used whenPWK02 equals ’AA’ if the Provider wants to send a document control number for anattachment remaining at the Providers office.

This data element is required when PWK02 DOES NOT equal ’AA’. Can be used whenPWK02 equals ’AA’ if the Provider wants to send a document control number for anattachment remaining at the Providers office.





Required if PWK02 equals BM, EL, EM or FX.Required if PWK02 equals BM, EL, EM or FX.

PWK07 352 Description O AN 1/80 Notrecommended

Description: A free-form description to clarify the related data elements and their contentIndustry: Attachment DescriptionIndustry: Attachment Description

This data element is used to add any additional information about the attachmentdescribed in this segment.This data element is used to add any additional information about the attachmentdescribed in this segment.


Comments: 1. PWK05 and PWK06 may be used to identify the addressee by a code number.



2. PWK07 may be used to indicate special information to be shown on the specified report.3. PWK08 may be used to indicate action pertaining to a report.

Notes:Notes:1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope.2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope.2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

Example:Example:PWK*AS*BM***AC*DMN0012~PWK*AS*BM***AC*DMN0012~

User Note 6:User Note 6:BSC's initial HIPAA implementation does not include PWK processing. Pending finalization of the HIPAA 275transaction, BSC will add PWK processing to its inbound claims capabilities.BSC's initial HIPAA implementation does not include PWK processing. Pending finalization of the HIPAA 275transaction, BSC will add PWK processing to its inbound claims capabilities.



CN1 Contract Information Pos: 160 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To specify basic data about the contract or contract line item

Element Summary: Ref Id Element Name Req Type Min/Max UsageCN101 1166 Contract Type Code M ID 2/2 Required

Description: Code identifying a contract type

CodeList Summary (Total Codes: 50, Included: 7)Code Name01 Diagnosis Related Group (DRG)

Description: A patient classification scheme, which provides means of relating thetype of patients a hospital treats to the costs incurred by the hospital, to determinequality of care and utilization of services in a hospital setting

02 Per DiemDescription: A contract which allows certain charges to be on a rate per day basis

03 Variable Per DiemDescription: A contract which allows certain charges to be on a rate per day basis,where the rate may not remain constant

04 FlatDescription: A contract between the provider of service and the destination payorwhereby the flat rate charges may differ from the total itemized charges

05 CapitatedDescription: A contract between the provider of service and the destination payorwhich allows payment to the provider of service on a per member per month basis

06 Percent09 Other

CN102 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Contract AmountIndustry: Contract Amount


CN103 332 Percent O R 1/6 Situational

Description: Percent expressed as a percentIndustry: Contract PercentageIndustry: Contract PercentageAlias: Allowance or Charge PercentAlias: Allowance or Charge Percent


CN104 127 Reference Identification O AN 1/30 Situational

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Contract CodeIndustry: Contract Code





CN105 338 Terms Discount Percent O R 1/6 Situational

Description: Terms discount percentage, expressed as a percent, available to thepurchaser if an invoice is paid on or before the Terms Discount Due DateIndustry: Terms Discount PercentageIndustry: Terms Discount Percentage


CN106 799 Version Identifier O AN 1/30 Situational

Description: Revision level of a particular format, program, technique or algorithmIndustry: Contract Version IdentifierIndustry: Contract Version Identifier


Semantics: 1. CN102 is the contract amount.2. CN103 is the allowance or charge percent.3. CN104 is the contract code.4. CN106 is an additional identifying number for the contract.

Notes:Notes:1. The developers of this implementation guide recommend that for non-capitated situations, contract informationbe maintained in the receiver’s files and not be transmitted with each claim whenever possible. It isrecommended that submitters always include CN1 for encounters that include only capitated services.2. Required if the provider is contractually obligated to provide contract information on this claim.

1. The developers of this implementation guide recommend that for non-capitated situations, contract informationbe maintained in the receiver’s files and not be transmitted with each claim whenever possible. It isrecommended that submitters always include CN1 for encounters that include only capitated services.2. Required if the provider is contractually obligated to provide contract information on this claim.

Example:Example:CN1*02*550~CN1*02*550~



AMT Payer Estimated AmountDue






CodeList Summary (Total Codes: 1473, Included: 1)Code NameC5 Claim Amount Due - Estimated

Description: Approximate value rightfully belonging to the individual


Description: Monetary amountIndustry: Estimated Claim Due AmountIndustry: Estimated Claim Due AmountUB-92 Ref. [UB-Name]: 55 (A-C) [Estimated Amount Due]UB-92 Ref. [UB-Name]: 55 (A-C) [Estimated Amount Due]EMC v.6.0 Reference: Record Type 30 Field No. 26EMC v.6.0 Reference: Record Type 30 Field No. 26

Notes:Notes:1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Payer Estimated Amount Due is applicable to this claim.

1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Payer Estimated Amount Due is applicable to this claim.

Example:Example:AMT*C5*14523.1~AMT*C5*14523.1~



AMT Patient Estimated AmountDue






CodeList Summary (Total Codes: 1473, Included: 1)Code NameF3 Patient Responsibility - Estimated

Description: Approximate value one receiving medical care is obliged to pay


Description: Monetary amountIndustry: Patient Responsibility AmountIndustry: Patient Responsibility AmountUB-92 Ref. [UB-Name]: 55, Patient Line [Estimated Amount Due]UB-92 Ref. [UB-Name]: 55, Patient Line [Estimated Amount Due]EMC v.6.0 Reference: Record Type 20 Field No. 24EMC v.6.0 Reference: Record Type 20 Field No. 24

Notes:Notes:1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Responsibility Amount is applicable to this claim.

1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Responsibility Amount is applicable to this claim.

Example:Example:AMT*F3*123~AMT*F3*123~



AMT Patient Paid Amount Pos: 175 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameF5 Patient Amount Paid

Description: Monetary amount value already paid by one receiving medical care


Description: Monetary amountIndustry: Patient Amount PaidIndustry: Patient Amount PaidUB-92 Ref. [UB-Name]: 54, Line P [Prior Payments - Payers and Patient]UB-92 Ref. [UB-Name]: 54, Line P [Prior Payments - Payers and Patient]EMC v.6.0 Reference: Record Type 20 Field No. 23EMC v.6.0 Reference: Record Type 20 Field No. 23

Notes:Notes:1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Paid Amount is applicable to this claim.

1. The amounts in this segment at the claim level Loop ID-2300 apply to all service lines unless overridden in theAMT segment in Loop ID-2400. An amount is considered to be overridden if the value in AMT01 is the same inboth the claim level AMT segment and the service line level AMT segment.2. This segment is required when the Patient Paid Amount is applicable to this claim.

Example:Example:AMT*F5*8.5~AMT*F5*8.5~



AMT Credit/Debit Card MaximumAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameMA Maximum Amount


Description: Monetary amountIndustry: Credit or Debit Card Maximum AmountIndustry: Credit or Debit Card Maximum Amount

Notes:Notes:1. Use this segment only for claims that contain credit/debit card information. This segment indicates themaximum amount that can be credited to the account indicated in 2010BB - CREDIT/DEBIT CARD ACCOUNTHOLDER NAME.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

1. Use this segment only for claims that contain credit/debit card information. This segment indicates themaximum amount that can be credited to the account indicated in 2010BB - CREDIT/DEBIT CARD ACCOUNTHOLDER NAME.2. The information carried under this segment must never be sent to the payer. This information is only for usebetween a provider and a service organization offering patient collection services. In this case, it is theresponsibility of the collection service organization to remove this segment before forwarding the claim to thepayer.

Example:Example:AMT*MA*25~AMT*MA*25~



REF Adjusted Repriced ClaimNumber





Description: Code qualifying the Reference IdentificationUser Note 6: Use F8 for Adjustment RequestsUser Note 6: Use F8 for Adjustment Requests

CodeList Summary (Total Codes: 1503, Included: 1)Code Name9C Adjusted Repriced Claim Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Adjusted Repriced Claim Reference NumberIndustry: Adjusted Repriced Claim Reference NumberUser Note 6: For Adjustment Requests: Use original Blue Shield claim number.User Note 6: For Adjustment Requests: Use original Blue Shield claim number.



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is required when Repricers need to attach their own claim identification number to a previouslyadjusted (resubmitted) claim they are processing.

1. Reference numbers at this position apply to the entire claim.2. This segment is required when Repricers need to attach their own claim identification number to a previouslyadjusted (resubmitted) claim they are processing.

Example:Example:REF*9C*XDE1234579~REF*9C*XDE1234579~



REF Repriced Claim Number Pos: 180 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1503, Included: 1)Code Name9A Repriced Claim Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Repriced Claim Reference NumberIndustry: Repriced Claim Reference Number



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is required when the Repricers need to attach their own claim identification to a claim they areprocessing.

1. Reference numbers at this position apply to the entire claim.2. This segment is required when the Repricers need to attach their own claim identification to a claim they areprocessing.

Example:Example:REF*9A*3456749387~REF*9A*3456749387~



REF Claim Identification NumberFor Clearinghouses andOther TransmissionIntermediaries





Description: Code qualifying the Reference IdentificationNumber assigned by clearinghouse/van/etc.Number assigned by clearinghouse/van/etc.

CodeList Summary (Total Codes: 1503, Included: 1)Code NameD9 Claim Number

Description: Sequence number to track the number of claims opened within aparticular line of business


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Value Added Network Trace NumberIndustry: Value Added Network Trace Number



Notes:Notes:1. Used only by transmission intermediaries (Value-Added Networks, Automated Clearing Houses, and others)who need to attach their own unique claim number.2. This number can be used to facilitate front-end acknowledgements such as the 277 Health Care PayerUnsolicited Claim Status.

1. Used only by transmission intermediaries (Value-Added Networks, Automated Clearing Houses, and others)who need to attach their own unique claim number.2. This number can be used to facilitate front-end acknowledgements such as the 277 Health Care PayerUnsolicited Claim Status.

Example:Example:REF*D9*4373649430ABES~REF*D9*4373649430ABES~



REF Document IdentificationCode






CodeList Summary (Total Codes: 1503, Included: 1)Code NameDD Document Identification Code


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Document Control IdentifierIndustry: Document Control IdentifierEMC v.6.0 Reference: Record Type 71 Field No. 4EMC v.6.0 Reference: Record Type 71 Field No. 4

Use the form name as shown in the example. If both the 485 and 486 forms are being sent,repeat the segment.Use the form name as shown in the example. If both the 485 and 486 forms are being sent,repeat the segment.



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey submittal of HCFA-485 and HCFA-486 data OR HCFA-486 data only.1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey submittal of HCFA-485 and HCFA-486 data OR HCFA-486 data only.

Example:Example:REF*DD*485~REF*DD*485~



REF Original Reference Number(ICN/DCN)






CodeList Summary (Total Codes: 1503, Included: 1)Code NameF8 Original Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Claim Original Reference NumberIndustry: Claim Original Reference NumberUB-92 Ref. [UB-Name]: 37 (A-C) [Internal Control Number (ICN)/ Document ControlNumber (DCN)]UB-92 Ref. [UB-Name]: 37 (A-C) [Internal Control Number (ICN)/ Document ControlNumber (DCN)]EMC v.6.0 Reference: Record Type 31 Field No. 14 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 14 (Sequence 01-03)



Notes:Notes:1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey the control number assigned to the original bill by the payer to identify a uniqueclaim.

1. Reference numbers at this position apply to the entire claim.2. This segment is used to convey the control number assigned to the original bill by the payer to identify a uniqueclaim.

Example:Example:REF*F8*1234636854~REF*F8*1234636854~

User Note 6:User Note 6:Corrected claims can be sent electronically to Blue Shield of California, however, please wait for the original claimto finalize before sending a corrected claim to avoid denial as a duplicate. Once the initial has finalized in our system, re-bill the corrected claim with the appropriate adjustment bill type. Youwill also need to include the following EDI segments on your adjusted claim: Send "F8" in REF01 (Loop 2300)Send "14 digit number BSC ICN of incorrect original claim in REF02 (Loop 2300). Sample: REF*F8*12345678912345~

Corrected claims can be sent electronically to Blue Shield of California, however, please wait for the original claimto finalize before sending a corrected claim to avoid denial as a duplicate. Once the initial has finalized in our system, re-bill the corrected claim with the appropriate adjustment bill type. Youwill also need to include the following EDI segments on your adjusted claim: Send "F8" in REF01 (Loop 2300)Send "14 digit number BSC ICN of incorrect original claim in REF02 (Loop 2300). Sample: REF*F8*12345678912345~



Note: 12345678912345 should be replaced with the original claim’s Blue Shield of California internal controlnumber (ICN). You can obtain the Blue Shield of California internal control number (ICN) using the claim status option onProvider Connection or from the explanation of benefits (EOB) or electronic remittance advice (ERA).

Note: 12345678912345 should be replaced with the original claim’s Blue Shield of California internal controlnumber (ICN). You can obtain the Blue Shield of California internal control number (ICN) using the claim status option onProvider Connection or from the explanation of benefits (EOB) or electronic remittance advice (ERA).



REF Investigational DeviceExemption Number






CodeList Summary (Total Codes: 1503, Included: 1)Code NameLX Qualified Products List


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Investigational Device Exemption IdentifierIndustry: Investigational Device Exemption IdentifierEMC v.6.0 Reference: Record Type 34 Field No. 5EMC v.6.0 Reference: Record Type 34 Field No. 5



Notes:Notes:1. Required only on claims involving an FDA assigned investigational device exemption (IDE) number. Only oneIDE per claim is to be reported.1. Required only on claims involving an FDA assigned investigational device exemption (IDE) number. Only oneIDE per claim is to be reported.

Example:Example:REF*LX*432907~REF*LX*432907~



REF Service AuthorizationException Code






CodeList Summary (Total Codes: 1503, Included: 1)Code Name4N Special Payment Reference Number


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Service Authorization Exception CodeIndustry: Service Authorization Exception Code

CodeList Summary (Total Codes: 7, Included: 7)Code Name1 Immediate/Urgent Care2 Services Rendered in a Retroactive Period3 Emergency Care4 Client as Temporary Medicaid5 Request from Country for Second Option to Recipient can Work 6 Request for Override Pending7 Special Handling



Notes:Notes:1. Used only in claims where providers are required by state law (e.g., New York State Medicaid) to obtainauthorization for specific services but, for the reasons listed in REF02, performed the service without obtainingthe service authorization. Check with your state Medicaid to see if this applies in your state.

1. Used only in claims where providers are required by state law (e.g., New York State Medicaid) to obtainauthorization for specific services but, for the reasons listed in REF02, performed the service without obtainingthe service authorization. Check with your state Medicaid to see if this applies in your state.

Example:Example:REF*4N*1~REF*4N*1~



REF Peer Review Organization(PRO) Approval Number






CodeList Summary (Total Codes: 1503, Included: 1)Code NameG4 Peer Review Organization (PRO) Approval Number

Description: An authorization number for certain surgical procedures and for anassistant at cataract surgery


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Peer Review Authorization NumberIndustry: Peer Review Authorization Number



Notes:Notes:1. Required when an external Peer Review Organization assigns an Approval Number to services deemedmedically necessary by that organization.1. Required when an external Peer Review Organization assigns an Approval Number to services deemedmedically necessary by that organization.




REF Prior Authorization orReferral Number









Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Prior Authorization NumberIndustry: Prior Authorization NumberUB-92 Ref. [UB-Name]: 63 (A-C) [Treatment Authorization Code]UB-92 Ref. [UB-Name]: 63 (A-C) [Treatment Authorization Code]EMC v.6.0 Reference: Record Type 40 Field No. 5, 6, 7 (Treatment Authorization Number)EMC v.6.0 Reference: Record Type 40 Field No. 5, 6, 7 (Treatment Authorization Number)



Notes:Notes:1. Required where services on this claim were preauthorized or where a referral is involved. Generally,preauthorization/referral numbers are those numbers assigned by the payer/UMO to authorize a service prior toits being performed. The UMO (Utilization Management Organization) is generally the entity empowered to makea decision regarding the outcome of a health services review or the owner of information. The referral or priorauthorization number carried in this REF is specific to the destination payer reported in the 2010BC loop. If otherpayers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payer’sinformation.

1. Required where services on this claim were preauthorized or where a referral is involved. Generally,preauthorization/referral numbers are those numbers assigned by the payer/UMO to authorize a service prior toits being performed. The UMO (Utilization Management Organization) is generally the entity empowered to makea decision regarding the outcome of a health services review or the owner of information. The referral or priorauthorization number carried in this REF is specific to the destination payer reported in the 2010BC loop. If otherpayers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payer’sinformation.


User Note 6:User Note 6:For Institutional EDI claims report Prior Authorization Number in REF02 segment in Loop 2300. Use the “G1”qualifier in the REF01 segment of Loop 2300. REF01 = G1REF02 = Authorization Number

For Institutional EDI claims report Prior Authorization Number in REF02 segment in Loop 2300. Use the “G1”qualifier in the REF01 segment of Loop 2300. REF01 = G1REF02 = Authorization Number



Sample: REF*G1*12456789ABCD Report the entity that approved the authorization (BSC, IPA, NIA), authorization date, date range service approvedand approved days/units in NTE02 Loop 2300. For Professional claims use Claim Note and for Institutional claimsuse Billing Note. In both Professional and Institutional claims, use “ADD” as the value in NTE01. Sample: NTE*ADD* BSC 20050719 20050719 20050722 4 DAYS • first field is either BSC, IPA, or NIA• second field is the date the auth was given (use ccyymmdd format)• third field is the date range approved (use ccyymmdd ccyymmdd format)• fourth field is either the amount of days approved or units

Sample: REF*G1*12456789ABCD Report the entity that approved the authorization (BSC, IPA, NIA), authorization date, date range service approvedand approved days/units in NTE02 Loop 2300. For Professional claims use Claim Note and for Institutional claimsuse Billing Note. In both Professional and Institutional claims, use “ADD” as the value in NTE01. Sample: NTE*ADD* BSC 20050719 20050719 20050722 4 DAYS • first field is either BSC, IPA, or NIA• second field is the date the auth was given (use ccyymmdd format)• third field is the date range approved (use ccyymmdd ccyymmdd format)• fourth field is either the amount of days approved or units



REF Medical Record Number Pos: 180 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1503, Included: 1)Code NameEA Medical Record Identification Number

Description: A unique number assigned to each patient by the provider of service(hospital) to assist in retrieval of medical records


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Medical Record NumberIndustry: Medical Record NumberEMC v.6.0 Reference: Record Type 20 Field No. 25 (Medical Record Number)EMC v.6.0 Reference: Record Type 20 Field No. 25 (Medical Record Number)



Notes:Notes:1. Required if provider needs to identify for future inquiries the actual medical record of the patient identified ineither Loop ID - 2010BA or 2010CA for this episode of care.2. Used if provider will utilize this information in a 276 - Claim Status Inquiry in order to receive and process a 277-Claim Status Response.

1. Required if provider needs to identify for future inquiries the actual medical record of the patient identified ineither Loop ID - 2010BA or 2010CA for this episode of care.2. Used if provider will utilize this information in a 276 - Claim Status Inquiry in order to receive and process a 277-Claim Status Response.

Example:Example:REF*EA*1230484376R~REF*EA*1230484376R~



REF Demonstration ProjectIdentifier






CodeList Summary (Total Codes: 1503, Included: 1)Code NameP4 Project Code


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Demonstration Project IdentifierIndustry: Demonstration Project Identifier



Notes:Notes:1. Required on claims/encounters where a demonstration project is being billed/reported. This information isspecific to the destination payer reported in the 2010BC loop. If other payers have a similar number, report thatinformation in the 2330 loop which holds that payer’s information.

1. Required on claims/encounters where a demonstration project is being billed/reported. This information isspecific to the destination payer reported in the 2010BC loop. If other payers have a similar number, report thatinformation in the 2330 loop which holds that payer’s information.

Example:Example:REF*P4*THJ1222~REF*P4*THJ1222~



K3 File Information Pos: 185 Max: 10Detail - Optional


User Option (Usage): SituationalPurpose: To transmit a fixed-format record or matrix contents

Element Summary: Ref Id Element Name Req Type Min/Max UsageK301 449 Fixed Format Information M AN 1/80 Required

Description: Data in fixed format agreed upon by sender and receiver

Semantics: 1. K303 identifies the value of the index.

Comments: 1. The default for K302 is content.

Notes:Notes:1. At the time of publication K3 segments have no specific use. However, they have been included in thisimplementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirementby a state regulatory authority.2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislativerequirement AND the administering state agency or other state organization has contacted the X12N workgroup,requested a review of the K3 data requirement to ensure there is not an existing method within theimplementation guide to meet this requirement, and X12N determines that there is no method to meet therequirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N willsubmit the necessary data maintenance and refer the request to the appropriate data content committee.

1. At the time of publication K3 segments have no specific use. However, they have been included in thisimplementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirementby a state regulatory authority.2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislativerequirement AND the administering state agency or other state organization has contacted the X12N workgroup,requested a review of the K3 data requirement to ensure there is not an existing method within theimplementation guide to meet this requirement, and X12N determines that there is no method to meet therequirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N willsubmit the necessary data maintenance and refer the request to the appropriate data content committee.

User Note 6:User Note 6:Using the 837I, submit the POA indicator in segment K3 in the 2300 loop, data element K301.

Example 1. POA indicators for an electronic claim with one principal and five secondary diagnoses should becoded as POAYNUW1YZPOA “POA” is always required first, followed by a single indicator for every diagnosis reported on the claimY The principal diagnosis is always the first indicator after “POA.” In this example, the principal diagnosis waspresent on admissionN The first secondary diagnosis was not present on admission, designated by “N.”

U It was unknown if the second secondary diagnosis was present on admission, designated by “U.”

W It is clinically undetermined if the third secondary diagnosis was present on admission, designated by “W.”

1 The fourth secondary diagnosis was exempt from reporting for POA, designated by “1.”

Y The fifth secondary diagnosis was present on admission, designated by “Y.”

Z The last secondary diagnosis indicator is followed by the letter “Z” to indicate the end of the data element Example 2. POA Indicator for an electronic claim with one principal diagnosis without any secondary diagnosisshould be coded as POAYZ

Using the 837I, submit the POA indicator in segment K3 in the 2300 loop, data element K301.

Example 1. POA indicators for an electronic claim with one principal and five secondary diagnoses should becoded as POAYNUW1YZPOA “POA” is always required first, followed by a single indicator for every diagnosis reported on the claimY The principal diagnosis is always the first indicator after “POA.” In this example, the principal diagnosis waspresent on admissionN The first secondary diagnosis was not present on admission, designated by “N.”

U It was unknown if the second secondary diagnosis was present on admission, designated by “U.”

W It is clinically undetermined if the third secondary diagnosis was present on admission, designated by “W.”

1 The fourth secondary diagnosis was exempt from reporting for POA, designated by “1.”

Y The fifth secondary diagnosis was present on admission, designated by “Y.”

Z The last secondary diagnosis indicator is followed by the letter “Z” to indicate the end of the data element Example 2. POA Indicator for an electronic claim with one principal diagnosis without any secondary diagnosisshould be coded as POAYZ



POA “POA” is always required first, followed by a single indicator for every diagnosis reported on the claim.

Y The principal diagnosis is always the first indicator after “POA.” In this example, the principal diagnosis waspresent on admission.

Z The letter “Z” is used to indicate the end of the data element Current Inbound examples K3*POANYZ~K3*POAYYYYYYYYY1Z~K3*POAYYYNYYYYYYYYYYYYYY111111Z~

POA “POA” is always required first, followed by a single indicator for every diagnosis reported on the claim.

Y The principal diagnosis is always the first indicator after “POA.” In this example, the principal diagnosis waspresent on admission.

Z The letter “Z” is used to indicate the end of the data element Current Inbound examples K3*POANYZ~K3*POAYYYYYYYYY1Z~K3*POAYYYNYYYYYYYYYYYYYY111111Z~



NTE Claim Note Pos: 190 Max: 10Detail - Optional




Description: Code identifying the functional area or purpose for which the note appliesEMC v.6.0 Reference: Record Type 73 Field No. 5EMC v.6.0 Reference: Record Type 73 Field No. 5

CodeList Summary (Total Codes: 241, Included: 14)Code NameALG Allergies


DCP Goals, Rehabilitation Potential, or Discharge PlansEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48522Record Type 73 Field No. 5 Code 48522

DGN Diagnosis DescriptionDescription: Verbal description of the condition involved

DME Durable Medical Equipment (DME) and SuppliesEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48514Record Type 73 Field No. 5 Code 48514

MED MedicationsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48510Record Type 73 Field No. 5 Code 48510

NTR Nutritional RequirementsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48516Record Type 73 Field No. 5 Code 48516

ODT Orders for Disciplines and TreatmentsEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48521Record Type 73 Field No. 5 Code 48521

RHB Functional Limitations, Reason Homebound, or BothEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48617Record Type 73 Field No. 5 Code 48617

RLH Reasons Patient Leaves HomeEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48621Record Type 73 Field No. 5 Code 48621

RNH Times and Reasons Patient Not at HomeEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48620Record Type 73 Field No. 5 Code 48620

SET Unusual Home, Social Environment, or BothEMC v.6.0 Reference:EMC v.6.0 Reference:


Code Name


Record Type 73 Field No. 5 Code 48619Record Type 73 Field No. 5 Code 48619SFM Safety Measures


SPT Supplementary Plan of TreatmentEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48521Record Type 73 Field No. 5 Code 48521

UPI Updated InformationEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 73 Field No. 5 Code 48616Record Type 73 Field No. 5 Code 48616


Description: A free-form description to clarify the related data elements and their contentIndustry: Claim Note TextIndustry: Claim Note TextUB-92 Ref. [UB-Name]: 84 [Remarks]UB-92 Ref. [UB-Name]: 84 [Remarks]EMC v.6.0 Reference: Record Type 73 Field No. 6EMC v.6.0 Reference: Record Type 73 Field No. 6



Notes:Notes:1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information inthe NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in LoopID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guidediscourage using narrative information within the 837. Trading partners who require narrative information withclaims are encouraged to codify that information within the X12 environment.2. Home Health Corresponding Data This segment is used to convey Home Health narrative information from theforms ‘‘Home Health Certification and Plan of Treatment’’ and ‘‘Medical Update and Patient Information.’’3. Required only when provider deems it necessary to transmit information not otherwise supported in thisimplementation.

1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information inthe NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in LoopID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guidediscourage using narrative information within the 837. Trading partners who require narrative information withclaims are encouraged to codify that information within the X12 environment.2. Home Health Corresponding Data This segment is used to convey Home Health narrative information from theforms ‘‘Home Health Certification and Plan of Treatment’’ and ‘‘Medical Update and Patient Information.’’3. Required only when provider deems it necessary to transmit information not otherwise supported in thisimplementation.

Example:Example:NTE*NTR*PATIENT REQUIRES TUBE FEEDING~NTE*NTR*PATIENT REQUIRES TUBE FEEDING~



NTE Billing Note Pos: 190 Max: 1Detail - Optional




Description: Code identifying the functional area or purpose for which the note applies

CodeList Summary (Total Codes: 241, Included: 1)Code NameADD Additional Information


Description: A free-form description to clarify the related data elements and their contentIndustry: Billing Note TextIndustry: Billing Note TextUB-92 Ref. [UB-Name]: 84 [Remarks]UB-92 Ref. [UB-Name]: 84 [Remarks]EMC v.6.0 Reference: Record Type 90 Field No. 4, 17EMC v.6.0 Reference: Record Type 90 Field No. 4, 17



Notes:Notes:1. This segment is used to convey additional information necessary to adjudicate the claim.2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) inthe opinion of the provider, the information is needed to substantiate the medical treatment and is not supportedelsewhere within the claim data set.

1. This segment is used to convey additional information necessary to adjudicate the claim.2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) inthe opinion of the provider, the information is needed to substantiate the medical treatment and is not supportedelsewhere within the claim data set.

Example:Example:NTE*ADD*NO LIABILITY, PATIENT FELL AT HOME~NTE*ADD*NO LIABILITY, PATIENT FELL AT HOME~



CR6 Home Health CareInformation



User Option (Usage): SituationalPurpose: To supply information related to the certification of a home health care patient

Element Summary: Ref Id Element Name Req Type Min/Max UsageCR601 923 Prognosis Code M ID 1/1 Required

Description: Code indicating physician's prognosis for the patientAlias: Prognosis IndicatorAlias: Prognosis IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 18EMC v.6.0 Reference: Record Type 71 Field No. 18

CodeList Summary (Total Codes: 8, Included: 8)Code Name1 Poor2 Guarded3 Fair4 Good5 Very Good6 Excellent7 Less than 6 Months to Live8 Terminal

CR602 373 Date M DT 8/8 Required

Description: Date expressed as CCYYMMDDIndustry: Service From DateIndustry: Service From DateAlias: SOC DateAlias: SOC DateEMC v.6.0 Reference: Record Type 71 Field No. 5 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 5 (MMDDYY)


Description: Code indicating the date format, time format, or date and time formatRequired on claims/encounters when a certification for Home Health Services waspreviously or is being submitted to the destination payer.Required on claims/encounters when a certification for Home Health Services waspreviously or is being submitted to the destination payer.




Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Home Health Certification PeriodIndustry: Home Health Certification PeriodAlias: Certification PeriodAlias: Certification Period




EMC v.6.0 Reference: Record Type 71 Field No. 6, 7EMC v.6.0 Reference: Record Type 71 Field No. 6, 7


CR605 373 Date O DT 8/8 Required

Description: Date expressed as CCYYMMDDIndustry: Diagnosis DateIndustry: Diagnosis DateAlias: Date of Onset or Exacerbation of Principal DiagnosisAlias: Date of Onset or Exacerbation of Principal DiagnosisEMC v.6.0 Reference: Record Type 71 Field No. 8 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 8 (MMDDYY)

CR606 1073 Yes/No Condition or Response Code O ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Skilled Nursing Facility IndicatorIndustry: Skilled Nursing Facility IndicatorAlias: Patient Receiving Care in 1861 (j) (1) Facility IndicatorAlias: Patient Receiving Care in 1861 (j) (1) Facility IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 27EMC v.6.0 Reference: Record Type 71 Field No. 27

CodeList Summary (Total Codes: 4, Included: 3)Code NameN NoU UnknownY Yes

CR607 1073 Yes/No Condition or Response Code M ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Medicare Coverage IndicatorIndustry: Medicare Coverage IndicatorAlias: Medicare Covered IndicatorAlias: Medicare Covered IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 24EMC v.6.0 Reference: Record Type 71 Field No. 24


CR608 1322 Certification Type Code M ID 1/1 Required

Description: Code indicating the type of certificationAlias: Certification Type IndicatorAlias: Certification Type IndicatorEMC v.6.0 Reference: Record Type 71 Field No. 28EMC v.6.0 Reference: Record Type 71 Field No. 28


CodeList Summary (Total Codes: 14, Included: 3)Code NameI InitialR RenewalS Revised

CR609 373 Date C DT 8/8 Situational

Description: Date expressed as CCYYMMDD




Industry: Surgery DateIndustry: Surgery DateAlias: Date Surgical Procedure PerformedAlias: Date Surgical Procedure PerformedEMC v.6.0 Reference: Record Type 71 Field No. 10 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 10 (MMDDYY)


CR610 235 Product/Service ID Qualifier C ID 2/2 Situational






ID International Classification of Diseases Clinical Modification (ICD-9-CM) -ProcedureDescription: The International Classification of Diseases, Clinical Modification, isdesignated for the classification of morbidity and mortality information for statisticalpurposes and for the indexing of hospital records by disease and operations, fordata storage and retrieval; this is a procedure codeCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

CR611 1137 Medical Code Value C AN 1/15 Situational

Description: Code value for describing a medical condition or procedureIndustry: Surgical Procedure CodeIndustry: Surgical Procedure CodeEMC v.6.0 Reference: Record Type 71 Field No. 9EMC v.6.0 Reference: Record Type 71 Field No. 9




Description: Date expressed as CCYYMMDDIndustry: Physician Order DateIndustry: Physician Order DateAlias: Verbal SOC DateAlias: Verbal SOC DateEMC v.6.0 Reference: Record Type 71 Field No. 19 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 19 (MMDDYY)




This data element is required when the Provider has the Physician Order Date informationon file.This data element is required when the Provider has the Physician Order Date informationon file.


Description: Date expressed as CCYYMMDDIndustry: Last Visit DateIndustry: Last Visit DateAlias: Date Physician Last Saw PatientAlias: Date Physician Last Saw PatientEMC v.6.0 Reference: Record Type 71 Field No. 25 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 25 (MMDDYY)

This data element is required when the Provider has the Last Visit Date information on file.This data element is required when the Provider has the Last Visit Date information on file.


Description: Date expressed as CCYYMMDDIndustry: Physician Contact DateIndustry: Physician Contact DateAlias: Date Last Contacted PhysicianAlias: Date Last Contacted PhysicianEMC v.6.0 Reference: Record Type 71 Field No. 26 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 26 (MMDDYY)

This data element is required when the Provider has the Physician Contact Dateinformation on file.This data element is required when the Provider has the Physician Contact Dateinformation on file.


Description: Code indicating the date format, time format, or date and time formatThis data element is required when a hospital admission occurred to the patient.This data element is required when a hospital admission occurred to the patient.




Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Last Admission PeriodIndustry: Last Admission PeriodAlias: Admission Date and Discharge DateAlias: Admission Date and Discharge DateEMC v.6.0 Reference: Record Type 71 Field No. 29, 30 (MMDDYY)EMC v.6.0 Reference: Record Type 71 Field No. 29, 30 (MMDDYY)

This data element is required when a hospital admission occurred to the patient.This data element is required when a hospital admission occurred to the patient.

CR617 1384 Patient Location Code C ID 1/1 Required

Description: Code identifying the location where patient is receiving medical treatmentIndustry: Patient Discharge Facility Type CodeIndustry: Patient Discharge Facility Type CodeAlias: Type of FacilityAlias: Type of FacilityEMC v.6.0 Reference: Record Type 71 Field No. 31EMC v.6.0 Reference: Record Type 71 Field No. 31

CodeList Summary (Total Codes: 15, Included: 14)Code NameA Acute Care FacilityB Boarding Home


Code Name


C HospiceD Intermediate Care FacilityE Long-term or Extended Care FacilityF Not SpecifiedG Nursing HomeH Sub-acute Care FacilityL Other LocationM Rehabilitation FacilityO Outpatient FacilityR Residential Treatment FacilityS Skilled Nursing HomeT Rest Home



This data element is required when a secondary diagnosis code is present on this claim.This data element is required when a secondary diagnosis code is present on this claim.



This data element is required when a second secondary diagnosis code is present on thisclaim.This data element is required when a second secondary diagnosis code is present on thisclaim.



This data element is required when a third secondary diagnosis code is present on thisclaim.This data element is required when a third secondary diagnosis code is present on thisclaim.



This data element is required when a fourth secondary diagnosis code is present on thisclaim.This data element is required when a fourth secondary diagnosis code is present on thisclaim.

Syntax Rules: 1. P0304 - If either CR603 or CR604 is present, then the other is required.2. P091011 - If either CR609, CR610 or CR611 are present, then the others are required.



3. P151617 - If either CR615, CR616 or CR617 are present, then the others are required.

Semantics: 1. CR602 is the date covered home health services began.2. CR604 is the certification period covered by this plan of treatment.3. CR605 is the date of onset or exacerbation of the principal diagnosis.4. A "Y" value indicates patient is receiving care in a 1861J1 (skilled nursing) facility. An "N" value indicates

patient is not receiving care in a 1861J1 facility. A "U" value indicates it is unknown whether or not the patientis receiving care in a 1861J1 facility.

5. CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered byMedicare; an "N" value indicates patient is not covered by Medicare.

6. CR609 is date that the surgery identified in CR614 was performed.7. CR610 qualifies CR611.8. CR611 is the surgical procedure most relevant to the care being rendered.9. CR612 is the date the agency received the verbal orders from the physician for start of care.

10. CR613 is the date that the patient was last seen by the physician.11. CR614 is the date of the home health agency's most recent contact with the physician.12. CR616 is the date range of the most recent inpatient stay.13. CR617 indicates the type of facility from which the patient was most recently discharged.14. CR618 is the date of onset or exacerbation of the first secondary diagnosis.15. CR619 is the date of onset or exacerbation of the second secondary diagnosis.16. CR620 is the date of onset or exacerbation of the third secondary diagnosis.17. CR621 is the date of onset or exacerbation of the fourth secondary diagnosis.

Notes:Notes:This segment is required for Home Health claims when applicable.This segment is required for Home Health claims when applicable.

Example:Example:CR6*4*941101*RD8*19941101- 19941231*941015*N*Y*I*****941101****A~CR6*4*941101*RD8*19941101- 19941231*941015*N*Y*I*****941101****A~



CRC Home Health FunctionalLimitations





Description: Specifies the situation or category to which the code applies

CodeList Summary (Total Codes: 341, Included: 1)Code Name75 Functional Limitations


Description: Code indicating a Yes or No condition or responseIndustry: Certification Condition IndicatorIndustry: Certification Condition Indicator



Description: Code indicating a conditionIndustry: Functional Limitation CodeIndustry: Functional Limitation CodeEMC v.6.0 Reference: Record Type 71 Field No. 15EMC v.6.0 Reference: Record Type 71 Field No. 15









Code Name




















Code Name




















Code Name




















Code Name




















Code Name






Notes:Notes:1. The CRC segment in Loop ID-2300 applies to the entire claim unless it is overridden by a CRC segment at theservice line level in Loop ID-2400 with the same value in CRC01.2. This segment is required to convey Home Health Plan of Treatment information when applicable.

1. The CRC segment in Loop ID-2300 applies to the entire claim unless it is overridden by a CRC segment at theservice line level in Loop ID-2400 with the same value in CRC01.2. This segment is required to convey Home Health Plan of Treatment information when applicable.

Example:Example:CRC*75*Y*AL~CRC*75*Y*AL~



CRC Home Health ActivitiesPermitted






CodeList Summary (Total Codes: 341, Included: 1)Code Name76 Activities Permitted





Description: Code indicating a conditionIndustry: Activities Permitted CodeIndustry: Activities Permitted CodeEMC v.6.0 Reference: Record Type 71 Field No. 16EMC v.6.0 Reference: Record Type 71 Field No. 16









Code Name




















Code Name




















Code Name




















Code Name




















Code Name












Notes:Notes:1. This segment is required to convey Home Health Plan of Treatment information when applicable.1. This segment is required to convey Home Health Plan of Treatment information when applicable.

Example:Example:CRC*76*Y*CB~CRC*76*Y*CB~



CRC Home Health Mental Status Pos: 220 Max: 2Detail - Optional





CodeList Summary (Total Codes: 341, Included: 1)Code Name77 Mental Status





Description: Code indicating a conditionIndustry: Mental Status CodeIndustry: Mental Status CodeEMC v.6.0 Reference: Record Type 71 Field No. 17EMC v.6.0 Reference: Record Type 71 Field No. 17







FO ForgetfulEMC v.6.0 Reference:EMC v.6.0 Reference:


Code Name


Record Type 71 Field No. 17 Code 3Record Type 71 Field No. 17 Code 3LE Lethargic




















Code NameAG Agitated


















Code Name


















Notes:Notes:



1. This segment is required to convey Home Health Plan of Treatment information when applicable.1. This segment is required to convey Home Health Plan of Treatment information when applicable.

Example:Example:CRC*77*Y*DI~CRC*77*Y*DI~



HI Principal, Admitting, E-Codeand Patient Reason For VisitDiagnosis Information








CodeList Summary (Total Codes: 558, Included: 1)Code NameBK Principal Diagnosis



Description: Code indicating a code from a specific industry code listUB-92 Ref. [UB-Name]: 67 [Principal Diagnosis Code]UB-92 Ref. [UB-Name]: 67 [Principal Diagnosis Code]EMC v.6.0 Reference: Record Type 70 Field No. 4EMC v.6.0 Reference: Record Type 70 Field No. 4



Description: To send health care codes and their associated dates, amounts andquantitiesRequired for all unscheduled outpatient visits or upon the patient’s admission to thehosptial.Required for all unscheduled outpatient visits or upon the patient’s admission to thehosptial.


Description: Code identifying a specific industry code listZZ used to indicate the “Patient Reason For Visit.”ZZ used to indicate the “Patient Reason For Visit.”

CodeList Summary (Total Codes: 558, Included: 2)Code NameBJ Admitting Diagnosis


ZZ Mutually Defined


Code Name


ZZ used to indicate the “Patient Reason For Visit.” See Code Source 131.ZZ used to indicate the “Patient Reason For Visit.” See Code Source 131.


Description: Code indicating a code from a specific industry code listUB-92 Ref. [UB-Name]: 76 [Admitting Diagnosis/Patient’s Reason for Visit]UB-92 Ref. [UB-Name]: 76 [Admitting Diagnosis/Patient’s Reason for Visit]EMC v.6.0 Reference: Record Type 70 Field No. 25EMC v.6.0 Reference: Record Type 70 Field No. 25






CodeList Summary (Total Codes: 558, Included: 1)Code NameBN United States Department of Health and Human Services, Office of Vital Statistics

E-codeCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure


Description: Code indicating a code from a specific industry code listUB-92 Ref. [UB-Name]: 77 [External Cause of Injury Code (E-code)]UB-92 Ref. [UB-Name]: 77 [External Cause of Injury Code (E-code)]EMC v.6.0 Reference: Record Type 70 Field No. 26EMC v.6.0 Reference: Record Type 70 Field No. 26


Notes:Notes:1. Required on all claims and encounters except claims for Religious Non-medical claims (Bill Types 4XX and5XX) and hospital other (Bill Types 14X).2. The Admitting Diagnosis is required on all inpatient admission claims and encounters.3. An E-Code diagnosis is required whenever a diagnosis is needed to describe an injury, poisoning or adverseeffect.4. The Patient Reason for Visit Diagnosis is required for all unscheduled outpatient visits.

1. Required on all claims and encounters except claims for Religious Non-medical claims (Bill Types 4XX and5XX) and hospital other (Bill Types 14X).2. The Admitting Diagnosis is required on all inpatient admission claims and encounters.3. An E-Code diagnosis is required whenever a diagnosis is needed to describe an injury, poisoning or adverseeffect.4. The Patient Reason for Visit Diagnosis is required for all unscheduled outpatient visits.

Example:Example:HI*BK:9976~HI*BK:9976~



HI Diagnosis Related Group(DRG) Information








CodeList Summary (Total Codes: 558, Included: 1)Code NameDR Diagnosis Related Group (DRG)

CODE SOURCE:CODE SOURCE:229: Diagnosis Related Group Number (DRG)229: Diagnosis Related Group Number (DRG)


Description: Code indicating a code from a specific industry code listIndustry: Diagnosis Related Group (DRG) CodeIndustry: Diagnosis Related Group (DRG) Code

ExternalCodeList Name: 229 Description: Diagnosis Related Group Number (DRG)

Notes:Notes:1. DRG Information is required when an inpatient hospital is under DRG contract with a payer and the contractrequires the provider to identify the DRG to the payer.1. DRG Information is required when an inpatient hospital is under DRG contract with a payer and the contractrequires the provider to identify the DRG to the payer.

Example:Example:HI*DR:123~HI*DR:123~



HI Other Diagnosis Information Pos: 231 Max: 2Detail - Optional





























































Description: Code indicating a code from a specific industry code listIndustry: Other DiagnosisIndustry: Other DiagnosisUB-92 Ref. [UB-Name]: 68 [Other Diagnoses Codes]UB-92 Ref. [UB-Name]: 68 [Other Diagnoses Codes]











































































Code Name






















































































































































75 [Other Diagnoses Codes]75 [Other Diagnoses Codes]Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12Record Type 70 Field No. 5, 6, 7, 8, 9, 10, 11, 12


























Notes:Notes:1. Required when other condition(s) co-exists with the principal diagnosis, co-exists at the time of admission ordevelops subsequently during the patient’s treatment.1. Required when other condition(s) co-exists with the principal diagnosis, co-exists at the time of admission ordevelops subsequently during the patient’s treatment.

Example:Example:HI*BF:V9782~HI*BF:V9782~



HI Principal ProcedureInformation








CodeList Summary (Total Codes: 558, Included: 2)Code NameBP Health Care Financing Administration Common Procedural Coding System

Principal ProcedureCODE SOURCE:CODE SOURCE:130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding System

BR International Classification of Diseases Clinical Modification (ICD-9-CM) PrincipalProcedureCODE SOURCE:CODE SOURCE:131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure


Description: Code indicating a code from a specific industry code listIndustry: Principal Procedure CodeIndustry: Principal Procedure CodeUB-92 Ref. [UB-Name]: 80 [Principal Procedure Code and Date]UB-92 Ref. [UB-Name]: 80 [Principal Procedure Code and Date]EMC v.6.0 Reference: Record Type 70 Field No. 13EMC v.6.0 Reference: Record Type 70 Field No. 13





Use code D8 when the value in composite data element HI01-1 equals “BR”.Use code D8 when the value in composite data element HI01-1 equals “BR”.





Description: Expression of a date, a time, or range of dates, times or dates and timesUB-92 Ref. [UB-Name]: 80, “DATE” field [Principal Procedure Code and Date]UB-92 Ref. [UB-Name]: 80, “DATE” field [Principal Procedure Code and Date]EMC v.6.0 Reference: Record Type 70 Field No. 14EMC v.6.0 Reference: Record Type 70 Field No. 14

Required when HI01-3 is used.Required when HI01-3 is used.

Notes:Notes:1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when a procedure was performed.

1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when a procedure was performed.

Example:Example:HI*BR:92795:D8:19980321~HI*BR:92795:D8:19980321~



HI Other Procedure Information Pos: 231 Max: 2Detail - Optional





































Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Procedure DateIndustry: Procedure DateUB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]




EMC v.6.0 Reference: Record Type 70 Field No. 16, 18, 20, 22, 24EMC v.6.0 Reference: Record Type 70 Field No. 16, 18, 20, 22, 24


















































































Code NameBO Health Care Financing Administration Common Procedural Coding System



















Code Name


130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding SystemBQ International Classification of Diseases Clinical Modification (ICD-9-CM) Procedure

















BQ International Classification of Diseases Clinical Modification (ICD-9-CM) ProcedureCODE SOURCE:CODE SOURCE:


Code Name


131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure





































Description: Code indicating a code from a specific industry code listIndustry: Procedure CodeIndustry: Procedure Code




UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]UB-92 Ref. [UB-Name]: 81 (A-E) [Other Procedure Codes and Dates]EMC v.6.0 Reference: Record Type 70 Field No. 15, 17, 19, 21, 23EMC v.6.0 Reference: Record Type 70 Field No. 15, 17, 19, 21, 23


























Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Procedure DateIndustry: Procedure DateUB-92 Ref. [UB-Name]: Record Type 70 Field No. 16, 18, 20, 22, 24UB-92 Ref. [UB-Name]: Record Type 70 Field No. 16, 18, 20, 22, 24EMC v.6.0 Reference: 81 (A-E) [Other Procedure Codes and Dates]EMC v.6.0 Reference: 81 (A-E) [Other Procedure Codes and Dates]

Notes:Notes:1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when additional procedures must be reported.

1. Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay fromwhich the course of therapy was initiated.2. Required on inpatient claims or encounters when additional procedures must be reported.

Example:Example:HI*BQ:92795:D8:19980321~HI*BQ:92795:D8:19980321~



HI Occurrence Span Information Pos: 231 Max: 2Detail - Optional





























































Code Name


132: National Uniform Billing Committee (NUBC) Codes132: National Uniform Billing Committee (NUBC) Codes

















Description: Code indicating a code from a specific industry code listIndustry: Occurrence Span CodeIndustry: Occurrence Span CodeUB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]UB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]




EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33






































Description: A range of dates expressed in the format CCYYMMDD-CCYYMMDDwhere CCYY is the numerical expression of the century CC and year YY, MM is the


Code Name


numerical expression of the month within the year, and DD is the numericalexpression of the day within the year; the first occurrence of CCYYMMDD is thebeginning date and the second occurrence is the ending date

















Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Occurrence or Occurrence Span Code Associated DateIndustry: Occurrence or Occurrence Span Code Associated Date




UB-92 Ref. [UB-Name]: 36 (a-b), “FROM” and “THROUGH” fields [Occurrence Span Codeand Dates]UB-92 Ref. [UB-Name]: 36 (a-b), “FROM” and “THROUGH” fields [Occurrence Span Codeand Dates]EMC v.6.0 Reference: Record Type 40 Field No. 29, 30, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 29, 30, 32, 33










































Code NameBI Occurrence Span


















Description: Code indicating a code from a specific industry code list




Industry: Occurrence Span CodeIndustry: Occurrence Span CodeUB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]UB-92 Ref. [UB-Name]: 36 (a-b) [Occurrence Span Code and Dates]EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33EMC v.6.0 Reference: Record Type 40 Field No. 28, 29, 30, 31, 32, 33








Notes:Notes:1. Required when occurrence span information applies to the claim or encounter.1. Required when occurrence span information applies to the claim or encounter.

Example:Example:HI*BI:70:RD8:19981202-19981212~HI*BI:70:RD8:19981202-19981212~



HI Occurrence Information Pos: 231 Max: 2Detail - Optional
























Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date

































Date












Notes:Notes:1. Required when occurrence information applies to the claim or encounter.1. Required when occurrence information applies to the claim or encounter.

Example:Example:HI*BH:42:D8:19981208~HI*BH:42:D8:19981208~



HI Value Information Pos: 231 Max: 2Detail - Optional
























































EMC v.6.0 Reference: Record Type 41 Field No. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31, 32, 33, 34, 35, 35, 37, 38, 39EMC v.6.0 Reference: Record Type 41 Field No. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27, 28, 29, 30, 31, 32, 33, 34, 35, 35, 37, 38, 39


















































Description: Code indicating a code from a specific industry code listIndustry: Value CodeIndustry: Value CodeUB-92 Ref. [UB-Name]: 39 (a-d) [Value Codes and Amounts]UB-92 Ref. [UB-Name]: 39 (a-d) [Value Codes and Amounts]














































































































CodeList Summary (Total Codes: 558, Included: 1)Code Name


Code Name


BE ValueCODE SOURCE:CODE SOURCE:132: National Uniform Billing Committee (NUBC) Codes132: National Uniform Billing Committee (NUBC) Codes












Notes:Notes:1. Required when value information applies to the claim or encounter.1. Required when value information applies to the claim or encounter.

Example:Example:HI*BE:08:::1740~HI*BE:08:::1740~



HI Condition Information Pos: 231 Max: 2Detail - Optional


































































































































Description: Code indicating a code from a specific industry code listIndustry: Condition CodeIndustry: Condition CodeUB-92 Ref. [UB-Name]: 24 [Condition Codes]UB-92 Ref. [UB-Name]: 24 [Condition Codes]














































































































































Code Name



















Notes:Notes:1. Required when condition information applies to the claim or encounter.1. Required when condition information applies to the claim or encounter.

Example:Example:HI*BG:67~HI*BG:67~



HI Treatment Code Information Pos: 231 Max: 2Detail - Optional



















Description: Code indicating a code from a specific industry code listIndustry: Treatment CodeIndustry: Treatment CodeEMC v.6.0 Reference: Record Type 72 Field No. 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,EMC v.6.0 Reference: Record Type 72 Field No. 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,




29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 4229, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42





























































Description: To send health care codes and their associated dates, amounts and




quantitiesUsed when necessary to report multiple additional co-existing conditions.Used when necessary to report multiple additional co-existing conditions.






































Notes:Notes:1. Required when Home Health Agencies need to report Plan of Treatment information under various payercontracts.1. Required when Home Health Agencies need to report Plan of Treatment information under various payercontracts.

Example:Example:HI*TC:A01~HI*TC:A01~



QTY Claim Quantity Pos: 240 Max: 4Detail - Optional


User Option (Usage): SituationalPurpose: To specify quantity information

Element Summary: Ref Id Element Name Req Type Min/Max UsageQTY01 673 Quantity Qualifier M ID 2/2 Required

Description: Code specifying the type of quantity

CodeList Summary (Total Codes: 832, Included: 4)Code NameCA Covered - Actual

Description: Days covered on this serviceUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:7 [Covered Days]7 [Covered Days]


CD Co-insured - ActualUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:9 [Coinsurance Days]9 [Coinsurance Days]


LA Life-time Reserve - ActualDescription: Medicare hospital insurance includes extra hospital days to be used ifthe patient has a long illness and is required to stay in the hospital over a specifiednumber of days; this is the actual number of days in reserveUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:10 [Lifetime Reserve Days]10 [Lifetime Reserve Days]


NA Number of Non-covered DaysUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:8 [Non-Covered Days]8 [Non-Covered Days]


QTY02 380 Quantity C R 1/15 Required

Description: Numeric value of quantityIndustry: Claim Days CountIndustry: Claim Days Count

QTY03 C001 Composite Unit of Measure O Comp Required

Description: To identify a composite unit of measure(See Figures Appendix for examplesof use)

QTY03-01 355 Unit or Basis for Measurement Code M ID 2/2 Required





CodeList Summary (Total Codes: 794, Included: 1)Code NameDA Days

Syntax Rules: 1. R0204 - At least one of QTY02 or QTY04 is required.2. E0204 - Only one of QTY02 or QTY04 may be present.

Semantics: 1. QTY04 is used when the quantity is non-numeric.

Notes:Notes:1. Use the Quantity segment at the claim level Loop ID-2300 to transmit quantities that apply to the entire claim.2. Required on Inpatient claims or encounters when covered, co-insured, life-time reserved or non-covered daysare being reported.

1. Use the Quantity segment at the claim level Loop ID-2300 to transmit quantities that apply to the entire claim.2. Required on Inpatient claims or encounters when covered, co-insured, life-time reserved or non-covered daysare being reported.

Example:Example:QTY*LA*20*DA~QTY*LA*20*DA~



HCP Claim Pricing/RepricingInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageHCP01 1473 Pricing Methodology C ID 2/2 Required

Description: Code specifying pricing methodology at which the claim or line item has beenpriced or repricedAlias: Pricing MethodologyAlias: Pricing Methodology

Trading partners need to agree on which codes to use in this element. There do not appearto be standard definitions for the code elements.Trading partners need to agree on which codes to use in this element. There do not appearto be standard definitions for the code elements.



Description: Monetary amountIndustry: Repriced Allowed AmountIndustry: Repriced Allowed AmountAlias: Allowed AmountAlias: Allowed Amount


Description: Monetary amountIndustry: Repriced Saving AmountIndustry: Repriced Saving AmountAlias: Savings AmountAlias: Savings Amount







specified by the Reference Identification QualifierIndustry: Repricing Organization IdentifierIndustry: Repricing Organization IdentifierAlias: Repricing Organization IDAlias: Repricing Organization ID



Description: Rate expressed in the standard monetary denomination for the currencyspecifiedIndustry: Repricing Per Diem or Flat Rate AmountIndustry: Repricing Per Diem or Flat Rate AmountAlias: Pricing RateAlias: Pricing Rate



Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Repriced Approved DRG CodeIndustry: Repriced Approved DRG CodeAlias: Approved DRG CodeAlias: Approved DRG Code



Description: Monetary amountIndustry: Repriced Approved AmountIndustry: Repriced Approved AmountAlias: Approved DRG AmountAlias: Approved DRG Amount

This data element is required when it is necessary to report Approved DRG Amount onclaims which has been priced or repriced.This data element is required when it is necessary to report Approved DRG Amount onclaims which has been priced or repriced.




HCP09 235 Product/Service ID Qualifier C ID 2/2 Situational


Required when HCP10 exists.Required when HCP10 exists.


(HCPCS) CodesDescription: HCFA coding scheme to group procedure(s) performed on anoutpatient basis for payment to hospital under Medicare; primarily used forambulatory surgical and other diagnostic departments


Code Name


This code includes Current Procedural Terminology (CPT) and HCPCS coding.This code includes Current Procedural Terminology (CPT) and HCPCS coding.CODE SOURCE:CODE SOURCE:130: Health Care Financing Administration Common Procedural Coding System130: Health Care Financing Administration Common Procedural Coding System

HCP10 234 Product/Service ID C AN 1/48 Situational

Description: Identifying number for a product or serviceIndustry: Repriced Approved HCPCS CodeIndustry: Repriced Approved HCPCS CodeAlias: Approved Procedure CodeAlias: Approved Procedure Code

This data element is required when it is necessary to report Approved HCPCS Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Approved HCPCS Code onclaims which has been priced or repriced.


HCP11 355 Unit or Basis for Measurement Code C ID 2/2 Situational

Description: Code specifying the units in which a value is being expressed, or manner inwhich a measurement has been takenRequired when HCP12 exists.Required when HCP12 exists.


HCP12 380 Quantity C R 1/15 Situational

Description: Numeric value of quantityIndustry: Repriced Approved Service Unit CountIndustry: Repriced Approved Service Unit CountAlias: Approved Service UnitsAlias: Approved Service Units


HCP13 901 Reject Reason Code C ID 2/2 Situational

Description: Code assigned by issuer to identify reason for rejectionAlias: Rejection MessageAlias: Rejection Message




Description: Code specifying policy compliance




Alias: Policy Compliance CodeAlias: Policy Compliance Code

This data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.



Description: Code specifying the exception reason for consideration of out-of-networkhealth care servicesAlias: Exception Reason CodeAlias: Exception Reason Code

This data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.This data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.






submitted values.



Notes:Notes:1. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualifyother information within the claim.2. This segment is used when the sender is required to provide the receiver with pricing or repricing informationnecessary to process the claim or encounter.

1. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualifyother information within the claim.2. This segment is used when the sender is required to provide the receiver with pricing or repricing informationnecessary to process the claim or encounter.




Loop Home Health Care PlanInformation




Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage242 CR7 Home Health Care Plan Information O 1 Situational243 HSD Health Care Services Delivery O 12 Situational







CR7 Home Health Care PlanInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageCR701 921 Discipline Type Code M ID 2/2 Required

Description: Code indicating disciplines ordered by a physicianAlias: Disipline Type CodeAlias: Disipline Type CodeEMC v.6.0 Reference: Record Type 72 Field No. 4EMC v.6.0 Reference: Record Type 72 Field No. 4

CodeList Summary (Total Codes: 6, Included: 6)Code NameAI Home Health AideMS Medical Social WorkerOT Occupational TherapyPT Physical TherapySN Skilled NursingST Speech Therapy


Description: A generic numberIndustry: Visits Prior to Recertification Date CountIndustry: Visits Prior to Recertification Date CountAlias: Total Visits Prior to Recertification DateAlias: Total Visits Prior to Recertification DateEMC v.6.0 Reference: Record Type 72 Field No. 5EMC v.6.0 Reference: Record Type 72 Field No. 5


Description: A generic numberIndustry: Total Visits Projected This Certification CountIndustry: Total Visits Projected This Certification CountAlias: Total Visits Projected During Certification PeriodAlias: Total Visits Projected During Certification PeriodEMC v.6.0 Reference: Record Type 72 Field No. 43EMC v.6.0 Reference: Record Type 72 Field No. 43







HSD Health Care ServicesDelivery



User Option (Usage): SituationalPurpose: To specify the delivery pattern of health care services

Element Summary: Ref Id Element Name Req Type Min/Max UsageHSD01 673 Quantity Qualifier C ID 2/2 Situational

Description: Code specifying the type of quantityIndustry: VisitsIndustry: VisitsAlias: Quantity QualifierAlias: Quantity Qualifier


CodeList Summary (Total Codes: 832, Included: 1)Code NameVS Visits

HSD02 380 Quantity C R 1/15 Situational

Description: Numeric value of quantityIndustry: Number of VisitsIndustry: Number of VisitsAlias: Frequency Number - 1Alias: Frequency Number - 1EMC v.6.0 Reference: Record Type 72 Field No. 6 (position 1)EMC v.6.0 Reference: Record Type 72 Field No. 6 (position 1)


HSD03 355 Unit or Basis for Measurement Code O ID 2/2 Situational

Description: Code specifying the units in which a value is being expressed, or manner inwhich a measurement has been takenIndustry: Frequency PeriodIndustry: Frequency PeriodAlias: Frequency Period - 1Alias: Frequency Period - 1EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 2-3)EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 2-3)


CodeList Summary (Total Codes: 794, Included: 4)Code NameDA DaysMO MonthsQ1 Quarter (Time)WK Week

HSD04 1167 Sample Selection Modulus O R 1/6 Situational

Description: To specify the sampling frequency in terms of a modulus of the Unit ofMeasure, e.g., every fifth bag, every 1.5 minutesIndustry: Frequency CountIndustry: Frequency Count


HSD05 615 Time Period Qualifier C ID 1/2 Situational




Description: Code defining periodsIndustry: Duration of Visits UnitsIndustry: Duration of Visits UnitsAlias: Frequency Time PeriodAlias: Frequency Time Period

Absence of data indicates PRN orders.Required if the physician’s order or prescription for the service contains the data.Absence of data indicates PRN orders.Required if the physician’s order or prescription for the service contains the data.

CodeList Summary (Total Codes: 36, Included: 2)Code Name7 Day35 Week

HSD06 616 Number of Periods O N0 1/3 Situational

Description: Total number of periodsIndustry: Duration of Visits, Number of UnitsIndustry: Duration of Visits, Number of UnitsAlias: Duration - 1Alias: Duration - 1EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 4-6)EMC v.6.0 Reference: Record Type 72 Field No. 6 (positions 4-6)


HSD07 678 Ship/Delivery or Calendar Pattern Code O ID 1/2 Situational

Description: Code which specifies the routine shipments, deliveries, or calendar patternIndustry: Ship, Delivery or Calendar Pattern CodeIndustry: Ship, Delivery or Calendar Pattern Code


CodeList Summary (Total Codes: 44, Included: 34)Code Name1 1st Week of the Month2 2nd Week of the Month3 3rd Week of the Month4 4th Week of the Month5 5th Week of the Month6 1st & 3rd Weeks of the Month7 2nd & 4th Weeks of the Month8 1st Working Day of Period9 Last Working Day of PeriodA Monday through FridayB Monday through SaturdayC Monday through SundayD MondayE TuesdayF WednesdayG ThursdayH FridayJ SaturdayK SundayL Monday through ThursdayN As DirectedO Daily Mon. through Fri.


Code Name


S Once Anytime Mon. through Fri.W Whenever NecessarySA Sunday, Monday, Thursday, Friday, SaturdaySB Tuesday through SaturdaySC Sunday, Wednesday, Thursday, Friday, SaturdaySD Monday, Wednesday, Thursday, Friday, SaturdaySG Tuesday through FridaySL Monday, Tuesday and ThursdaySP Monday, Tuesday and FridaySX Wednesday and ThursdaySY Monday, Wednesday and ThursdaySZ Tuesday, Thursday and Friday

HSD08 679 Ship/Delivery Pattern Time Code O ID 1/1 Situational

Description: Code which specifies the time for routine shipments or deliveriesIndustry: Delivery Pattern Time CodeIndustry: Delivery Pattern Time Code


CodeList Summary (Total Codes: 9, Included: 3)Code NameD A.M.E P.M.F As Directed

Syntax Rules: 1. P0102 - If either HSD01 or HSD02 is present, then the other is required.2. C0605 - If HSD06 is present, then HSD05 is required.

Notes:Notes:1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearlysubstantiate medical treatment.2. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.Between HDS02 and HSD03 verbally insert a “per every.” HSD03 qualifies HSD04: If the value in HSD04=3 andthe value in HSD03=DA (Day), this means “three days.” Between HSD04 and HSD05 verbally insert a “for.”HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.” Thetotal message reads: HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”3. Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.4. An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means“1 visit on Wednesday and Thursday morning.”

1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearlysubstantiate medical treatment.2. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.Between HDS02 and HSD03 verbally insert a “per every.” HSD03 qualifies HSD04: If the value in HSD04=3 andthe value in HSD03=DA (Day), this means “three days.” Between HSD04 and HSD05 verbally insert a “for.”HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.” Thetotal message reads: HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”3. Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.4. An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means“1 visit on Wednesday and Thursday morning.”

Example:Example:HSD*VS*1*DA**7*10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days.")HSD*VS*1*DA~ (This indicates one visit per day.)HSD*VS*1*DA**7*10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days.")HSD*VS*1*DA~ (This indicates one visit per day.)




Loop:2310A

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage250 NM1 Attending Physician Name O 1 Situational255 PRV Attending Physician Specialty Information O 1 Situational271 REF Attending Physician Secondary










Loop:2310A

Elements: 8










Description: Individual last name or organizational nameIndustry: Attending Physician Last NameIndustry: Attending Physician Last NameUB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]UB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 91-106 (Also maps toRecord Type 71 Field No. 20 if you are creating this attachment)EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 91-106 (Also maps toRecord Type 71 Field No. 20 if you are creating this attachment)


Description: Individual first nameIndustry: Attending Physician First NameIndustry: Attending Physician First NameUB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]UB-92 Ref. [UB-Name]: 82, Line b [Attending Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 107-114 (Also maps to EMCv.4.1 Record Type 71 Field No. 21 if you are creating this attachment)EMC v.6.0 Reference: Record Type 80 Field No. 9, Positions 107-114 (Also maps to EMCv.4.1 Record Type 71 Field No. 21 if you are creating this attachment)Required if NM102=1 (person).Required if NM102=1 (person).








Description: Suffix to individual nameIndustry: Attending Physician Name SuffixIndustry: Attending Physician Name Suffix



Description: Code designating the system/method of code structure used for IdentificationCode (67)EMC v.6.0 Reference: Record Type 80 Field No. 4 (The National Registry for Medicareassigns the UPIN to the provider for identification purposes.)EMC v.6.0 Reference: Record Type 80 Field No. 4 (The National Registry for Medicareassigns the UPIN to the provider for identification purposes.)




Description: Code identifying a party or other codeIndustry: Attending Physician Primary IdentifierIndustry: Attending Physician Primary IdentifierUB-92 Ref. [UB-Name]: 82, Line a [Attending Physician ID]UB-92 Ref. [UB-Name]: 82, Line a [Attending Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 5EMC v.6.0 Reference: Record Type 80 Field No. 5User Note 6: The attending provider information must be provided when the services are being billed bysomeone other than the billing or pay to provider.(i.e., group, clinic, etc.)

User Note 6: The attending provider information must be provided when the services are being billed bysomeone other than the billing or pay to provider.(i.e., group, clinic, etc.)







Example:Example:



NM1*71*1*JONES*JOHN****XX*12345678~NM1*71*1*JONES*JOHN****XX*12345678~

User Note 6:User Note 6:The attending provider information must be provided when the services are being billed by someone other than thebilling or pay to provider.(i.e., group, clinic, etc.)

The attending provider information must be provided when the services are being billed by someone other than thebilling or pay to provider.(i.e., group, clinic, etc.)



PRV Attending PhysicianSpecialty Information


Loop:2310A

Elements: 3



Description: Code identifying the type of provider

CodeList Summary (Total Codes: 26, Included: 2)Code NameAT AttendingSU Supervising





Provider Taxonomy CodeProvider Taxonomy Code


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Provider Taxonomy CodeIndustry: Provider Taxonomy CodeAlias: Provider Specialty CodeAlias: Provider Specialty Code


Notes:Notes:1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by thepresence of a PRV segment with the same value in PRV01.2. Use code value AT to report the specialty of the attending physician. Use code value SU when the physician isresponsible for the patient’s Home Health Plan of Treatment. 3. PRV02 qualifies PRV03.4. Required when the billing provider is a billing service and taxonomy is know to impact the adjudication of theclaim.

1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by thepresence of a PRV segment with the same value in PRV01.2. Use code value AT to report the specialty of the attending physician. Use code value SU when the physician isresponsible for the patient’s Home Health Plan of Treatment. 3. PRV02 qualifies PRV03.4. Required when the billing provider is a billing service and taxonomy is know to impact the adjudication of theclaim.

Example:Example:PRV*AT*ZZ*363LP0200N~PRV*AT*ZZ*363LP0200N~





Loop:2310A

Elements: 2














Example:Example:



REF*1G*A12345~REF*1G*A12345~




Loop:2310B

Elements: N/A












Loop:2310B

Elements: 8










Description: Individual last name or organizational nameIndustry: Operating Physician Last NameIndustry: Operating Physician Last NameUB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 10, Positions 116-131.EMC v.6.0 Reference: Record Type 80 Field No. 10, Positions 116-131.


Description: Individual first nameIndustry: Operating Physician First NameIndustry: Operating Physician First NameUB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83A, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 10, Position 132-139EMC v.6.0 Reference: Record Type 80 Field No. 10, Position 132-139



This data element is required when NM102 equals one (1) and the Middle Name or Initialof the person is known by the provider.This data element is required when NM102 equals one (1) and the Middle Name or Initialof the person is known by the provider.


Description: Suffix to individual nameIndustry: Operating Physician Name SuffixIndustry: Operating Physician Name Suffix










Description: Code identifying a party or other codeIndustry: Operating Physician Primary IdentifierIndustry: Operating Physician Primary IdentifierUB-92 Ref. [UB-Name]: 83A, Line a [Other Physician ID]UB-92 Ref. [UB-Name]: 83A, Line a [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 6EMC v.6.0 Reference: Record Type 80 Field No. 6












Loop:2310B

Elements: 2














Example:Example:



REF*1G*A12345~REF*1G*A12345~




Loop:2310C

Elements: N/A





Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required when the claim/encounter involves an other provider such as, but not limited to: Referring Provider,Ordering Provider, Assisting Provider, etc.

1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2420 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required when the claim/encounter involves an other provider such as, but not limited to: Referring Provider,Ordering Provider, Assisting Provider, etc.





Loop:2310C

Elements: 8










Description: Individual last name or organizational nameIndustry: Other Physician Last NameIndustry: Other Physician Last NameUB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 11, 12EMC v.6.0 Reference: Record Type 80 Field No. 11, 12


Description: Individual first nameIndustry: Other Physician First NameIndustry: Other Physician First NameUB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]UB-92 Ref. [UB-Name]: 83B, Line b [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 11, 12EMC v.6.0 Reference: Record Type 80 Field No. 11, 12




Required when NM102=1-Person and the Middle Name or Initial of the person is known bythe provider.Required when NM102=1-Person and the Middle Name or Initial of the person is known bythe provider.


Description: Suffix to individual name




Industry: Other Provider Name SuffixIndustry: Other Provider Name Suffix

Other Provider GenerationRequired if known.Other Provider GenerationRequired if known.






Description: Code identifying a party or other codeIndustry: Other Physician IdentifierIndustry: Other Physician IdentifierAlias: Other Physician Primary IDAlias: Other Physician Primary IDUB-92 Ref. [UB-Name]: 83B, Line a [Other Physician ID]UB-92 Ref. [UB-Name]: 83B, Line a [Other Physician ID]EMC v.6.0 Reference: Record Type 80 Field No. 7








Notes:Notes:1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2410 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required on all outpatient and home health claims/encounters to indicate the person or organization (HomeHealth Agency) who rendered the care. In the case where a subsitute provider (locum tenans) was used, thatperson should be entered here. Required when the Other Provider NM1 information is different than that carriedin either the Billing Provider NM1 or the Pay-to Provider in the 2010AA/AB loops.4. Required on non-outpatient (e.g inpatient, SNF, ICF etc.) claims or encounters to indicate the physician whorendered service for the principal procedure if other than the operating physician reported in Loop 2310B. Notrequired on non-outpatient claims or ncounters if no principal procedure was performed.

1. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a service line by the presenceof Loop ID-2410 with the same value in NM101.2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.3. Required on all outpatient and home health claims/encounters to indicate the person or organization (HomeHealth Agency) who rendered the care. In the case where a subsitute provider (locum tenans) was used, thatperson should be entered here. Required when the Other Provider NM1 information is different than that carriedin either the Billing Provider NM1 or the Pay-to Provider in the 2010AA/AB loops.4. Required on non-outpatient (e.g inpatient, SNF, ICF etc.) claims or encounters to indicate the physician whorendered service for the principal procedure if other than the operating physician reported in Loop 2310B. Notrequired on non-outpatient claims or ncounters if no principal procedure was performed.




User Note 6:User Note 6:To indicate Self Referral for Point of Service (POS)For Institutional EDI claims Loop 2310C NM103= SELFREFERRAL Loop 2310C NM104= leave blank First Name = SELFREFERRAL Use Generic NPI =1002233777 Sample: NM1*73*2*SELFREFERRAL*****XX*1002233777~

To indicate Self Referral for Point of Service (POS)For Institutional EDI claims Loop 2310C NM103= SELFREFERRAL Loop 2310C NM104= leave blank First Name = SELFREFERRAL Use Generic NPI =1002233777 Sample: NM1*73*2*SELFREFERRAL*****XX*1002233777~





Loop:2310C

Elements: 2



Description: Code qualifying the Reference IdentificationUser Note 6: Use 0B for CA State license #Use 1B for BSC Provider IDDo not use if the information is the same as 2310 Loop











Notes:Notes:



1. Use this REF only when a second number is necessary to identify the provider. The primary identification mustbe contained in NM109.1. Use this REF only when a second number is necessary to identify the provider. The primary identification mustbe contained in NM109.




Loop Service Facility Name Pos: 250 Repeat: 1Optional

Loop:2310E

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage250 NM1 Service Facility Name O 1 Situational265 N3 Service Facility Address O 1 Required270 N4 Service Facility City/State/Zip Code O 1 Required271 REF Service Facility Secondary Identification O 5 Situational








NM1 Service Facility Name Pos: 250 Max: 1Detail - Optional

Loop:2310E

Elements: 5









Description: Individual last name or organizational nameIndustry: Laboratory or Facility NameIndustry: Laboratory or Facility NameAlias: Laboratory/Facility NameAlias: Laboratory/Facility Name


Description: Code designating the system/method of code structure used for IdentificationCode (67)Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.




Description: Code identifying a party or other codeIndustry: Laboratory or Facility Primary IdentifierIndustry: Laboratory or Facility Primary IdentifierAlias: Laboratory/Facility Primary IdentifierAlias: Laboratory/Facility Primary Identifier

Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.Required if either Employer’s Identification/Social Security Number or National ProviderIdentifier is known.













N3 Service Facility Address Pos: 265 Max: 1Detail - Optional

Loop:2310E

Elements: 2



Description: Address informationIndustry: Laboratory or Facility Address LineIndustry: Laboratory or Facility Address LineAlias: Laboratory/Facility Address 1Alias: Laboratory/Facility Address 1


Description: Address informationIndustry: Laboratory or Facility Address LineIndustry: Laboratory or Facility Address Line





N4 Service Facility City/State/ZipCode


Loop:2310E

Elements: 4



Description: Free-form text for city nameIndustry: Laboratory or Facility City NameIndustry: Laboratory or Facility City NameAlias: Laboratory/Facility CityAlias: Laboratory/Facility City


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Laboratory or Facility State or Province CodeIndustry: Laboratory or Facility State or Province CodeAlias: Laboratory/Facility StateAlias: Laboratory/Facility State



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Laboratory or Facility Postal Zone or ZIP CodeIndustry: Laboratory or Facility Postal Zone or ZIP CodeAlias: Laboratory/Facility Zip CodeAlias: Laboratory/Facility Zip Code



Description: Code identifying the countryAlias: Laboratory/Facility Country CodeAlias: Laboratory/Facility Country Code

Required if the address is out of the U.S.Required if the address is out of the U.S.






Example:Example:N4*ANY TOWN*TX*75123~N4*ANY TOWN*TX*75123~



REF Service Facility SecondaryIdentification


Loop:2310E

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 15)Code Name0B State License Number1A Blue Cross Provider Number1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider Number1G Provider UPIN Number1H CHAMPUS Identification Number1J Facility ID NumberEI Employer's Identification NumberFH Clinic Number


Description: A unique number assigned to a provider by a commercial insurerG5 Provider Site NumberLU Location NumberN5 Provider Plan Network Identification Number




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Laboratory or Facility Secondary IdentifierIndustry: Laboratory or Facility Secondary Identifier









Loop Other Subscriber Information Pos: 290 Repeat: 10Optional



Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage290 SBR Other Subscriber Information O 1 Situational295 CAS Claim Level Adjustment O 5 Situational300 AMT Payer Prior Payment O 1 Situational300 AMT Coordination of Benefits (COB) Total

Allowed AmountO 1 Situational

300 AMT Coordination of Benefits (COB) TotalSubmitted Charges

O 1 Situational

300 AMT Diagnostic Related Group (DRG) OutlierAmount

O 1 Situational

300 AMT Coordination of Benefits (COB) TotalMedicare Paid Amount

O 1 Situational

300 AMT Medicare Paid Amount - 100% O 1 Situational300 AMT Medicare Paid Amount - 80% O 1 Situational300 AMT Coordination of Benefits (COB) Medicare A

Trust Fund Paid AmountO 1 Situational

300 AMT Coordination of Benefits (COB) Medicare BTrust Fund Paid Amount

O 1 Situational

300 AMT Coordination of Benefits (COB) TotalNon-covered Amount

O 1 Situational

300 AMT Coordination of Benefits (COB) TotalDenied Amount

O 1 Situational

305 DMG Other Subscriber Demographic Information O 1 Situational310 OI Other Insurance Coverage Information O 1 Required315 MIA Medicare Inpatient Adjudication


320 MOA Medicare Outpatient AdjudicationInformation

O 1 Situational

325 Loop 2330A O 1 Required325 Loop 2330B O 1 Required325 Loop 2330C O 1 Situational325 Loop 2330D O 1 Situational325 Loop 2330E O 1 Situational325 Loop 2330F O 1 Situational325 Loop 2330H O 1 Situational










SBR Other SubscriberInformation













































Code Name



Used to indicate “payer of last resort”.Used to indicate “payer of last resort”.

SBR02 1069 Individual Relationship Code O ID 2/2 Required

Description: Code indicating the relationship between two individuals or entitiesUB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]UB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)








15 WardUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 07 [Ward of the Court]59 Code 07 [Ward of the Court]


18 SelfUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 01 [Patient Is Insured]59 Code 01 [Patient Is Insured]



21 UnknownUB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:


Code Name


59 Code 09 [Unknown]59 Code 09 [Unknown]22 Handicapped Dependent

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:59 Code 10 [Handicapped Dependent]59 Code 10 [Handicapped Dependent]












Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Insured Group or Policy NumberIndustry: Insured Group or Policy Number




UB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number]UB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number]EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03) Insurance GroupNo.EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03) Insurance GroupNo.Use this element to carry the subscriber’s group number but not the number that uniquelyidentifies the subscriber. The subscriber’s number should be carried in NM109. Using codeIL in NM101 identifies the number in NM109 as the insured’s Identification Number.



Description: Free-form nameIndustry: Other Insured Group NameIndustry: Other Insured Group NameUB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name]UB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name]EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03)




Description: Code identifying type of claimEMC v.6.0 Reference: Record Type 30 Field No. 4 (Sequence 01-03. See SBR09 inLOOP 2000B for EMC code translation.)EMC v.6.0 Reference: Record Type 30 Field No. 4 (Sequence 01-03. See SBR09 inLOOP 2000B for EMC code translation.)Required prior to mandated used of PlanID. Not used after PlanID is mandated.Required prior to mandated used of PlanID. Not used after PlanID is mandated.

CodeList Summary (Total Codes: 45, Included: 24)Code Name09 Self-pay10 Central Certification11 Other Non-Federal Programs12 Preferred Provider Organization (PPO)13 Point of Service (POS)14 Exclusive Provider Organization (EPO)15 Indemnity Insurance16 Health Maintenance Organization (HMO) Medicare RiskAM Automobile MedicalBL Blue Cross/Blue ShieldCH ChampusCI Commercial Insurance Co.DS DisabilityHM Health Maintenance OrganizationLI LiabilityLM Liability MedicalMA Medicare Part AMB Medicare Part BMC MedicaidOF Other Federal ProgramTV Title VVA Veteran Administration Plan

Refers to Veterans Affairs Plan.Refers to Veterans Affairs Plan.WC Workers' Compensation Health Claim


Code Name


ZZ Mutually DefinedUnknownUnknown








CAS Claim Level Adjustment Pos: 295 Max: 5Detail - Optional




Description: Code identifying the general category of payment adjustmentEMC v.6.0 Reference: Record Type 42 Field No. 5EMC v.6.0 Reference: Record Type 42 Field No. 5









Use this number for the units of service being adjusted.Use this number for the units of service being adjusted.




ExternalCodeList



Name: 139 Description: Claim Adjustment Reason Code



























































Notes:Notes:1. Submitter should use this CAS segment to report prior payers claim level adjustments that cause the amountpaid to differ from the amount originally charged.2. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim

1. Submitter should use this CAS segment to report prior payers claim level adjustments that cause the amountpaid to differ from the amount originally charged.2. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim





Example:Example:CAS*CO*96*555.52~CAS*CO*96*555.52~



AMT Payer Prior Payment Pos: 300 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameC4 Prior Payment - Actual

Description: Amount paid in reality at an earlier time


Description: Monetary amountIndustry: Other Payer Patient Paid AmountIndustry: Other Payer Patient Paid AmountUB-92 Ref. [UB-Name]: 54 (A-C) [Prior Payments - Payers and Patient]UB-92 Ref. [UB-Name]: 54 (A-C) [Prior Payments - Payers and Patient]EMC v.6.0 Reference: Record Type 30 Field No. 25 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 25 (Sequence 01-03)

Notes:Notes:1. The amount this payer has paid to the provider towards this bill.2. This segment is required when the present payer has paid an amount to the provider towards this bill.1. The amount this payer has paid to the provider towards this bill.2. This segment is required when the present payer has paid an amount to the provider towards this bill.

Example:Example:AMT*C4*150~AMT*C4*150~



AMT Coordination of Benefits(COB) Total AllowedAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameB6 Allowed - Actual

Description: Amount considered for payment under the provisions of the contract


Description: Monetary amountIndustry: Allowed AmountIndustry: Allowed AmountEMC v.6.0 Reference: Record Type 92 Field No. 8 (For COB use. Use this amount for thetotal claim level charges allowed.)EMC v.6.0 Reference: Record Type 92 Field No. 8 (For COB use. Use this amount for thetotal claim level charges allowed.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Allowed Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Allowed Amount applicable to this claim when known.

Example:Example:AMT*B6*3794.82~AMT*B6*3794.82~



AMT Coordination of Benefits(COB) Total SubmittedCharges






CodeList Summary (Total Codes: 1473, Included: 1)Code NameT3 Total Submitted Charges


Description: Monetary amountIndustry: Coordination of Benefits Total Submitted Charge AmountIndustry: Coordination of Benefits Total Submitted Charge AmountEMC v.6.0 Reference: Record Type 92 Field No. 6 (For COB use. Use this amount for thetotal claim level submitted charges.)EMC v.6.0 Reference: Record Type 92 Field No. 6 (For COB use. Use this amount for thetotal claim level submitted charges.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Submitted Charges applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Submitted Charges applicable to this claim when known.

Example:Example:AMT*T3*7490.7~AMT*T3*7490.7~



AMT Diagnostic Related Group(DRG) Outlier Amount








Description: Monetary amountIndustry: Claim DRG Outlier AmountIndustry: Claim DRG Outlier Amount

Record Type 92 Field No. 15 (For COB use [temporary qualifier]. Use this amount for theDRG outlier amount.)Record Type 92 Field No. 15 (For COB use [temporary qualifier]. Use this amount for theDRG outlier amount.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the DRG Outlier Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the DRG Outlier Amount applicable to this claim when known.

Example:Example:AMT*ZZ*9034.7~AMT*ZZ*9034.7~



AMT Coordination of Benefits(COB) Total Medicare PaidAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameN1 Net Worth


Description: Monetary amountIndustry: Total Medicare Paid AmountIndustry: Total Medicare Paid Amount

Record Type 92 Field No. 9 (For COB use [temporary qualifier]. Use this amount for thetotal Medicare reimbursement.)Record Type 92 Field No. 9 (For COB use [temporary qualifier]. Use this amount for thetotal Medicare reimbursement.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Medicare Paid Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Medicare Paid Amount applicable to this claim when known.

Example:Example:AMT*N1*873.4~AMT*N1*873.4~



AMT Medicare Paid Amount -100%






CodeList Summary (Total Codes: 1473, Included: 1)Code NameKF Net Paid Amount




Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount -100% applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount -100% applicable to this claim when known.

Example:Example:AMT*KF*73.01~AMT*KF*73.01~



AMT Medicare Paid Amount - 80% Pos: 300 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NamePG Payoff




Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount - 80% applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Medicare Paid Amount - 80% applicable to this claim when known.

Example:Example:AMT*PG*639.4~AMT*PG*639.4~



AMT Coordination of Benefits(COB) Medicare A TrustFund Paid Amount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameAA Allocated


Description: Monetary amountIndustry: Paid From Part A Medicare Trust Fund AmountIndustry: Paid From Part A Medicare Trust Fund Amount

Record Type 93 Field No. 6 (For COB use [temporary qualifier]. Use this amount for theamount paid from the Medicare A trust fund.)Record Type 93 Field No. 6 (For COB use [temporary qualifier]. Use this amount for theamount paid from the Medicare A trust fund.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare A Trust Fund Paid Amount applicable to this claim whenknown.

1. This segment is for COB use.2. This segment is used to convey the COB Medicare A Trust Fund Paid Amount applicable to this claim whenknown.

Example:Example:AMT*AA*4394.7~AMT*AA*4394.7~



AMT Coordination of Benefits(COB) Medicare B TrustFund Paid Amount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameB1 Benefit Amount

Use this qualifier until a more suitable one is developed. At this time, B1represents the Paid From Medicare B Trust Fund Amount.Use this qualifier until a more suitable one is developed. At this time, B1represents the Paid From Medicare B Trust Fund Amount.


Description: Monetary amountIndustry: Paid From Part B Medicare Trust Fund AmountIndustry: Paid From Part B Medicare Trust Fund AmountEMC v.6.0 Reference: Record Type 93 Field No. 7 (For COB use [temporary qualifier].Use this amount for the amount paid from the Medicare B trust fund.)EMC v.6.0 Reference: Record Type 93 Field No. 7 (For COB use [temporary qualifier].Use this amount for the amount paid from the Medicare B trust fund.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Medicare B Trust Fund Paid Amount applicable to this claim whenknown.

1. This segment is for COB use.2. This segment is used to convey the COB Medicare B Trust Fund Paid Amount applicable to this claim whenknown.

Example:Example:AMT*B1*150~AMT*B1*150~



AMT Coordination of Benefits(COB) Total Non-coveredAmount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameA8 Noncovered Charges - Actual

Description: Calculated value not covered by the benefit plan


Description: Monetary amountIndustry: Non-Covered Charge AmountIndustry: Non-Covered Charge AmountEMC v.6.0 Reference: Record Type 92 Field No. 7 (For COB use [temporary qualifier].Use this amount for the total of non-covered claim level charges.)EMC v.6.0 Reference: Record Type 92 Field No. 7 (For COB use [temporary qualifier].Use this amount for the total of non-covered claim level charges.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Non-Covered Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Non-Covered Amount applicable to this claim when known.

Example:Example:AMT*A8*273~AMT*A8*273~



AMT Coordination of Benefits(COB) Total Denied Amount






CodeList Summary (Total Codes: 1473, Included: 1)Code NameYT Denied


Description: Monetary amountIndustry: Claim Total Denied Charge AmountIndustry: Claim Total Denied Charge AmountEMC v.6.0 Reference: Record Type 92 Field No. 16 (For COB use. Use this amount forthe total claim level denied charges.)EMC v.6.0 Reference: Record Type 92 Field No. 16 (For COB use. Use this amount forthe total claim level denied charges.)

Notes:Notes:1. This segment is for COB use.2. This segment is used to convey the COB Total Denied Amount applicable to this claim when known.1. This segment is for COB use.2. This segment is used to convey the COB Total Denied Amount applicable to this claim when known.

Example:Example:AMT*YT*32~AMT*YT*32~



DMG Other SubscriberDemographic Information








Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Other Insured Birth DateIndustry: Other Insured Birth Date


Description: Code indicating the sex of the individualIndustry: Other Insured Gender CodeIndustry: Other Insured Gender CodeEMC v.6.0 Reference: Record Type 30 Field No. 15EMC v.6.0 Reference: Record Type 30 Field No. 15




Notes:Notes:1. Required when 2330A - Other Subscriber Name NM102 = 1 (Person).1. Required when 2330A - Other Subscriber Name NM102 = 1 (Person).

Example:Example:DMG***F~DMG***F~



OI Other Insurance CoverageInformation



User Option (Usage): RequiredPurpose: To specify information associated with other health insurance coverage

Element Summary: Ref Id Element Name Req Type Min/Max UsageOI03 1073 Yes/No Condition or Response Code O ID 1/1 Required

Description: Code indicating a Yes or No condition or responseIndustry: Benefits Assignment Certification IndicatorIndustry: Benefits Assignment Certification IndicatorEMC v.6.0 Reference: Record Type 30 Field No. 17EMC v.6.0 Reference: Record Type 30 Field No. 17

Assignment of Benefits IndicatorAssignment of Benefits Indicator


OI06 1363 Release of Information Code O ID 1/1 Required

Description: Code indicating whether the provider has on file a signed statement by thepatient authorizing the release of medical data to other organizationsEMC v.6.0 Reference: Record Type 30 Field No. 16EMC v.6.0 Reference: Record Type 30 Field No. 16





N No, Provider is Not Allowed to Release DataEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 16 Code NRecord Type 30 Field No. 16 Code N


Related to a ClaimEMC v.6.0 Reference:EMC v.6.0 Reference:Record Type 30 Field No. 16 Code YRecord Type 30 Field No. 16 Code Y

Semantics: 1. OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes


Notes:Notes:



1. All information contained in the OI segment applies only to the payer who is identified in the 2330B loop of thisiteration of the 2320 loop. It is specific only to that payer.1. All information contained in the OI segment applies only to the payer who is identified in the 2330B loop of thisiteration of the 2320 loop. It is specific only to that payer.

Example:Example:OI***Y***Y~OI***Y***Y~



MIA Medicare InpatientAdjudication Information



User Option (Usage): SituationalPurpose: To provide claim-level data related to the adjudication of Medicare inpatient claims

Element Summary: Ref Id Element Name Req Type Min/Max UsageMIA01 380 Quantity M R 1/15 Required

Description: Numeric value of quantityIndustry: Covered Days or Visits CountIndustry: Covered Days or Visits Count


Description: Numeric value of quantityIndustry: Lifetime Reserve Days CountIndustry: Lifetime Reserve Days Count

Use this quantity to indicate the lifetime reserve days.Use this quantity to indicate the lifetime reserve days.


Description: Numeric value of quantityIndustry: Lifetime Psychiatric Days CountIndustry: Lifetime Psychiatric Days CountEMC v.6.0 Reference: Record Type 92 Field No. 18EMC v.6.0 Reference: Record Type 92 Field No. 18


Description: Monetary amountIndustry: Claim DRG AmountIndustry: Claim DRG AmountEMC v.6.0 Reference: Record Type 92 Field No. 14EMC v.6.0 Reference: Record Type 92 Field No. 14

Use this amount to indicate the Diagnosis Related Group (DRG) amount.Use this amount to indicate the Diagnosis Related Group (DRG) amount.






Description: Monetary amountIndustry: Claim Disproportionate Share AmountIndustry: Claim Disproportionate Share Amount

Use this amount to indicate the disproportionate share amount.Use this amount to indicate the disproportionate share amount.


Description: Monetary amount




Industry: Claim MSP Pass-through AmountIndustry: Claim MSP Pass-through Amount

Use this amount to indicate the Medicare Secondary Payer (MSP) pass-through amount.Use this amount to indicate the Medicare Secondary Payer (MSP) pass-through amount.


Description: Monetary amountIndustry: Claim PPS Capital AmountIndustry: Claim PPS Capital Amount

Use this amount to indicate the Total Prospective Payment System (PPS) capital amount.Use this amount to indicate the Total Prospective Payment System (PPS) capital amount.


Description: Monetary amountIndustry: PPS-Capital FSP DRG AmountIndustry: PPS-Capital FSP DRG Amount

Use this amount to indicate the Prospective Payment System (PPS) capital,federal-specific portion, Diagnosis Related Group (DRG) amount.Use this amount to indicate the Prospective Payment System (PPS) capital,federal-specific portion, Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: PPS-Capital HSP DRG AmountIndustry: PPS-Capital HSP DRG Amount

Use this amount to indicate the Prospective Payment System (PPS) capital,hospital-specific portion, Diagnosis Related Group (DRG) amount.Use this amount to indicate the Prospective Payment System (PPS) capital,hospital-specific portion, Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: PPS-Capital DSH DRG AmountIndustry: PPS-Capital DSH DRG Amount

Use this amount to indicate the Prospective Payment System (PPS) capital,disproportionate share, hospital Diagnosis Related Group (DRG) amount.Use this amount to indicate the Prospective Payment System (PPS) capital,disproportionate share, hospital Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: Old Capital AmountIndustry: Old Capital Amount

Use this amount to indicate the old capital amount.Use this amount to indicate the old capital amount.


Description: Monetary amountIndustry: PPS-Capital IME amountIndustry: PPS-Capital IME amount

Use this amount to indicate the Prospective Payment System (PPS) capital indirectmedical education claim amount.Use this amount to indicate the Prospective Payment System (PPS) capital indirectmedical education claim amount.


Description: Monetary amountIndustry: PPS-Operating Hospital Specific DRG AmountIndustry: PPS-Operating Hospital Specific DRG Amount

Use this amount to indicate the hospital-specific, Diagnosis Related Group (DRG) amount.Use this amount to indicate the hospital-specific, Diagnosis Related Group (DRG) amount.


Description: Numeric value of quantityIndustry: Cost Report Day CountIndustry: Cost Report Day CountEMC v.6.0 Reference: Record Type 92 Field No. 17EMC v.6.0 Reference: Record Type 92 Field No. 17





Description: Monetary amountIndustry: PPS-Operating Federal Specific DRG AmountIndustry: PPS-Operating Federal Specific DRG Amount

Use this amount to indicate the federal-specific, Diagnosis Related Group (DRG) amount.Use this amount to indicate the federal-specific, Diagnosis Related Group (DRG) amount.


Description: Monetary amountIndustry: Claim PPS Capital Outlier AmountIndustry: Claim PPS Capital Outlier Amount

Use this amount to indicate the Prospective Payment System (PPS) Capital Outlier amount.Use this amount to indicate the Prospective Payment System (PPS) Capital Outlier amount.


Description: Monetary amountIndustry: Claim Indirect Teaching AmountIndustry: Claim Indirect Teaching Amount

Use this amount to indicate the indirect teaching amount.Use this amount to indicate the indirect teaching amount.



Use this amount to indicate the professional component amount billed but not payable.Use this amount to indicate the professional component amount billed but not payable.











Use this reference identification for the Health Care Financing Administration claim Use this reference identification for the Health Care Financing Administration claim




payment remark code.payment remark code.







Description: Monetary amountIndustry: PPS-Capital Exception AmountIndustry: PPS-Capital Exception Amount

Use this amount to indicate the capital exception amount.Use this amount to indicate the capital exception amount.

Semantics: 1. MIA01 is the covered days.2. MIA02 is the lifetime reserve days.3. MIA03 is the lifetime psychiatric days.4. MIA04 is the Diagnosis Related Group (DRG) amount.5. MIA05 is the Claim Payment Remark Code. See Code Source 411.6. MIA06 is the disproportionate share amount.7. MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.8. MIA08 is the total Prospective Payment System (PPS) capital amount.9. MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group

(DRG) amount.10. MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group

(DRG), amount.11. MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related

Group (DRG) amount.12. MIA12 is the old capital amount.13. MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.14. MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.15. MIA15 is the cost report days.16. MIA16 is the federal specific Diagnosis Related Group (DRG) amount.17. MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.18. MIA18 is the indirect teaching amount.19. MIA19 is the professional component amount billed but not payable.20. MIA20 is the Claim Payment Remark Code. See Code Source 411.21. MIA21 is the Claim Payment Remark Code. See Code Source 411.22. MIA22 is the Claim Payment Remark Code. See Code Source 411.



23. MIA23 is the Claim Payment Remark Code. See Code Source 411.24. MIA24 is the capital exception amount.

Notes:Notes:1. This segment is used to convey the Medicare Inpatient Adjudication Information if returned in the 835.1. This segment is used to convey the Medicare Inpatient Adjudication Information if returned in the 835.

Example:Example:MIA*1***3568.98*MAO***************21***MA25~MIA*1***3568.98*MAO***************21***MA25~



MOA Medicare OutpatientAdjudication Information



User Option (Usage): SituationalPurpose: To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Element Summary: Ref Id Element Name Req Type Min/Max UsageMOA01 954 Percent O R 1/10 Situational

Description: Percentage expressed as a decimalIndustry: Reimbursement RateIndustry: Reimbursement RateEMC v.6.0 Reference: Record Type 92 Field No. 20EMC v.6.0 Reference: Record Type 92 Field No. 20

Required if returned on the Electronic Remittance Advice (835).Required if returned on the Electronic Remittance Advice (835).


Description: Monetary amountIndustry: Claim HCPCS Payable AmountIndustry: Claim HCPCS Payable Amount




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierUse this amount to indicate the Claim Health Care Financing Administration CommonProcedural Coding System (HCPCS) payable amount.Required if returned on the Electronic Remittance Advice (835).









Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Remark CodeIndustry: Remark Code




EMC v.6.0 Reference: Record Type 42 Field No. 25EMC v.6.0 Reference: Record Type 42 Field No. 25















Description: Monetary amountIndustry: Remark CodeIndustry: Remark CodeEMC v.6.0 Reference: Record Type 42 Field No. 28EMC v.6.0 Reference: Record Type 42 Field No. 28





Use this amount to indicate the professional component amount billed but not payable.Required if returned on the Electronic Remittance Advice (835).Use this amount to indicate the professional component amount billed but not payable.Required if returned on the Electronic Remittance Advice (835).

Semantics:



1. MOA01 is the reimbursement rate.2. MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS)

payable amount.3. MOA03 is the Claim Payment Remark Code. See Code Source 411.4. MOA04 is the Claim Payment Remark Code. See Code Source 411.5. MOA05 is the Claim Payment Remark Code. See Code Source 411.6. MOA06 is the Claim Payment Remark Code. See Code Source 411.7. MOA07 is the Claim Payment Remark Code. See Code Source 411.8. MOA08 is the End Stage Renal Disease (ESRD) payment amount.9. MOA09 is the professional component amount billed but not payable.

Notes:Notes:1. Required to convey the Medicare Outpatient Adjudication Information if returned in the Electronic RemittanceAdvice (835).1. Required to convey the Medicare Outpatient Adjudication Information if returned in the Electronic RemittanceAdvice (835).

Example:Example:MOA*12.5**MAO1~MOA*12.5**MAO1~



Loop Other Subscriber Name Pos: 325 Repeat: 1Optional

Loop:2330A

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Subscriber Name O 1 Required332 N3 Other Subscriber Address O 1 Situational340 N4 Other Subscriber City/State/ZIP Code O 1 Situational355 REF Other Subscriber Secondary Information O 3 Situational








NM1 Other Subscriber Name Pos: 325 Max: 1Detail - Optional

Loop:2330A

Elements: 8









Description: Individual last name or organizational nameIndustry: Other Insured Last NameIndustry: Other Insured Last NameAlias: Subscriber’s Last NameAlias: Subscriber’s Last NameUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 12 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 12 (Sequence 01-03)


Description: Individual first nameIndustry: Other Insured First NameIndustry: Other Insured First NameAlias: Subscriber’s First NameAlias: Subscriber’s First NameUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 13 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 13 (Sequence 01-03)



Description: Individual middle name or initialIndustry: Other Insured Middle NameIndustry: Other Insured Middle NameAlias: Subscriber’s Middle InitialAlias: Subscriber’s Middle InitialUB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]UB-92 Ref. [UB-Name]: 58 (A-C) [Insured’s Name]EMC v.6.0 Reference: Record Type 30 Field No. 14 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 14 (Sequence 01-03)






Description: Suffix to individual nameIndustry: Other Insured Name SuffixIndustry: Other Insured Name Suffix

Examples: I, II, III, IV, Jr, SrRequired if known.Examples: I, II, III, IV, Jr, SrRequired if known.






ZZ Mutually DefinedThe value ’ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.

The value ’ZZ’, when used in this data element shall be defined as “HIPAAIndividual Identifier” once this identifier has been adopted. Under the HealthInsurance Portability and Accountability Act of 1996, the Secretary of theDepartment of Health and Human Services must adopt a standard individualidentifier for use in this transaction.


Description: Code identifying a party or other codeIndustry: Other Insured IdentifierIndustry: Other Insured IdentifierAlias: Subscriber Primary IDAlias: Subscriber Primary IDUB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]UB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)









N3 Other Subscriber Address Pos: 332 Max: 1Detail - Optional

Loop:2330A

Elements: 2



Description: Address informationIndustry: Other Insured Address LineIndustry: Other Insured Address LineAlias: Subscriber’s Address 1Alias: Subscriber’s Address 1UB-92 Ref. [UB-Name]: 84, Line b [Remarks]UB-92 Ref. [UB-Name]: 84, Line b [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 4 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 4 (Sequence 01-03)


Description: Address informationIndustry: Other Insured Address LineIndustry: Other Insured Address LineAlias: Subscriber Address 2Alias: Subscriber Address 2EMC v.6.0 Reference: Record Type 31 Field No. 5 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 5 (Sequence 01-03)


Notes:Notes:1. This segment is required when the Provider has the Other Subscriber Address information on file.1. This segment is required when the Provider has the Other Subscriber Address information on file.




N4 Other SubscriberCity/State/ZIP Code


Loop:2330A

Elements: 4



Description: Free-form text for city nameIndustry: Other Insured City NameIndustry: Other Insured City NameAlias: Subscriber’s CityAlias: Subscriber’s CityUB-92 Ref. [UB-Name]: 84, Line c [Remarks]UB-92 Ref. [UB-Name]: 84, Line c [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 6 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 6 (Sequence 01-03)


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Other Insured State CodeIndustry: Other Insured State CodeAlias: Subscriber’s StateAlias: Subscriber’s StateUB-92 Ref. [UB-Name]: 84, Line c [Remarks]UB-92 Ref. [UB-Name]: 84, Line c [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 7 (Sequence 01-03)



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Other Insured Postal Zone or ZIP CodeIndustry: Other Insured Postal Zone or ZIP CodeAlias: Subscriber’s ZIP CodeAlias: Subscriber’s ZIP CodeUB-92 Ref. [UB-Name]: 84, Line d [Remarks]UB-92 Ref. [UB-Name]: 84, Line d [Remarks]EMC v.6.0 Reference: Record Type 31 Field No. 8 (Sequence 01-03)EMC v.6.0 Reference: Record Type 31 Field No. 8 (Sequence 01-03)



Description: Code identifying the countryAlias: Subscriber Country CodeAlias: Subscriber Country Code











REF Other Subscriber SecondaryInformation


Loop:2330A

Elements: 2











Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Insured Additional IdentifierIndustry: Other Insured Additional IdentifierUB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]UB-92 Ref. [UB-Name]: 60 (A-C) [Certificate/Social Security Number/Health InsuranceClaim/ Identification Number]EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 30 Field No. 7 (Sequence 01-03)



Notes:Notes:1. This segment is required when additional identification numbers are required.1. This segment is required when additional identification numbers are required.




Loop Other Payer Name Pos: 325 Repeat: 1Optional

Loop:2330B

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Name O 1 Required332 N3 Other Payer Address O 1 Situational340 N4 Other Payer City/State/ZIP Code O 1 Situational350 DTP Claim Adjudication Date O 1 Situational355 REF Other Payer Secondary Identification and

Reference NumberO 2 Situational

355 REF Other Payer Prior Authorization or ReferralNumber

O 1 Situational







NM1 Other Payer Name Pos: 325 Max: 1Detail - Optional

Loop:2330B

Elements: 5









Description: Individual last name or organizational nameIndustry: Other Payer Last or Organization NameIndustry: Other Payer Last or Organization NameAlias: Payer NameAlias: Payer NameUB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]UB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification]EMC v.6.0 Reference: Record Type 30 Field No. 8b (Sequence 01-03)







(PAYERID)Description: Required if the National PlanID is mandated for use. Otherwise, oneof the other listed codes may be used.CODE SOURCE:CODE SOURCE:540: Health Care Financing Administration National PlanID540: Health Care Financing Administration National PlanID





Description: Code identifying a party or other codeIndustry: Other Payer Primary IdentifierIndustry: Other Payer Primary IdentifierAlias: Payer Primary IDAlias: Payer Primary ID

This number must be identical to SVD01 (L00p ID - 2430) for COB.This number must be identical to SVD01 (L00p ID - 2430) for COB.









N3 Other Payer Address Pos: 332 Max: 1Detail - Optional

Loop:2330B

Elements: 2







Notes:Notes:1. This segment is only to be used when the Provider needs to identify the address for paper claim printingpurposes.1. This segment is only to be used when the Provider needs to identify the address for paper claim printingpurposes.




N4 Other Payer City/State/ZIPCode


Loop:2330B

Elements: 4



Description: Free-form text for city nameIndustry: Other Payer City NameIndustry: Other Payer City NameAlias: Payer City NameAlias: Payer City NameEMC v.6.0 Reference: Record Type 32 Field No. 7 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 7 (Sequence 01-03)


Description: Code (Standard State/Province) as defined by appropriate governmentagencyIndustry: Other Payer State CodeIndustry: Other Payer State CodeAlias: Payer State CodeAlias: Payer State CodeEMC v.6.0 Reference: Record Type 32 Field No. 8 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 8 (Sequence 01-03)



Description: Code defining international postal zone code excluding punctuation andblanks (zip code for United States)Industry: Other Payer Postal Zone or ZIP CodeIndustry: Other Payer Postal Zone or ZIP CodeAlias: Payer Postal CodeAlias: Payer Postal CodeEMC v.6.0 Reference: Record Type 32 Field No. 9 (Sequence 01-03)EMC v.6.0 Reference: Record Type 32 Field No. 9 (Sequence 01-03)














DTP Claim Adjudication Date Pos: 350 Max: 1Detail - Optional

Loop:2330B

Elements: 3









Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Adjudication or Payment DateIndustry: Adjudication or Payment Date


Notes:Notes:1. This segment is required when Loop-ID 2430 (Line Adjudication Date) is not used and this payer hasadjudicated the claim.1. This segment is required when Loop-ID 2430 (Line Adjudication Date) is not used and this payer hasadjudicated the claim.




REF Other Payer SecondaryIdentification and ReferenceNumber


Loop:2330B

Elements: 2



Description: Code qualifying the Reference IdentificationUse code F8 to indicate the payer’s claim number assigned to this claim by the payerreferenced in this interation of Loop ID - 2330B.Use code F8 to indicate the payer’s claim number assigned to this claim by the payerreferenced in this interation of Loop ID - 2330B.

CodeList Summary (Total Codes: 1503, Included: 5)Code Name2U Payer Identification NumberF8 Original Reference Number

UB-92 Ref. [UB-Name]:UB-92 Ref. [UB-Name]:37 (A-C) [Internal Control Number (ICN)/ Document Control Number (DCN)]37 (A-C) [Internal Control Number (ICN)/ Document Control Number (DCN)]



NF National Association of Insurance Commissioners (NAIC) CodeDescription: A unique number assigned to each insurance companyCODE SOURCE:CODE SOURCE:245: National Association of Insurance Commissioners (NAIC) Code245: National Association of Insurance Commissioners (NAIC) Code



Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Secondary IdentifierIndustry: Other Payer Secondary Identifier




Notes:Notes:





Example:Example:REF*FY*465980789~REF*FY*465980789~



REF Other Payer PriorAuthorization or ReferralNumber


Loop:2330B

Elements: 2







Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Prior Authorization or Referral NumberIndustry: Other Payer Prior Authorization or Referral Number



Notes:Notes:1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. Thiselement is primalrily used in payer-to-payer COB situations.2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.

1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. Thiselement is primalrily used in payer-to-payer COB situations.2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.

Example:Example:REF*G1*AB333-Y5~REF*G1*AB333-Y5~



Loop Other Payer PatientInformation


Loop:2330C

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Patient Information O 1 Situational355 REF Other Payer Patient Identification Number O 3 Situational








NM1 Other Payer PatientInformation


Loop:2330C

Elements: 4











CodeList Summary (Total Codes: 215, Included: 2)Code NameEI Employee Identification NumberMI Member Identification Number




Description: Code identifying a party or other codeIndustry: Other Payer Patient Primary IdentifierIndustry: Other Payer Patient Primary IdentifierAlias: Patient’s Other Payer Primary Identification NumberAlias: Patient’s Other Payer Primary Identification Number


Semantics:



1. NM102 qualifies NM103.







REF Other Payer PatientIdentification Number


Loop:2330C

Elements: 2





If NM108 = MI, this qualifier cannot be used.If NM108 = MI, this qualifier cannot be used.IG Insurance Policy NumberSY Social Security Number

Do not use this code for Medicare.Do not use this code for Medicare.


Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Patient Secondary IdentifierIndustry: Other Payer Patient Secondary Identifier



Notes:Notes:1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers forthis claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop.1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers forthis claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop.

Example:Example:REF*AZ*B333-Y5~REF*AZ*B333-Y5~



Loop Other Payer AttendingProvider


Loop:2330D

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Attending Provider O 1 Situational355 REF Other Payer Attending Provider









NM1 Other Payer AttendingProvider


Loop:2330D

Elements: 2

















REF Other Payer AttendingProvider Identification


Loop:2330D

Elements: 2








Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Attending Provider IdentifierIndustry: Other Payer Attending Provider Identifier







Loop Other Payer OperatingProvider


Loop:2330E

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Operating Provider O 1 Situational355 REF Other Payer Operating Provider









NM1 Other Payer OperatingProvider


Loop:2330E

Elements: 2

















REF Other Payer OperatingProvider Identification


Loop:2330E

Elements: 2








Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Operating Provider IdentifierIndustry: Other Payer Operating Provider Identifier






Loop Other Payer Other Provider Pos: 325 Repeat: 1Optional

Loop:2330F

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Other Provider O 1 Situational355 REF Other Payer Other Provider Identification O 3 Required








NM1 Other Payer Other Provider Pos: 325 Max: 1Detail - Optional

Loop:2330F

Elements: 2

















REF Other Payer Other ProviderIdentification


Loop:2330F

Elements: 2









Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Other Provider IdentifierIndustry: Other Payer Other Provider Identifier







Loop Other Payer Service FacilityProvider


Loop:2330H

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage325 NM1 Other Payer Service Facility Provider O 1 Situational355 REF Other Payer Service Facility Provider









NM1 Other Payer Service FacilityProvider


Loop:2330H

Elements: 2
















REF Other Payer Service FacilityProvider Identification


Loop:2330H

Elements: 2




CodeList Summary (Total Codes: 1503, Included: 7)Code Name1B Blue Shield Provider Number1C Medicare Provider Number1D Medicaid Provider NumberEI Employer's Identification NumberG2 Provider Commercial Number




Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Other Payer Service Facility Provider IdentifierIndustry: Other Payer Service Facility Provider Identifier







Loop Service Line Number Pos: 365 Repeat: 999Optional



Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage365 LX Service Line Number O 1 Required375 SV2 Institutional Service Line O 1 Required420 PWK Line Supplemental Information O 5 Situational455 DTP Service Line Date O 1 Situational455 DTP Assessment Date O 1 Situational475 AMT Service Tax Amount O 1 Situational475 AMT Facility Tax Amount O 1 Situational492 HCP Line Pricing/Repricing Information O 1 Situational494 Loop 2410 O 25 Situational500 Loop 2420A O 1 Situational500 Loop 2420B O 1 Situational500 Loop 2420C O 1 Situational540 Loop 2430 O 25 Situational






LX Service Line Number Pos: 365 Max: 1Detail - Optional



Element Summary: Ref Id Element Name Req Type Min/Max UsageLX01 554 Assigned Number M N0 1/6 Required

Description: Number assigned for differentiation within a transaction setThis is the service line number. Begin with 1 and increment by 1 for each new LX segmentwithin a claim.This is the service line number. Begin with 1 and increment by 1 for each new LX segmentwithin a claim.






SV2 Institutional Service Line Pos: 375 Max: 1Detail - Optional


User Option (Usage): RequiredPurpose: To specify the claim service detail for a Health Care institution

Element Summary: Ref Id Element Name Req Type Min/Max UsageSV201 234 Product/Service ID C AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Service Line Revenue CodeIndustry: Service Line Revenue CodeUB-92 Ref. [UB-Name]: 42 [Revenue Code]UB-92 Ref. [UB-Name]: 42 [Revenue Code]EMC v.6.0 Reference: Record Type 50 Field No. 4, 11, 12, 13





Record Type 61 Field No. 4, 14, 15See Code Source 132: National Uniform Billing Committee (NUBC) Codes.See Code Source 132: National Uniform Billing Committee (NUBC) Codes.User Note 6: . 'non-addenda' submissions and HC in both '"non-addenda' and 'addenda'

submissions . Use of HC qualifier is required on outpatient submissions

User Note 6: . 'non-addenda' submissions and HC in both '"non-addenda' and 'addenda'

submissions . Use of HC qualifier is required on outpatient submissions

User Note 7: . BSC can accept NDC Codes in this element for 'non-addenda' submissions and in the

2410 loop of 'addenda' submissions . BSC requires a HCPCS/CPT code in the 837 Institutional transaction for outpatient

services


2410 loop of 'addenda' submissions . BSC requires a HCPCS/CPT code in the 837 Institutional transaction for outpatient

services


SV202 C003 Composite Medical ProcedureIdentifier

C Comp Situational

Description: To identify a medical procedure by its standardized codes and applicablemodifiersAlias: Service Line Procedure CodeAlias: Service Line Procedure CodeUB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]

This data element required for outpatient claims when an appropriate HCPCS exists for theservice line item.This data element required for outpatient claims when an appropriate HCPCS exists for theservice line item.

SV202-01 235 Product/Service ID Qualifier M ID 2/2 Required







User Note 6: HC, IV, N1, N2, N3, N4, ZZ . HC, N4 . BSC can accept N4 only in 'non-addenda' submissions and HC in both '"non-addenda'

and 'addenda' submissions . Use of HC qualifier is required on outpatient submissions

User Note 6: HC, IV, N1, N2, N3, N4, ZZ . HC, N4 . BSC can accept N4 only in 'non-addenda' submissions and HC in both '"non-addenda'

and 'addenda' submissions . Use of HC qualifier is required on outpatient submissions




IV Home Infusion EDI Coalition (HIEC) Product/Service CodeThis code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code setunder HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.

This code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code setunder HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.


ZZ Mutually DefinedUse code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code. This code list is available from:Division of Institutional CareHealth Care Financing Administration S1-03-067500 Security Boulevard Baltimore, MD 21244-1850

Use code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code. This code list is available from:Division of Institutional CareHealth Care Financing Administration S1-03-067500 Security Boulevard Baltimore, MD 21244-1850

SV202-02 234 Product/Service ID M AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Procedure CodeIndustry: Procedure CodeAlias: HCPCS Procedure CodeAlias: HCPCS Procedure CodeUB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]EMC v.6.0 Reference: Record Type 60 Field No. 5, 13, 14



Record Type 61 Field No. 5, 14, 15User Note 6: . BSC can accept NDC Codes in this element for 'non-addenda' submissions and in the

2410 loop of 'addenda' submissions. . BSC requires a HCPCS/CPT code in the 837 Institutional transaction for outpatient

services.


2410 loop of 'addenda' submissions. . BSC requires a HCPCS/CPT code in the 837 Institutional transaction for outpatient

services.

ExternalCodeList Name: 130 Description: Health Care Financing Administration Common Procedural Coding System ExternalCodeList



Name: 513 Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List ExternalCodeList Name: SNFR Description: Skilled Nursing Facility Rate Code





Record Type 61 Field No. 10, 14, 15Use this modifier for the first procedure code modifier.This data element is required when the Provider needs to convey additional clarification forthe associated procedure code.

Use this modifier for the first procedure code modifier.This data element is required when the Provider needs to convey additional clarification forthe associated procedure code.User Note 6: . With the exception of members in National Account and Medicare Risk groups, BSC

can take adjudicative action on only the first modifier received, SV202-3, foranesthesia services. Claims including anesthesia services for members in NationalAccount groups require submission of both the HCPCS and CPT modifiersappropriate for the anesthesia service provided. i.e: both SV202-3 and SV202-4should be populated

. SV202-3 is required on all ambulance services using the appropriate origin anddestination codes

User Note 6: . With the exception of members in National Account and Medicare Risk groups, BSC

can take adjudicative action on only the first modifier received, SV202-3, foranesthesia services. Claims including anesthesia services for members in NationalAccount groups require submission of both the HCPCS and CPT modifiersappropriate for the anesthesia service provided. i.e: both SV202-3 and SV202-4should be populated

. SV202-3 is required on all ambulance services using the appropriate origin anddestination codes






Record Type 61 Field No. 7, 14, 15Use this modifier for the second procedure code modifier.See SV202-3Use this modifier for the second procedure code modifier.See SV202-3













SV203 782 Monetary Amount O R 1/18 Required

Description: Monetary amountIndustry: Line Item Charge AmountIndustry: Line Item Charge AmountAlias: Service Line Charge AmountAlias: Service Line Charge AmountUB-92 Ref. [UB-Name]: 47 [Total Charges (by Revenue Code Category)]UB-92 Ref. [UB-Name]: 47 [Total Charges (by Revenue Code Category)]EMC v.6.0 Reference: Record Type 50 Field No. 7, 11, 12, 13





Record Type 61 Field No. 10, 14, 15Use this amount to indicate the submitted charge amount.Use this amount to indicate the submitted charge amount.

SV204 355 Unit or Basis for Measurement Code C ID 2/2 Required


CodeList Summary (Total Codes: 794, Included: 3)Code NameDA DaysF2 International Unit


Code Name


Description: A unit accepted by an international agency; potency of a drug/vitaminbased on a specific weight of that drug/vitaminDosage amount is only used for drug claims when the dosage of the drug isvariable within a single NDC number (e.g. blood factors).Dosage amount is only used for drug claims when the dosage of the drug isvariable within a single NDC number (e.g. blood factors).

UN Unit

SV205 380 Quantity C R 1/15 Required

Description: Numeric value of quantityIndustry: Service Unit CountIndustry: Service Unit CountAlias: Service Line UnitsAlias: Service Line UnitsUB-92 Ref. [UB-Name]: 46 [Units of Service]UB-92 Ref. [UB-Name]: 46 [Units of Service]EMC v.6.0 Reference: Record Type 50 Field No. 6, 11, 12, 13






SV206 1371 Unit Rate O R 1/10 Situational

Description: The rate per unit of associate revenue for hospital accommodationIndustry: Service Line RateIndustry: Service Line RateAlias: Service Line Rate AmountAlias: Service Line Rate AmountUB-92 Ref. [UB-Name]: 44 (“RATES”) [HCPCS/Rates/HIPPS Rate Codes]UB-92 Ref. [UB-Name]: 44 (“RATES”) [HCPCS/Rates/HIPPS Rate Codes]EMC v.6.0 Reference: Record Type 50 Field No. 5, 11, 12, 13EMC v.6.0 Reference: Record Type 50 Field No. 5, 11, 12, 13

This data element is required when the associated revenue code is 100-219.This data element is required when the associated revenue code is 100-219.

SV207 782 Monetary Amount O R 1/18 Situational

Description: Monetary amountIndustry: Line Item Denied Charge or Non-Covered Charge AmountIndustry: Line Item Denied Charge or Non-Covered Charge AmountAlias: Service Line Non-Covered Charge AmountAlias: Service Line Non-Covered Charge AmountUB-92 Ref. [UB-Name]: 48 [Non-Covered Charges]UB-92 Ref. [UB-Name]: 48 [Non-Covered Charges]EMC v.6.0 Reference: Record Type 50 Field No. 8, 11, 12, 13





Record Type 61 Field No. 11, 14, 15Use this amount if needed to report line specific non-covered charge amount.Use this amount if needed to report line specific non-covered charge amount.

Syntax Rules: 1. R0102 - At least one of SV201 or SV202 is required.2. P0405 - If either SV204 or SV205 is present, then the other is required.

Semantics: 1. SV201 is the revenue code.2. SV203 is a submitted charge amount.3. SV207 is a noncovered charge amount.4. SV208 is the detail service line indicator. A "Y" value indicates a detail service line; an "N" value indicates a

summary service line.



Notes:Notes:1. This segment is required for inpatient claims or outpatient or other claims that require procedure or druginformation to be reported for claim adjudication.1. This segment is required for inpatient claims or outpatient or other claims that require procedure or druginformation to be reported for claim adjudication.

Example:Example:SV2*300*HC:80019*73.42*UN*1~SV2*120**1500*DA*5*300~SV2*300*HC:80019*73.42*UN*1~SV2*120**1500*DA*5*300~



PWK Line SupplementalInformation




















Code Name











AB Previously Submitted to PayerAD Certification Included in this ClaimAF Narrative Segment Included in this ClaimAG No Documentation is RequiredBM By MailEL Electronically OnlyEM E-MailFX By Fax


Description: Code designating the system/method of code structure used for IdentificationCode (67)Required if PWK02 = “BM”, “EL”, “EM” or “FX”Required if PWK02 = “BM”, “EL”, “EM” or “FX”





Required if PWK02 = “BM”, “EL”, “EM” or “FX”Required if PWK02 = “BM”, “EL”, “EM” or “FX”


Comments:



1. PWK05 and PWK06 may be used to identify the addressee by a code number.2. PWK07 may be used to indicate special information to be shown on the specified report.3. PWK08 may be used to indicate action pertaining to a report.

Notes:Notes:1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope unless reportingHome Infusion (see codes AD & AF in PWK02).2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment shouldnot be used if the information related to the claim is being sent within the 837 ST-SE envelope unless reportingHome Infusion (see codes AD & AF in PWK02).2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but aretransmitted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attachedelectronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is availableupon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA inPWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

Example:Example:PWK*B2*AA***AC*29438476~PWK*B2*AA***AC*29438476~



DTP Service Line Date Pos: 455 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name472 Service

Use RD8 in DTP02 to indicate begin/end or from/to dates.Use RD8 in DTP02 to indicate begin/end or from/to dates.






Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Service DateIndustry: Service DateUB-92 Ref. [UB-Name]: 45 [Service Date]UB-92 Ref. [UB-Name]: 45 [Service Date]EMC v.6.0 Reference: Record Type 60 Field No. 12, 13, 14





Notes:Notes:1. Required on outpatient claims when revenue, procedure, HIEC or drug codes are reported in the SV2 segment.2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate therange of dates through which the drug will be used by the patient. Use RD8 for this purpose.3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date theprescription was written (or otherwise communicated by the prescriber if not written).4. Assessment Date DTP is not used when this segment is present.

1. Required on outpatient claims when revenue, procedure, HIEC or drug codes are reported in the SV2 segment.2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate therange of dates through which the drug will be used by the patient. Use RD8 for this purpose.3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date theprescription was written (or otherwise communicated by the prescriber if not written).4. Assessment Date DTP is not used when this segment is present.






DTP Assessment Date Pos: 455 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1112, Included: 1)Code Name866 Examination





Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Assessment DateIndustry: Assessment DateUB-92 Ref. [UB-Name]: 45 [Service Date]UB-92 Ref. [UB-Name]: 45 [Service Date]EMC v.6.0 Reference: Record Type 60 Field No. 13EMC v.6.0 Reference: Record Type 60 Field No. 13


Notes:Notes:1. Required when an assessment date is necessary (i.e. Medicare PPS processing).2. Refer to Code Source 132 National Uniform Billing Committee (NUBC) Codes for instructions on the use of thisdate.3. Service date DTP is not used when this segment is present.

1. Required when an assessment date is necessary (i.e. Medicare PPS processing).2. Refer to Code Source 132 National Uniform Billing Committee (NUBC) Codes for instructions on the use of thisdate.3. Service date DTP is not used when this segment is present.

Example:Example:DTP*866*19981210~DTP*866*19981210~



AMT Service Tax Amount Pos: 475 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameGT Goods and Services Tax

Description: Canadian value-added tax


Description: Monetary amountIndustry: Service Tax AmountIndustry: Service Tax Amount


Example:Example:AMT*GT*15~AMT*GT*15~



AMT Facility Tax Amount Pos: 475 Max: 1Detail - Optional





CodeList Summary (Total Codes: 1473, Included: 1)Code NameN8 Miscellaneous Taxes


Description: Monetary amountIndustry: Facility Tax AmountIndustry: Facility Tax Amount


Example:Example:AMT*N8*22~AMT*N8*22~



HCP Line Pricing/RepricingInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageHCP01 1473 Pricing Methodology X ID 2/2 Situational

Description: Code specifying pricing methodology at which the claim or line item has beenpriced or repricedAlias: Pricing/Repricing MethodologyAlias: Pricing/Repricing Methodology

Trading partners need to agree on which codes to use in this data element. There do notappear to be standard definitions for the code elements.Trading partners need to agree on which codes to use in this data element. There do notappear to be standard definitions for the code elements.



Description: Monetary amountIndustry: Repriced Allowed AmountIndustry: Repriced Allowed AmountAlias: Pricing/Repricing Allowed AmountAlias: Pricing/Repricing Allowed Amount


Description: Monetary amountIndustry: Repriced Saving AmountIndustry: Repriced Saving AmountAlias: Pricing/Repricing Saving AmountAlias: Pricing/Repricing Saving Amount







specified by the Reference Identification QualifierIndustry: Repriced Organizational IdentifierIndustry: Repriced Organizational IdentifierAlias: Pricing/Repricing Organizational IdentifierAlias: Pricing/Repricing Organizational Identifier



Description: Rate expressed in the standard monetary denomination for the currencyspecifiedIndustry: Repricing Per Diem or Flat Rate AmountIndustry: Repricing Per Diem or Flat Rate AmountAlias: Pricing/Repricing RateAlias: Pricing/Repricing Rate



Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Repriced Approved Ambulatory Patient Group CodeIndustry: Repriced Approved Ambulatory Patient Group CodeAlias: Approved APG Code, PricingAlias: Approved APG Code, Pricing



Description: Monetary amountIndustry: Repriced Approved Ambulatory Patient Group AmountIndustry: Repriced Approved Ambulatory Patient Group AmountAlias: Approved APG Amount, PricingAlias: Approved APG Amount, Pricing

This data element is required when it is necessary to reort Approved DRG Amount onclaims which has been priced or repriced.This data element is required when it is necessary to reort Approved DRG Amount onclaims which has been priced or repriced.




HCP09 235 Product/Service ID Qualifier X ID 2/2 Situational

Description: Code identifying the type/source of the descriptive number used inProduct/Service ID (234)Required when HCP10 exists.Required when HCP10 exists.




Code Name



HCP10 234 Product/Service ID X AN 1/48 Situational

Description: Identifying number for a product or serviceIndustry: Procedure CodeIndustry: Procedure CodeAlias: Pricing/Repricing Approved Procedure CodeAlias: Pricing/Repricing Approved Procedure Code

This data element is required when it is necessary to reort Approved HCPCS Code onclaims which has been priced or repriced.This data element is required when it is necessary to reort Approved HCPCS Code onclaims which has been priced or repriced.


HCP11 355 Unit or Basis for Measurement Code X ID 2/2 Situational



HCP12 380 Quantity X R 1/15 Situational

Description: Numeric value of quantityIndustry: Repricing Approved Service Unit CountIndustry: Repricing Approved Service Unit CountAlias: Pricing/Repricing Approved Units or Inpatient DaysAlias: Pricing/Repricing Approved Units or Inpatient Days


HCP13 901 Reject Reason Code X ID 2/2 Situational

Description: Code assigned by issuer to identify reason for rejectionAlias: Reject Reason CodeAlias: Reject Reason Code




Description: Code specifying policy complianceThis data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.This data element is required when it is necessary to report Policy Compliance Code onclaims which has been priced or repriced.






Description: Code specifying the exception reason for consideration of out-of-networkhealth care servicesThis data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.This data element is required when it is necessary to report Exception Reason Code onclaims which have been priced or repriced.






submitted values.

Notes:Notes:1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BBloop.1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BBloop.






Loop Drug Identification Pos: 494 Repeat: 25Optional



Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage494 LIN Drug Identification O 1 Situational495 CTP Drug Pricing O 1 Situational496 REF Prescription Number O 1 Situational






LIN Drug Identification Pos: 494 Max: 1Detail - Optional



Element Summary: Ref Id Element Name Req Type Min/Max UsageLIN02 235 Product/Service ID Qualifier M ID 2/2 Required

Description: Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

CodeList Summary (Total Codes: 477, Included: 1)Code NameN4 National Drug Code in 5-4-2 Format

Description: 5-digit manufacturer ID, 4-digit product ID, 2-digit trade package sizeCODE SOURCE:CODE SOURCE:240: National Drug Code by Format240: National Drug Code by Format

LIN03 234 Product/Service ID M AN 1/48 Required

Description: Identifying number for a product or serviceAlias: National Drug CodeAlias: National Drug Code

ExternalCodeList Name: 240 Description: National Drug Code by Format

Syntax Rules: 1. P0405 - If either LIN04 or LIN05 is present, then the other is required.2. P0607 - If either LIN06 or LIN07 is present, then the other is required.3. P0809 - If either LIN08 or LIN09 is present, then the other is required.4. P1011 - If either LIN10 or LIN11 is present, then the other is required.5. P1213 - If either LIN12 or LIN13 is present, then the other is required.6. P1415 - If either LIN14 or LIN15 is present, then the other is required.7. P1617 - If either LIN16 or LIN17 is present, then the other is required.8. P1819 - If either LIN18 or LIN19 is present, then the other is required.9. P2021 - If either LIN20 or LIN21 is present, then the other is required.

10. P2223 - If either LIN22 or LIN23 is present, then the other is required.11. P2425 - If either LIN24 or LIN25 is present, then the other is required.12. P2627 - If either LIN26 or LIN27 is present, then the other is required.13. P2829 - If either LIN28 or LIN29 is present, then the other is required.14. P3031 - If either LIN30 or LIN31 is present, then the other is required.

Semantics: 1. LIN01 is the line item identification

Comments: 1. See the Data Dictionary for a complete list of IDs.



2. LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color,Drawing No., U.P.C. No., ISBN No., Model No., or SKU.




User Note 6:User Note 6:BSC can take adjudicative action on only the first of any 2410 loops received. NDC codes should be reported in Loop 2410 for X12N Institutional claims and encounters. The following threesegments in Loop 2410 should be used: LIN, CTP and REF. 1. LIN (Drug Identification) Segment usage:LIN02 = N4 qualifier for NDC Drug CodeLIN03 = NDC code in 5-4-2 format. Sample: LIN**N4*01234567891~ Please refer to page 35 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 2. CTP (Drug Pricing) Segment usage:CTP03 = Unit PriceCTP04 = QuantityCTP05-1 = Unit of Measurement Code values (see below for available list) F2 International Unit GR Gram ML Milliliter UN Unit Sample: CTP***1.15*2*UN~ Please refer to page 38 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 3. REF (Prescription Number) Segment usage:REF01 = XZ qualifier for Prescription NumberREF02 = Prescription NumberSample: REF*XZ*123456~ Please refer to page 40 of the X12 Institutional Addenda (004010X096A1) for additional usage information. Sample of complete NDC reporting:

BSC can take adjudicative action on only the first of any 2410 loops received. NDC codes should be reported in Loop 2410 for X12N Institutional claims and encounters. The following threesegments in Loop 2410 should be used: LIN, CTP and REF. 1. LIN (Drug Identification) Segment usage:LIN02 = N4 qualifier for NDC Drug CodeLIN03 = NDC code in 5-4-2 format. Sample: LIN**N4*01234567891~ Please refer to page 35 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 2. CTP (Drug Pricing) Segment usage:CTP03 = Unit PriceCTP04 = QuantityCTP05-1 = Unit of Measurement Code values (see below for available list) F2 International Unit GR Gram ML Milliliter UN Unit Sample: CTP***1.15*2*UN~ Please refer to page 38 of the X12 Institutional Addenda (004010X096A1) for additional usage information. 3. REF (Prescription Number) Segment usage:REF01 = XZ qualifier for Prescription NumberREF02 = Prescription NumberSample: REF*XZ*123456~ Please refer to page 40 of the X12 Institutional Addenda (004010X096A1) for additional usage information. Sample of complete NDC reporting:



LIN**N4*01234567891~CTP***1.15*2*UN~REF*XZ*123456~

LIN**N4*01234567891~CTP***1.15*2*UN~REF*XZ*123456~



CTP Drug Pricing Pos: 495 Max: 1Detail - Optional


User Option (Usage): SituationalPurpose: To specify pricing information

Element Summary: Ref Id Element Name Req Type Min/Max UsageCTP03 212 Unit Price X R 1/17 Required

Description: Price per unit of product, service, commodity, etc.Alias: Drug Unit PriceAlias: Drug Unit Price

CTP04 380 Quantity X R 1/15 Required

Description: Numeric value of quantityAlias: National Drug Unit CountAlias: National Drug Unit Count

CTP05 C001 Composite Unit of Measure O Comp Required

Description: To identify a composite unit of measure(See Figures Appendix for examplesof use)Alias: Unit/Basis of MeasurementAlias: Unit/Basis of Measurement

CTP05-01 355 Unit or Basis for Measurement Code M ID 2/2 Required


CodeList Summary (Total Codes: 794, Included: 4)Code NameF2 International Unit

Description: A unit accepted by an international agency; potency of a drug/vitaminbased on a specific weight of that drug/vitamin

GR GramML MilliliterUN Unit

Syntax Rules: 1. P0405 - If either CTP04 or CTP05 is present, then the other is required.2. C0607 - If CTP06 is present, then CTP07 is required.3. C0902 - If CTP09 is present, then CTP02 is required.4. C1002 - If CTP10 is present, then CTP02 is required.5. C1103 - If CTP11 is present, then CTP03 is required.

Semantics: 1. CTP07 is a multiplier factor to arrive at a final discounted price. A multiplier of .90 would be the factor if a 10%

discount is given.2. CTP08 is the rebate amount.

Comments: 1. See Figures Appendix for an example detailing the use of CTP03 and CTP04.2. See Figures Appendix for an example detailing the use of CTP03, CTP04 and CTP07.



Notes:Notes:1. Required when it is necessary to provide a price specific to the NDC provided in LIN03 that is different than theprice reported in SV203.1. Required when it is necessary to provide a price specific to the NDC provided in LIN03 that is different than theprice reported in SV203.

Example:Example:CTP***1.15*2*UN~CTP***1.15*2*UN~



REF Prescription Number Pos: 496 Max: 1Detail - Optional




Description: Code qualifying the Reference IdentificationAlias: Code QualifierAlias: Code Qualifier

CodeList Summary (Total Codes: 1503, Included: 1)Code NameXZ Pharmacy Prescription Number

REF02 127 Reference Identification X AN 1/30 Required

Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierAlias: Prescription NumberAlias: Prescription Number



Notes:Notes:1. Required if dispense of the drug has been done with an assigned Rx number.2. In cases where a compound drug is being billed, the components of the compound will all have the sameprescription number. Payers receiving the claim can relate all the components by matching the prescriptionnumber.

1. Required if dispense of the drug has been done with an assigned Rx number.2. In cases where a compound drug is being billed, the components of the compound will all have the sameprescription number. Payers receiving the claim can relate all the components by matching the prescriptionnumber.

Example:Example:REF*XZ*123456~REF*XZ*123456~




Loop:2420A

Elements: N/A


Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage500 NM1 Attending Physician Name O 1 Situational525 REF Attending Physician Secondary










Loop:2420A

Elements: 8










Description: Individual last name or organizational nameIndustry: Attending Physician Last NameIndustry: Attending Physician Last Name

Attending Provider Last NameAttending Provider Last Name


Description: Individual first nameIndustry: Attending Physician First NameIndustry: Attending Physician First Name






Description: Suffix to individual nameIndustry: Attending Physician Name SuffixIndustry: Attending Physician Name SuffixAlias: Attending Provider GenerationAlias: Attending Provider Generation










Description: Code identifying a party or other codeIndustry: Attending Physician Primary IdentifierIndustry: Attending Physician Primary Identifier

Attending Provider Primary IdentifierAttending Provider Primary Identifier












Loop:2420A

Elements: 2



Description: Code qualifying the Reference IdentificationUser Note 6: Use 0B for CA State license #Use 1B for BSC Provider IDDo not use if the information is the same as 2310 Loop








Description: Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification QualifierIndustry: Attending Physician Secondary IdentifierIndustry: Attending Physician Secondary IdentifierUser Note 6: Use only California State License Number or BSC Provider ID with the appropriate REF01qualifier.Do not use if the information is the same as 2310 Loop

User Note 6: Use only California State License Number or BSC Provider ID with the appropriate REF01qualifier.Do not use if the information is the same as 2310 Loop






Example:Example:REF*1D*AC12345H~REF*1D*AC12345H~




Loop:2420B

Elements: N/A












Loop:2420B

Elements: 8










Description: Individual last name or organizational nameIndustry: Operating Physician Last NameIndustry: Operating Physician Last Name


Description: Individual first nameIndustry: Operating Physician First NameIndustry: Operating Physician First Name



Required when the middle name/initial of the person is known.Required when the middle name/initial of the person is known.


Description: Suffix to individual nameIndustry: Operating Physician Name SuffixIndustry: Operating Physician Name SuffixAlias: Operating Physician GenerationAlias: Operating Physician Generation







Code Name24 Employer's Identification Number34 Social Security Number

Social Security Number cannot be used for Medicare claims.Social Security Number cannot be used for Medicare claims.XX Health Care Financing Administration National Provider Identifier



Description: Code identifying a party or other codeIndustry: Operating Physician Primary IdentifierIndustry: Operating Physician Primary IdentifierAlias: Operating Physician Primary Identifier.Alias: Operating Physician Primary Identifier.












Loop:2420B

Elements: 2














Example:Example:







Loop:2420C

Elements: N/A











Loop:2420C

Elements: 8










Description: Individual last name or organizational nameIndustry: Other Physician Last NameIndustry: Other Physician Last NameAlias: Other Provider Last NameAlias: Other Provider Last Name


Description: Individual first nameIndustry: Other Physician First NameIndustry: Other Physician First Name






Description: Suffix to individual nameIndustry: Other Provider Name SuffixIndustry: Other Provider Name SuffixAlias: Other Provider GenerationAlias: Other Provider Generation








Social Security Number cannot be used forMedicare claims.Social Security Number cannot be used forMedicare claims.

XX Health Care Financing Administration National Provider IdentifierDescription: Required value if the National Provider ID is mandated for use.Otherwise, one of the other listed codes may be used.


Description: Code identifying a party or other codeIndustry: Other Provider IdentifierIndustry: Other Provider IdentifierAlias: Other Provider Primary IdentifierAlias: Other Provider Primary Identifier












Loop:2420C

Elements: 2













Notes:Notes:1. Use this REF segment only if a second number is necessary to identify the provider. The primary identificationnumber should be contained in NM109.2. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.

1. Use this REF segment only if a second number is necessary to identify the provider. The primary identificationnumber should be contained in NM109.2. Required when a secondary identification number is necessary to identify the entity. The primary identificationnumber should be carried in NM109.






Loop Service Line AdjudicationInformation




Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage540 SVD Service Line Adjudication Information O 1 Situational545 CAS Service Line Adjustment O 99 Situational550 DTP Service Adjudication Date O 1 Situational










SVD Service Line AdjudicationInformation




Element Summary: Ref Id Element Name Req Type Min/Max UsageSVD01 67 Identification Code M AN 2/80 Required

Description: Code identifying a party or other codeIndustry: Payer IdentifierIndustry: Payer IdentifierEMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (This must match one of thecorresponding loops: 2010BC - Payer Name, or 2330B - Other Payer Name.)EMC v.6.0 Reference: Record Type 30 Field No. 5, 6 (This must match one of thecorresponding loops: 2010BC - Payer Name, or 2330B - Other Payer Name.)

SVD02 782 Monetary Amount M R 1/18 Required

Description: Monetary amountIndustry: Service Line Paid AmountIndustry: Service Line Paid AmountAlias: Service Line Amount PaidAlias: Service Line Amount Paid

SVD03 C003 Composite Medical ProcedureIdentifier

O Comp Situational

Description: To identify a medical procedure by its standardized codes and applicablemodifiersRequired when returned on an 835 payment for this claim or when needed to identify theservice line adjudicated.Required when returned on an 835 payment for this claim or when needed to identify theservice line adjudicated.

SVD03-01 235 Product/Service ID Qualifier M ID 2/2 Required







IV Home Infusion EDI Coalition (HIEC) Product/Service CodeThis code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code set This code set is not allowed for use under HIPAA at the time of this writing. Thequalifier can only be used: 1) If a new rule names HIEC as an allowable code set


Code Name


under HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.under HIPAA. 2) For Property & Casualty claims/encounters that are not coveredunder HIPAA.


ZZ Mutually DefinedUse code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code.Use code ZZ to convey the Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code.

SVD03-02 234 Product/Service ID M AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Procedure CodeIndustry: Procedure Code



















SVD03-07 352 Description O AN 1/80 Situational

Description: A free-form description to clarify the related data elements and their contentIndustry: Procedure Code DescriptionIndustry: Procedure Code Description

Required if SVC01-7 was returned in the 835 transaction.Required if SVC01-7 was returned in the 835 transaction.

SVD04 234 Product/Service ID O AN 1/48 Required

Description: Identifying number for a product or serviceIndustry: Service Line Revenue CodeIndustry: Service Line Revenue CodeEMC v.6.0 Reference: Record Type 52 Field No. 5







SVD05 380 Quantity O R 1/15 Required

Description: Numeric value of quantityIndustry: Adjustment QuantityIndustry: Adjustment QuantityAlias: Paid Units of ServiceAlias: Paid Units of Service

Crosswalk from SVC05 in 835 or, if not present in 835, use original billed units.Crosswalk from SVC05 in 835 or, if not present in 835, use original billed units.




SVD06 554 Assigned Number O N0 1/6 Situational

Description: Number assigned for differentiation within a transaction setIndustry: Bundled or Unbundled Line NumberIndustry: Bundled or Unbundled Line Number

Use the LX from this transaction which points to the bundled/unbundled line.Required if payer bundled/unbundled this service line.Use the LX from this transaction which points to the bundled/unbundled line.Required if payer bundled/unbundled this service line.










CAS Service Line Adjustment Pos: 545 Max: 99Detail - Optional




Description: Code identifying the general category of payment adjustmentEMC v.6.0 Reference: Record Type 52 Field No. 6















Record Type 63 Field No. 8Use this amount for the amount of adjustment.Use this amount for the charges applied to the preceding reason code.Use this amount for the amount of adjustment.Use this amount for the charges applied to the preceding reason code.









Use this value for the quantity applied to the preceding reason code.Use this value for the quantity applied to the preceding reason code.































Use this amount for the charges applied to the preceding reason code.See CAS03Use this amount for the charges applied to the preceding reason code.See CAS03

































































Notes:Notes:1. Inpatient or Outpatient - Service Line Adjustments2. Submitters should use this CAS segment to report line level adjustments from prior payments which cause theamount paid to differ from the amount originally charged.3. The Claim Adjustment Reason codes are located on the Washington Publishing Company web sitehttp://www.wpc-edi.com.4. Required when the prior payment had service line adjustments reported on a remittance.

1. Inpatient or Outpatient - Service Line Adjustments2. Submitters should use this CAS segment to report line level adjustments from prior payments which cause theamount paid to differ from the amount originally charged.3. The Claim Adjustment Reason codes are located on the Washington Publishing Company web sitehttp://www.wpc-edi.com.4. Required when the prior payment had service line adjustments reported on a remittance.

Example:Example:CAS*CO*A1*25~CAS*CO*A1*25~



DTP Service Adjudication Date Pos: 550 Max: 1Detail - Optional










Description: Expression of a date, a time, or range of dates, times or dates and timesIndustry: Service Adjudication or Payment DateIndustry: Service Adjudication or Payment Date


Notes:Notes:1. This segment is required when Service line adjudication has been performed.1. This segment is required when Service line adjudication has been performed.




SE Transaction Set Trailer Pos: 555 Max: 1Detail - Mandatory


User Option (Usage): RequiredPurpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including thebeginning (ST) and ending (SE) segments)

Element Summary: Ref Id Element Name Req Type Min/Max UsageSE01 96 Number of Included Segments M N0 1/10 Required

Description: Total number of segments included in a transaction set including ST and SEsegmentsIndustry: Transaction Segment CountIndustry: Transaction Segment Count

SE02 329 Transaction Set Control Number M AN 4/9 Required

Description: Identifying control number that must be unique within the transaction setfunctional group assigned by the originator for a transaction setSE02 must match ST02.SE02 must match ST02.

Comments: 1. SE is the last segment of each transaction set.

Example:Example:SE*1230*987654~SE*1230*987654~



GE Functional Group Trailer Pos: Max: 1Not Defined - Mandatory


User Option (Usage): RequiredPurpose: To indicate the end of a functional group and to provide control information

Element Summary: Ref Id Element Name Req Type Min/Max UsageGE01 97 Number of Transaction Sets Included M N0 1/6 Required

Description: Total number of transaction sets included in the functional group orinterchange (transmission) group terminated by the trailer containing this data element

GE02 28 Group Control Number M N0 1/9 Required

Description: Assigned number originated and maintained by the sender

Semantics: 1. The data interchange control number GE02 in this trailer must be identical to the same data element in the

associated functional group header, GS06.

Comments: 1. The use of identical data interchange control numbers in the associated functional group header and trailer is

designed to maximize functional group integrity. The control number is the same as that used in thecorresponding header.

Example:Example:GE*1*1~GE*1*1~



IEA Interchange Control Trailer Pos: Max: 1Not Defined - Mandatory


User Option (Usage): RequiredPurpose: To define the end of an interchange of zero or more functional groups and interchange-related controlsegments

Element Summary: Ref Id Element Name Req Type Min/Max UsageIEA01 I16 Number of Included Functional Groups M N0 1/5 Required

Description: A count of the number of functional groups included in an interchange

IEA02 I12 Interchange Control Number M N0 9/9 Required

Description: A control number assigned by the interchange sender

Example:Example:IEA*1*000000905~IEA*1*000000905~

Documents

837 Health Care Claim: Institutional: Companion Guide · 837 Health Care Claim: Institutional: Companion Guide HIPAA/V4010X096A1/837: 837 Health Care Claim: Institutional Version: