X12 837 Institutional Mapping

Transcription

General Companion Guide
837 Professional and Institutional
Healthcare Claims Submission
Version 5010
Version Date: December 2011
837 Health Care Claims Transaction - Professional and Institutional – version 5010
Introduction
*****************************************************************************
Purpose of the Companion Guide
This document has been prepared as a Colorado Access specific companion document to the ANSI ASC X12N 837 Health Care Claims
(837) transaction for professional and institutional claims. The following information should be used to clarify when situational
fields and segments must be used for reporting to Colorado Access and identifies those codes and data elements, which do not
apply to Colorado Access. This companion guide document is only a supplement, and is not intended to contradict any requirements
in the ANSI ASC X12N implementation guides.
What is HIPAA?
The Health Insurance Portability and Accountability Act - Administration Simplification (HIPAA-AS) requires that Colorado Access,
Medicare, and all other health insurance payers in the United States, comply with the electronic data interchange standards for
health care as established by the Secretary of Health and Human Services.
Purpose of the Health Care Claim (837) Implementation Guide
The X12N 837 version 5010 implementation guide for Health Care Claims has been established as the standard for claims
transactions compliance as of 1/1/2012. Although the implementation guide contains requirements for use of specific segments and
data elements within the segments, the guide was written for use by all health benefit payers. There are separate transactions for
Health Care Claims - institutional (837I) and, professional (837P).
Loop usage within ASC X12 transactions and their implementation guides can be confusing. Care must be used to read the loop
requirements in terms of the context or location within the transaction. If the first segment is Situational, there will a segment note
addressing use of the loop. Any required segments in loops beginning with a Situational segment only occur when the loop is used.
How to obtain copies of the Implementation Guides
The implementation guides for all HIPAA transactions are available at http://www.wpc-edi.com/content/view/817/1 .
Intended Audience
The intended audience for this document is the technical area that is responsible for submitting electronic claims transactions to
Colorado Access. In addition, this information should be communicated and coordinated with the provider's billing office in order to
ensure the required billing information is provided to their billing agent/submitter.
Establishing Connectivity with Colorado Access
*****************************************************************************
The purpose of this section is to identify the process for establishing connectivity to transmit electronic transactions to Colorado
Access.
Testing Procedures
Before you can submit electronic transaction files for testing (or make changes from or additions to your current electronic
transaction files), you must complete the following test submission procedures.
1.
2.
3.
4.
5.
Contact Colorado Access at EDI_coordinator@coaccess.comto request Colorado Access’ Remote User documentation.
Download and review the Colorado Access Companion Guide for the transaction you wish to exchange with Colorado
Access.
When you have a test file ready, contact the EDI Coordinator to discuss a testing schedule.
Access authority to transmit files through our FTP (file transfer protocols) is available Please discuss your file transfer
options with the EDI Coordinator.
If you have any questions, please contact the Colorado Access at EDI_coordinator@coaccess.com.
Transmission Hours
We provide 24 hours a day, 7 days a week availability for claims transmission and report retrieval. This availability is subject to
scheduled and unscheduled host downtime. It is operational policy to schedule preventive maintenance periods on weekends
whenever possible.
Test File Requirements
1.
2.
3.
4.
Test files must contain twenty to twenty-five test transactions.
Test transactions should include:
a. Several examples for each line of business or plan for which you anticipate submitting claims transactions
b. Examples of claims which may have been particularly problematic in the past (e.g., emergency room or newborn
claims, etc)
c. A representative sampling of the providers for whom you are submitting claims.
Test files, and ultimately production files, must be named according to the guidelines below. Files that do not follow the
appropriate naming conventions, may not be recognized by our system and processed appropriately. If files are named
incorrectly, you will becontacted and asked to rename and resubmit the file.
Test files must be transmitted in the same format that will be used for production files (e.g., stream or unwrapped). Colorado
Access can support either format, but your testing experience and ultimate move to production will be more positive if the
same format is used throughout.
3
File Naming Convention
For files transmitted to Colorado Access
File Naming convention – XXyymmdd&Z.txt
XX
yy
mm
dd
&
Z
= unique ID for the submitter
= current Year
= month of the current year
= day of the month
= I for institutional, P for professional
= this value allows for multiple files to be submitted per day. Use alpha or numeric values. (0-9,
A-Z)
File Acceptance Requirements
1.
2.
3.
4.
5.
.
Files must follow the correct naming convention as described above.
Files must be in the correct EDI Format.
If Colorado Access is unable to open a transmitted file, the provider will be notified via email to resubmit a corrected file.
EDI submissions are not considered “clean” until our transactional system EDI load program completes successfully.
EDI submissions with format or syntax problems will be rejected and the submitter will be notified via email.
Confirmation Reports
Electronic claims confirmation reports for test files are placed in the submitter’s Web File Share Portal folders once testing has been
completed.
Production file confirmation reports are available through the Web File Share Portal. For EDI claim files submitted prior to 3:00 p.m.
Mountain time, Monday through Friday, the confirmation reports are available the next business day. For EDI claim files received
after 3:00 p.m., the confirmation reports are available by the second business day after submission. All specific claim rejection or
acceptance information will be provided o on the payment voucher after the claim has completed adjudication.
FAQ - Required Testing Information
1.
What validation will be used during testing?
Will you be using a validation tool?
We will be using a EDIFECS for 837P, EDIFECS and Foresight for 837I until the 5010 version of EDIFECS is ready.
Which level of validation will be used?
Must pass SNIP level 3
2.
Can a trading partner use existing 4010 production data and up convert it to a 5010 test file?
Yes, for testing, converting the data is fine. Colorado Access will not accept converted 4010 data in production
once we go live with the 5010.
3.
Should a full or partial production file be used?
For testing, we would prefer a partial file is fine, 25-50 claims per file.
4.
Is it acceptable to populate ISA15 with "T" for test indicator?
Yes, we use the ISA15 to determine a test from a production file.
5.
Do you have a preference for the Repetition Separator ISA11?
a.
b.
Data Element Separator: *
Composite Separator: :
4
c.
d.
Repetition Separator: ^
Segment Terminator: ~
6.
Can we use the existing connection for testing:
Yes, The current connection is https://sftp.coaccess.com/action/login. Put the test files in the TestClaims folder.
7.
What reports will be received in response to 5010 testing?
999
TA1
277U
Proprietary report to replace the C02.
8.
Is Colorado Access going to be testing the Errata version of 5010 immediately?
Yes, we will be testing with the Errata.
9.
Will you be accepting dual submission of both 4010 and 5010 files in production or will you specify a cut over date to stop
receiving 4010 files and only accept 5010 files?
Once we go live with 5010 files for each trading partner, we will only be receiving 5010 files in production.
5
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6
837 Health Care Claims Transaction - Professional– version 5010
Payer Specific Data Requirements
Professional Claims (837P) Data Requirements
************************************************************************************************************************************************
General
The purpose of this section is to clarify the data elements and segments that must be used for (payer specific) professional claims transactions. This document has been
prepared as Colorado Access specific companion document to that implementation guide and to clarify when conditional data elements and segments must be used for
Colorado Access reporting, and identify those codes and data elements that do not apply to Colorado Access. The following information is designed to help you complete the
837P transaction. If you follow these guidelines, we'll be better able to process your claims accurately and efficiently.
X12 837 Professional Mapping - 5010
Loop
Rpt Req
Seg
Req
Rpt
Field
ID
Req
Field Name
Min
Max
DT
Comments
Legend:
Loop - Describes the positioning of business data within the data structure/stream.
Seg - Describes the individual data within the loops in the data structure/stream.
Rpt - Indicates the maximum number of times the Loop or Segment can repeat.
Req - Indicates whether a Loop, Segment, or Field ID is required by the X12 standards. R - Required, S - Situational, NU - Not used.
Field ID - Name of the field within the segment structure.
Field Name - Name of the field referred to in the Field ID column.
Min - Mininum length the field can be. (*** - Indicates a null field)
Max - Maximum length the field can be. (*** - Indicates a null field)
DT - Data Type as specified in Implementation Guides (Nn = Numeric, R = Decinal, ID = Identifier, AN = String, DT = Date, TM = Time, B = Binary)
Control
1
R
Control
Control
ISA
R
Interchange Control Header
ISA01
R
Auth Information Qualifier
2
2
ID
Valid Values: 00 (No auth information
present), 03 (Additional data
identification)
ISA02
R
Authorization Information
10
10 AN
ISA03
R
Security Information Qualifier
2
2
ID
Valid Values: 00 (No security information
present), 01 (Password)
ISA04
ISA05
R
R
Security Information
Interchange ID Qualifier
10
2
10
2
AN
ID
ISA06
R
Interchange Sender ID
15
15
AN
Valid Values: 01 (Duns), 14 (Duns plus
suffix), 20 (HIN), 27 (HCFA carrier ID), 28
(HCFA - fiscal intermediary ID), 29
(Medicare provider and supplier ID), 30
(US Fed Tax ID), 33 (NAIC), ZZ (Mutually
defined)
ID code published by sender for other
parties to use as receiver ID to route data
to them.
Valid Values
ISA
00
Spaces
00
Spaces
ZZ
Submitter ID assigned by Colorado Access
837 Health Care Claims Transaction - Professional – version 5010
GS
ISA07
R
2
2
ID
ISA08
R
Interchange Receiver ID
15
15
AN
ISA09
ISA10
ISA11
R
R
R
Interchange Date
Interchange Time
Repetition Separator
6
4
1
6
4
1
DT
TM
ID
Format: YYMMDD
Format: HHMM
Valid Value: ^
ISA12
R
Interchange Control Version
No.
5
5
ID
Valid Value: 00501 (Standards Approved
for Publication by ASC X12 Procedures
Review Board)
ISA13
R
Interchange Control No.
9
9
N0
Numeric. Must match IEA02
ISA14
R
Acknowledgment Requested
1
1
ID
Valid Values: 0 (No acknowledgment
requested), 1 (TA1 Interchange
acknowledgment requested)
ISA15
R
Usage Indicator
1
1
ID
Valid Values: P (Production data), T (Test
data)
P=Production
T=Test
ISA16
R
Component Element Separator
1
1
***
Used to separate component data
elements within a composite data
structure. This value must be different
than the data element separator and the
segment terminator
Use a colon (:)
GS01
GS02
GS03
GS04
R
R
R
R
Functional Group Header
Functional ID Code
Application Sender's Code
Application Receiver's Code
Date
2
2
2
8
2
15
15
8
ID
AN
AN
DT
Valid Value: HC (Health Care Claim (837)
Codes agreed to by trading partners
Format: CCYYMMDD; functional group
creation date
GS05
R
Time
4
8
TM
Formats: HHMM (recommended),
HHMMSS, HHMMSSD, HHMMSSDD
GS06
R
Group Control No.
1
9
N0
Numeric. Must match GE02
R
Valid Values: 01 (Duns), 14 (Duns plus
suffix), 20 (HIN), 27 (HCFA carrier ID), 28
(HCFA - fiscal intermediary ID), 29
(Medicare provider and supplier ID), 30
(US Fed Tax ID), 33 (NAIC), ZZ (Mutually
defined)
ID code published by receiver of data to
route data to them.
ZZ
COA
Date of Transmission
Time of Transaction
^
00501
Begins with 00000001 and increments by +1
for each subsequent file create each day.
Resets each day.
1
GS
HC
COA
Create Date
Create Time
Begins with 1 and increments +1 for each
subsequent GS within the file. Resets back to
1 with each new file.
8
Header
1
BHT
1
R
Responsible Agency Code
1
2
ID
Valid Value: X (Accredited Standards
Committee X12)
GS08
R
Version/Release/Industry ID
Code
1
12
AN
Valid Value: 005010XX222A1
R
ST
1000A
GS07
R
R
1
ST01
ST02
R
R
ST03
R
1
R
Implementation Convention
Reference
005010X222A1
Header
3
4
3
9
ID
AN
1
35
AN
Valid Value: 837 (Health Care Claim)
Must match value in SE02 Transaction Set
Control Number. The number must be
unique within the specified functional
group (GS-SE) and interchange (ISA-IEA)
but can repeat in other groups and
interchanges
Valid value: 005010X222A1
Beginning of Hierarchical
Transaction
ST
837
Begins with 0001 and invrements +1 for each
subsequent ST within the GE. Resets back to
005010X222A1
BHT
BHT01
R
Hierarchical Structure Code
4
4
ID
Valid Value: 0019 (Information Source,
Subscriber, Dependent)
0019
BHT02
BHT03
R
R
Transaction Set Purpose Code
Reference Identification
2
1
2
50
ID
AN
Valid Values: 00 (Original), 18 (Reissue)
User Defined
00
Must be filled in by the submitter. BHT03 is
the number assigned by the originator to
identify the transaction within the originator's
business application system.
BHT04
R
Date
8
8
DT
Format: CCYYMMDD (Identifies the date
that the submitter created the file)
File create date
BHT05
BHT06
R
R
Time
Transaction Type Code
4
2
8
2
TM
ID
Format: HHMMSS, HHMM, HHMMSSD
Valid Values: 31 (Subrogation Demand),
CH (Chargeable), RP (Reporting)
File create time
CH
R
NM1
Header
Transaction Set Header
Transaction Set ID Code
Transaction Set Control
Number
X
Submitter Name
Submitter Name
1
Submitter Name
Submitter Name
NM101
NM102
R
R
Entity Identifier Code
Entity Type Qualifier
2
1
3
1
ID
ID
NM103
R
Name Last or Organization
Name
1
60
AN
Valid Value: 41 (Submitter)
Valid Values: 1 (Person), 2 (Non-Person
Entity)
Submitter Last or Org Name
NM1
41
2
Submitter name or organization name
9
PER
1000B
1
R
NM104
NM105
NM106
NM107
NM108
S
S
NU
NU
R
Submitter First Name
Submitter Middle Name
Name Prefix
Name Suffix
Identification Code Qualifier
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Required if NM102 = 1
User Defined
Not Used
Not Used
Valid Value: 46 (Electronic Transmitter ID
Number ETIN, established by trading
partner agreement)
NM109
NM110
NM111
NM112
R
NU
NU
NU
Identification Code
Entity Relationship Code
Entity Identifier code
Name
2
2
2
1
80
2
3
60
AN
ID
ID
AN
Submitter Identifier
Not Used
Not Used
Not Used
2
Submitter EDI Contact
Information
R
Leave blank
Leave blank
Leave blank
Submitter EDI Contact Information
PER01
PER02
PER03
R
R
R
Contact Function Code
Submitter Contact Name
Communication Number
Qualifier
2
1
2
2
60
2
ID
AN
ID
Valid Value: IC (Information Contact)
User Defined
Valid Values: ED (Electronic Data
Interchange Address Number), EM
(Electronic Mail), FX (Fax), TE (Phone)
IC
Submitter contact name
TE
PER04
R
1
256
AN
Submitter telephone number
PER05
S
Qualifier
2
2
ID
PER06
PER07
S
S
Qualifier
1
2
256
2
AN
ID
PER08
PER09
NU
NU
Contact Inquiry Reference
1
1
256
20
AN
AN
Complete communications number
including country or area code when
applicable
Valid Values: EM (Electronic Mail), EX
(Telephone Extension), FX (Fax), TE
(Phone)
See PER04
(Phone)
See PER04
Not Used
R
NM1
Leave blank
Leave blank
Leave blank
Leave blank
46
Receiver Name
Receiver Name
1
NM101
NM102
NM103
NM104
NM105
R
R
R
N
N
Receiver Name
First Name
Name Middle
FX
Submitter fax number
EM
Submitter email address
Leave blank
Receiver Name
NM1
2
1
1
1
1
3
1
60
35
25
ID
ID
AN
AN
AN
Valid Value: 40 (Receiver)
Valid Value: 2 (Non-Person Entity)
User Defined
Not Used
Not Used
40
2
COA
Leave blank
Leave blank
10
2000A
>1
NM106
NM107
NM108
N
N
R
Name Prefix
Name Suffix
1
1
1
10
10
2
AN
AN
ID
Not Used
Not Used
Valid Value: 46 (Electronic Transmitter
Identification Number ETIN)
Leave blank
Leave blank
46
NM109
NM110
NM111
NM112
R
N
N
N
Identification Code
Name
2
2
2
1
80
2
3
60
AN
ID
ID
AN
Receiver Primary ID
Not Used
Not Used
Not Used
COA
Leave blank
Leave blank
R
HL
PRV
CUR
R
R
R
Billing/Pay-To Provider
Hierarchical Level
1
HL01
R
HL02
HL03
HL04
NU
R
R
1
HL
Hierarchical ID Number
1
12
AN
Must begin with "1" and increment by one
for each HL used. Only Numeric values are
allowed.
Begins with 1 and invrements +1 for each
servicing provider.Possible to include this
record for each claim.
Hierarchical Parent ID Number
Hierarchical Level Code
Hierarchical Child Code
1
1
1
12
2
1
AN
ID
ID
Not Used
Valid Value: 20 (Information Source)
Valid Value: 1 (Additional Subordinate HL
data segment in this hierarchical structure)
Leave blank
20
1
Specialty Information
Colorado Access does not use this segment.
PRV01
PRV02
R
R
Provider Code
Qualifier
1
2
3
3
ID
ID
Valid Values: BI (Billing)
Valid Value: PXC (Health Care Provider
Taxonomy Code)
PRV03
R
Provider Taxonomy Code
1
50
AN
PRV04
PRV05
NU
NU
State or Province Code
Provider Specialty Information
2
***
2
***
ID
***
Required when adjudication is known to
be impacted by taxonomy code, and
rendering provider is same entity as billing
or pay-to provider and loop 2310B is not
used
Not Used
Not Used
PRV06
NU
Provider Organization Code
3
3
ID
Not Used
CUR01
CUR02
CUR03
CUR04
R
R
NU
NU
Foreign Currency Information
Currency Code
Exchange Rate
2
3
4
2
3
3
10
3
ID
ID
R
ID
Valid Value: 85 (Billing Provider)
Standard ISO code for country
Not Used
Not Used
1
11
2010AA
1
CUR05
CUR06
NU
NU
Currency Code
Currency Market/Exchange
Code
3
3
3
3
ID
ID
Not Used
Not Used
CUR07
CUR08
CUR09
CUR10
CUR11
CUR12
CUR13
CUR14
CUR15
CUR16
CUR17
CUR18
CUR19
CUR20
CUR21
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
Date/Time Qualifier
Date
Time
Date/Time Qualifier
Date
Time
Date/Time Qualifier
Date
Time
Date/Time Qualifier
Date
Time
Date/Time Qualifier
Date
Time
3
8
4
3
8
4
3
8
4
3
8
4
3
8
4
3
8
8
3
8
8
3
8
8
3
8
8
3
8
8
ID
DT
TM
ID
DT
TM
ID
DT
TM
ID
DT
TM
ID
DT
TM
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
R
NM1
N3
R
R
Billing Provider Name
1
1
NM1
NM101
NM102
R
R
2
1
3
1
ID
ID
NM103
R
Name
1
60
AN
NM104
NM105
NM106
NM107
NM108
NM109
S
S
NU
S
R
R
Billing Provider First Name
Billing Provider Middle Name
Name Prefix
Name Suffix
Billing provider ID Number
1
1
1
1
1
2
35
25
10
10
2
80
AN
AN
AN
AN
ID
AN
Required if NM102=1
Required if known and NM102=1
Not Used
Billing Provider Suffix
Valid Values: XX (NPI)
Required for Billing provider ID; Used in
provider Matching
NM110
NM111
NM112
NU
NU
NU
Last Name or Organization
Name
2
2
1
2
3
60
ID
ID
AN
Not Used
Not Used
Not Used
Billing Provider Address
Entity)
Billing Provider Last Name or Org Name
85
2
Billing provider name or oganization name
Billing provider first name, if applicable.
Leave blank
Leave blank
Leave blank
XX
Billing Provider's National Provider ID (NPI)
Leave blank
Leave blank
Leave blank
N3
12
N301
N302
N4
REF
REF
PER
R
R
S
S
R
S
1
Address Information
Address Information
1
1
55
55
AN
AN
Billing Provider Address 1
Billing Provider City/State/ZIP
Code
N401
N402
N403
R
R
R
N404
N405
N406
N407
N4
City Name
Postal Code
2
2
3
30
2
15
AN
ID
ID
S
NU
NU
S
Billing Provider Country Code
Location Qualifier
Location Identifier
Country Subdivision Code
2
1
1
1
3
2
30
3
ID
ID
AN
ID
REF01
R
Billing Provider Secondary ID
Qualifier
2
3
ID
REF02
REF03
REF04
R
NU
NU
1
1
***
50
80
***
1
2
Description
Reference Identifier
AN
AN
***
Billing Provider UPIN/License
Information
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
Reference Identified
1
1
***
50
80
***
2
Billing Provider City Name
Billing Provider State or Province
Billing Provider Postal Code (the full nine
digit
ZIP code must be provided)
Not Used
Not Used
Not Used
Valid Values: EI (Employer's Id #), SY
(Social Security #)
Billing Provider Secondary ID
Not Used
Not Used
Billing Provider State or Province
Billing Provider Postal Code
Leave blank
Leave blank
Leave blank
Leave blank
REF
EI or SY
Billing Provider's Tax ID
Leave blank
Leave blank
Billing Provider UPIN/License Information
ID
Valid Values: 0B (State License Number),
1G (Provider UPIN Number)
AN
AN
***
Billing Provider UPIN/License Information
Not Used
Not Used
Billing Provider Contact
Information
PER
PER01
PER02
PER03
R
R
R
Billing Provider Contact Name
Qualifier
2
1
2
2
60
2
ID
AN
ID
PER04
R
1
256
AN
Complete communications number
including country or area code when
applicable
Valid Values: EM (Electronic Mail), FX
(Fax), TE (Telephone)
IC
TE
Billing Provider Contact Number
13
2010AB
1
PER05
S
Qualifier
2
2
ID
(Telephone)
EM
PER06
PER07
S
S
Qualifier
1
2
256
2
AN
ID
See PER04
(Telephone)
Billing Provider Contact Email Address
Leave blank
PER08
PER09
S
NU
1
1
256
20
AN
AN
See PER04
Not Used
S
NM1
N3
S
R
Pay-To Provider Name
1
NM101
NM102
R
R
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
1
N301
N302
N4
R
R
S
1
Pay-To-Provider Name
2
1
3
1
ID
ID
Pay to Provider Last Name
Pay to Provider First Name
Pay to Provider Middle Name
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
1
1
1
2
2
2
1
60
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
AN
ID
AN
ID
ID
AN
Valid Value: 87 (Pay-to Provider)
Entity)
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
1
1
55
55
AN
AN
Pay to Prov Address 1
Pay to Prov Address 2
Pay-To Provider Address
Address Information
Address Information
Pay-To Provider City/State/ZIP
Code
N401
N402
N403
N404
N405
N406
R
R
R
S
NU
NU
City Name
Postal Code
Pay to Provider Country code
Location Qualifier
Location Identifier
Leave blank
Leave blank
2
2
3
2
1
1
30
2
15
3
2
30
AN
ID
ID
ID
ID
AN
Pay to Provider City
Pay to Provider State
Pay to Provider Zip
Not Used
Not Used
14
N407
2010AC
1
NU
S
NM1
N3
S
R
R
1
3
Pay-To Plan Name
Pay-To Plan Name
1
NM101
NM102
NM103
R
R
R
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
Not Used
Pay-To Plan Name
Pay-To Plan Name
Name
2
1
1
3
1
60
ID
ID
AN
Valid Values: PE (Payee)
Valid Values: 2 (Non-Person Entity)
Pay-To Plan Name
NU
NU
NU
NU
R
Name First
Name Middle
Name Prefix
Name Suffix
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Not Used
Not Used
Not Used
Not Used
Valid Values: PI (Payor Identification), XV
(NPIN)
R
NU
NU
NU
Identification Code
Entry Identifier Code
Name
2
2
2
1
80
2
3
60
AN
ID
ID
AN
Pay-To Plan Primary Identifier
Not Used
Not Used
Not Used
1
1
55
55
AN
AN
Pay-To Plan Address
Pay-To Plan Address 1
Pay-To Plan Address 2
Pay-To Plan City, State, Zip Code
Pay-To Plan City Name
Pay-To Plan State
Pay-To Zip Code
Required when the address is outside the
US.
Not Used
Not Used
Required when the address is not in the
US, including its territories or Canada, and
the country in N404 has administrative
subdivisions such as but not limited to
states, province, cantons, etc.
1
N301
N301
N4
R
R
1
Pay-To Plan Address
Address Information
Address Information
Pay-To Plan City, State, Zip
Code
N401
N402
N403
N404
R
S
S
S
N405
N406
N407
NU
NU
S
City Name
Data or Province Code
Postal Code
Country Code
2
2
3
2
30
2
15
3
AN
ID
ID
ID
Location Qualifier
Location Identifier
1
1
1
2
30
3
ID
AN
ID
15
REF
REF
2000B
>1
S
S
1
Pay-To Plan Secondary
Identification
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
SBR
R
R
ID
AN
AN
***
Pay-To Plan Tax Identification
Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
R
HL
ID
AN
AN
***
Valid Values: 2U (Payer Identification
Number), FY (Claim Office Number), NF
(National Association of Insurance
Commissioners (NAIC) Code)
Pay-To Plan Secondary Identification
Not Used
Not Used
Pay-To Plan Tax Identification Number
Valid Values: EI (Employer’s Identification
Number)
Pay-To Plan Tax Identification Number
Not Used
Not Used
HL01
HL02
R
R
Subscriber
Subscriber Hierarchical Level
HL03
HL04
R
R
1
1
2
1
ID
ID
Valid Value: 22 (Subscriber)
Valid Values: 0 (No subordinate HL
segment in this hierarchical structure), 1
(Additional subordinate HL data segment
in this hierarchical structure
SBR01
R
Subscriber Information
Payer Responsibility Sequence
Number Code
1
1
ID
Valid Values: P (Primary), S (Secondary), T
(Tertiary)
SBR02
SBR03
SBR04
S
S
S
Relationship Code
Name
2
1
1
2
30
60
ID
AN
AN
Valid Value: 18 (Self)
Insured Group or Policy Number
Insured Group or Plan Name
1
1
Subscriber
1
1
12
12
AN
AN
Unique Number Assigned by sender
HL
Increments +1 fron the previous HL segment
Identification number of the next higher
hierarchical data segment
22
0
SBR
P
18
Leave blank
Leave blank
16
PAT
S
SBR05
S
Insurance Type Code
1
3
ID
Valid Values: 12 (Medicare Secondary
Working Aged Beneficiary or Spouse with
Employer Group Health Plan), 13
(Medicare Secondary End-Stage Renal
Disease), 14 (Medicare Secondary, no-fault
insurance including auto is primary), 15
(Medicare Secondary worker's comp), 16
(Medicare Secondary Public Health
Service), 41 (Medicare Secondary Black
Lung), 42 (Medicare Secondary Veteran's
Admin), 43 (Medicare Secondary Disabled
Beneficiary Under age 65 large group
health plan), 47 (Medicare Secondary,
other liability Insur Primary). Required
when the destination payer is Medicare
/Medicare not primary
Leave blank
SBR06
SBR07
SBR08
SBR09
NU
NU
NU
S
Coordination of Benefits Code
Yes No Condition or Resp
Employment Status code
Claim Filing Indicator Code
1
1
2
1
1
1
2
2
ID
ID
ID
ID
Not Used
Not Used
Not Used
Valid Values: 11 (Other Non-Federal
Programs), 12 (Preferred Provider
Organization), 13 (Point of Service), 14
(Exclusive Provider Organization), 15
(Indemnity Insurance), 16 (Health
Maintenance Organization-Medicare), 17
(Dental Maintenance Organization), AM
(Automobile Medical), BL (Blue
Cross/BlueShield), CH (CHAMPUS), CI
(Commercial Insurance), DS (Disability),
HM (Health Maintenance Organization),
LM (Liability Medical), MA (Medicare Part
A), MB (Medicare Part B), MC (Medicaid),
OF (Other Federal Program or Medicare
Part D), TV (Title V), VA (Veteran
Administration Plan), WC (Workers'
Compensation Health Claim), ZZ (Mutually
Defined or unknown).
Leave blank
Leave blank
Leave blank
(Commercial Insurance), DS (Disability), HM
(Health Maintenance Organization), LM
(Liability Medical), MA (Medicare Part A), MB
(Medicare Part B), MC (Medicaid), OF (Other
Federal Program or Medicare Part D), TV (Title
V), VA (Veteran Administration Plan), WC
(Workers' Compensation Health Claim), ZZ
(Mutually Defined or unknown).
PAT01
PAT02
PAT03
PAT04
NU
NU
NU
NU
Patient Information
Individual Relationship Code
Patient Location Code
Employment Status Code
Student Status Code
2
1
2
1
2
1
2
1
ID
ID
ID
ID
Not Used
Not Used
Not Used
Not Used
1
17
2010BA
1
PAT05
S
Date Time Period Format
Qualifier
2
3
ID
Valid Value: D8 (CCYYMMDD)
PAT06
S
Date of Death
1
35
AN
Required if patient is known to be
deceased and date of death is available to
provider billing system.
PAT07
S
Unit or Basis for Measurement
Code
2
2
ID
Valid Value: GR 01 (Actual Pounds)
PAT08
S
Patient Weight
1
10
R
Required when claims/encounters involve
Medicare Durable Medical Equipment
Regional Carriers certificate of medical
necessity (DMERC CMN), 02.03, 10.02, or
DME MAC 10.03.
PAT09
S
Pregnancy Indicator
1
1
ID
Valid Value: Y (Yes). Required when
mandated by law. Determination of
pregnancy should be completed in
compliance with applicable law. If PAT 09
not used then patient is not pregnant
R
NM1
R
Subscriber Name
Subscriber Name
1
NM101
NM102
R
R
NM103
NM104
NM105
NM106
NM107
NM108
Subscriber Name
NM1
2
1
3
1
ID
ID
Valid Value: IL (Insured or Subscriber)
Valid Value: 1 (Person), 2 (Non-Person
Entity)
Subscriber Last Name
Required if NM102=1
Not Used
R
S
S
NU
S
S
Subscriber First Name
Subscriber Middle Name
Name Prefix
Name Suffix
1
1
1
1
1
1
60
35
25
10
10
2
AN
AN
AN
AN
AN
ID
NM109
S
Subscriber Primary Identifier
2
80
AN
Required if subscriber is the patient;
otherwise use if known
Member ID
NM110
NM111
NM112
NU
NU
NU
Name
2
2
1
2
3
60
ID
ID
AN
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Valid Values: II (Standard Unique Health
Identifier for each Individual in the US.
Required if the HIPAA Individual Patient
Identifier is mandated use), MI (Member
Id Number), use if not required)
IL
1
Subscriber'sLast Name
Subscriber's First Name
Subdcriber\'s Middle Name
Leave blank
Leave blank
MI
18
N3
N4
DMG
REF
REF
S
S
S
S
S
1
N301
N302
R
S
N401
N402
N403
N404
N405
N406
N407
R
S
R
S
NU
NU
S
1
1
1
1
55
55
AN
AN
Subscriber Address 1
Subscriber City/State/ZIP Code
City Name
Postal Code
Subscriber Country Code
Location Qualifier
Location Identifier
2
2
3
2
1
1
1
30
2
15
3
2
30
3
AN
ID
ID
ID
ID
AN
ID
Subscriber City Name
Subscriber State Code
Subscriber Zip Code (must be 9 digits)
Not Used
Not Used
Not Used
Subscriber Demographic
Information
R
Qualifier
2
3
ID
DMG02
DMG03
R
R
Subscriber Birth Date
Gender
1
1
35
1
AN
ID
DMG04
DMG05
DMG06
DMG07
DMG08
DMG09
DMG10
DMG11
NU
NU
NU
NU
NU
NU
NU
NU
Martial Status Code
Race or Ethnicity Code
Citizenship Status Code
Country Code
Basis of Verification Code
Quantity
Code List Qualifier Code
Industry Code
1
1
1
2
1
1
1
1
1
1
2
3
2
15
3
30
ID
ID
ID
ID
ID
R
ID
AN
Valid Values: F (Female), M (Male), U
(Unknown)`
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Subscriber Secondary
Identification
N4
Subscriber/Patient's City Name
Subscriber/Patient's State
Subscriber/Patient's Zip Code
Leave blank
Leave blank
Leave blank
Leave blank
D8
Subscriber/Patient's Birth Date
F = Female, M = Male, U = Unknown
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
REF
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
Property and Casualty Claim
Number
N3
DMG
DMG01
1
1
Subscriber Address
Address Information
Address Information
ID
AN
AN
***
Valid Values: SY (Social Security Number)
Subscriber Supplemental ID
Not Used
Not Used
SY
Social Security Number
Leave blank
Leave blank
19
PER
2010BB
1
R
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
R
AN
AN
***
Property and Casualty
Subscriber Contact
information
Valid Value: Y4 (Agency Claim Number)
Property Casualty Claim Number
Not Used
Not Used
Property and Casualty Subscriber Contact
information
Valid Values: IC (Information Contact)
Valid Values: TE (Telephone)
PER01
PER02
PER03
R
S
R
Name
Qualifier
2
1
2
2
60
2
PER04
PER05
R
S
Qualifier
1
2
256
2
Valid Values: EX (Telephone Extension)
PER06
PER07
S
NU
Qualifier
1
2
256
2
Not Used
PER08
PER09
NU
NU
1
1
256
20
Not Used
Not Used
R
NM1
ID
Payer Name
Payer Name
1
NM101
NM102
NM103
R
R
R
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
Payer Name
NM1
Name
2
1
1
3
1
60
ID
ID
AN
Valid Value: PR (Payer)
Valid Value: 2 (Non-person Entity)
Payer Name - Last
PR
2
CO Access
NU
NU
NU
NU
R
Name First
Name Middle
Name Prefix
Name Suffix
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Not Used
Not Used
Not Used
Not Used
Valid Values: PI (Payer Identification), XV
(National Plan ID)
Leave blank
Leave blank
Leave blank
Leave blank
PI
R
NU
NU
Identification Code
2
2
2
80
2
3
AN
ID
ID
Payer Primary ID
Not Used
Not Used
Coacc
Leave blank
Leave blank
20
NM112
N3
N4
REF
REF
2000C
>1
S
S
S
S
NU
1
N301
N302
R
S
N401
N402
N403
N404
N405
N406
N407
R
R
R
S
NU
NU
S
REF01
R
REF02
REF03
REF04
R
NU
NU
1
3
2
S
Name
1
60
AN
Not Used
Payer Address
Address Information
Address Information
1
1
55
55
AN
AN
Payer Address 1
Payer Address 2
Payer City/State/ZIP Code
City Name
Postal Code
Payer Country Code
Location Qualifier
Location Identifier
2
2
3
2
1
1
1
30
2
15
3
2
30
3
AN
ID
ID
ID
ID
AN
ID
Payer City Name
Payer State Code
Payer Zip Code
2
3
ID
Valid Values: 2U (Payer ID), EI (Employer's
Identification Number), FY (Claim Office
Number), NF (NAIC Code)
1
1
***
50
80
***
Payer Secondary Identification
Qualifier
Description
S
1
Payer Additional ID
Not Used
Not Used
Billing Provider Secondary
Identification
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
Patient Hierarchical Level
N4
PO Box 17470
Leave blank
N4
Denver
CO
80217
Leave blank
Leave blank
Leave blank
Leave blank
REF01
Patient
HL
AN
AN
***
Not Used
Not Used
Not Used
Leave blank
ID
Valid Values: G2 (Provider Commercial
Number), LU (Location Number)
AN
AN
***
Billing Provider Secondary Identification
Not Used
Not Used
Required when the patient is a dependent of
the subscriber identified in
Loop ID-2000B and cannot be uniquely
identified to the payer using the
subscriber’s identifier in the Subscriber Level.
HL
21
PAT
2010CA
1
R
HL01
R
1
12
AN
Unique number to identify hierarchical
structure
structure
HL02
HL03
HL04
R
R
R
1
1
1
12
2
1
AN
ID
ID
Next higher Hierarchical data segment
Valid Value: 23 (Dependent)
Valid Value: 0 (No subordinate HL segment
in this hierarchical structure)
Next higher hierarchical data segment
23
0
PAT01
R
Patient Information
2
2
ID
Valid Values: 01 (Spouse), 19 (Child), 20
(Employee), 21 (Unknown), 39 (Organ
Donor), 40 (Cadaver Donor), 53 (Life
Partner), G8 (Other Relationship)
PAT02
PAT03
PAT04
PAT05
NU
NU
NU
S
Student Status Code
Qualifier
1
2
1
2
1
2
1
3
ID
ID
ID
ID
Not Used
Not Used
Not Used
Valid Value: D8 Format: CCYYMMDD
PAT06
S
Patient Death Date
1
35
AN
Required if patient is known to be
deceased and date of death is available to
provider billing system.
PAT07
S
Code
2
2
ID
Valid Value: GR=Grams 01 (Actual
pounds); Required when PAT08 is used
Leave blank
PAT08
S
Patient Weight
1
10
R
Required on claims/encounters involving
Medicare Durable Medical Equipment
Regional Carriers certificate of medical
necessity (DMERC CMN) 02.03, 10.02, or
DME MAC 10.03
Leave blank
PAT09
S
Pregnancy Indicator
1
1
ID
Valid Value: Y (Yes). Required when
mandated by law. Determination of
pregnancy should be completed in
compliance with applicable law. If PAT 09
not used then patient is not pregnant
Leave blank
1
S
NM1
R
Patient Name
Patient Name
1
NM101
NM102
NM103
R
R
R
Name
PAT
Patient Relationship Code
Leave blank
Leave blank
Leave blank
D8
Patient Date of Death, if known, CCYYMMDD
Patient Name
NM
2
1
1
3
1
60
ID
ID
AN
Valid Value: QC (Patient)
Valid Value: 1 (Person)
Patient Last Name
QC
1
Patient Last Name
22
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
N3
N4
DMG
REF
R
S
R
S
S
S
NU
S
NU
NU
NU
NU
1
N301
N302
R
S
N401
N402
N403
N404
N405
N406
N407
R
S
R
S
NU
NU
S
1
1
Patient First Name
Patient Middle Initial
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
35
25
10
10
2
80
2
3
AN
AN
AN
AN
ID
AN
ID
ID
Not Used
Patient Name Suffix
Not Used
Not Used
Not Used
Not Used
Patient First Name
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Patient Address
Address Information
Address Information
1
1
55
55
AN
AN
Patient Address
Patient Address 1
Patient Address 2
N3
Patient Address 1
Patient Address 2
Patient City/State/ZIP Code
City Name
Postal Code
Patient Country Code
Location Qualifier
Location Identifier
2
2
3
2
1
1
1
30
2
15
3
2
30
3
AN
ID
ID
ID
ID
AN
AN
Patient City Name
Patient State Code
Patient Zip Code
N4
Patient City Name
Patient State Code
Patient Zip Code
Leave blank
Leave blank
Leave blank
Leave blank
Patient Demographic
Information
Patient Demographic Information
DMG01
R
Qualifier
2
3
ID
DMG02
DMG03
R
R
Patient Date of Birth
Patient Gender Code
1
1
35
1
AN
ID
DMG04
DMG05
DMG06
DMG07
DMG08
DMG09
NU
NU
NU
NU
NU
NU
Martial Status Code
Country Code
Quantity
1
1
1
2
1
1
1
1
2
3
2
15
ID
ID
ID
ID
ID
R
1
Property and Casualty Patient
Identifier
REF01
R
Qualifier
Not Used
Not Used
Not Used
2
3
ID
(Unknown)
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
DMG
D8
Patient Date of Birth, CCYYMMDD
F = Female, M = Male, U = Unknown
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Property and Casualty Patient Identifier
Valid Values: 1W (Member Identification
Number), SY (Social Security Number)
23
REF02
REF03
REF04
PER
2300
100
S
R
NU
NU
1
R
1
1
***
50
80
***
AN
AN
***
Patient Contact Information
Property and Casualty Patient Identifier
Not Used
Not Used
Property and Casualty Claim Patient
Contact Information
Valid Values: IC (Information Contact)
User Defined
Valid Values: TE (Telephone)
PER01
PER02
PER03
R
S
R
Name
Qualifier
2
1
2
2
60
2
PER04
PER05
R
S
Qualifier
1
2
256
2
Valid Values: EX (Extension)
PER06
PER07
S
NU
Qualifier
1
2
256
2
Not Used
PER08
PER09
NU
NU
1
1
256
20
Not Used
Not Used
CLM01
R
Claim Information
Claim Information
Patient Account Number
1
38
AN
CLM02
R
Monetary Amount
1
18
R
Total Claim Charges; may be zero (0) for
encounters
CLM03
CLM04
CLM05
NU
NU
R
Non-Institutional Claim Type
Place of Service Code
Composite
1
1
*
2
2
*
ID
ID
*
Not Used
Not Used
SEE BELOW CLM05-___
R
CLM
Description
1
Claim Information
Patient Account Number - should be
echoed back in the 835; maximum number
of characters support in this field is 20
CLM
Patient Account Number assigned by the
Provider
Total Claim Amount
Leave blank
Leave blank
24
CLM0501
R
Facility Code Value
1
2
AN
Valid Values: 11 (Office), 12 (Home), 21
(Inpatient Hosp), 22 (Outpatient Hosp), 23
(Emergency Room - Hospital), 24
(Ambulatory Surgical Ctr), 25 (Birthing
Center), 26 (Military Treatment Facility),
31 (Skilled Nursing Facility), 33 (Custodial
Care Facility), 34 (Hospice), 41 (Ambulance
Land), 42 (Ambulance- Air or Water), 51
(Inpatient Psychiatric Facility), 52
(Psychiatric Facility Partial Hospitalization),
53 (Community Mental Health Center), 54
(Intermediate Care Facility), 55
(Residential Substance Abuse Treatment
Facility), 56 (Psychiatric Residential
Treatment Ctr), 50 (Federally Qualified
Health Center), 60 (Mass Immunization
Ctr), 61 (Comprehensive Inpatient Rehab
Facility), 62 (Comprehensive Outpatient
Rehabilitation Facility), 65 (End Stage
Renal Disease Treatment Facility), 71
(State or Local Public Health Clinic), 72
(Rural Health Clinic), 81 (Independent Lab),
99 (Other Unlisted Facility). For others see
Code Source ###
CLM0502
R
Facility Code Qualifier
1
2
ID
Valid Values: B (Place of Service Code or
Dental Services)
B
CLM0503
R
Claim Frequency Code
1
1
ID
1=original; 6=corrected; 7=replacement;
8=void Removed per addenda
Default to 1
CLM06
CLM07
R
R
Provider Signature on File
Provider Accept Assignment
1
1
1
1
ID
ID
Valid Values: Y (Yes), N (No)
Valid Values: A (Assigned), B (Lab
Services), C (Not Assigned)
CLM08
R
Assignment of Benefits
Indicator
1
1
ID
Valid Values: Y (Yes), N (No), W (Not
Applicable)
Y = Yes
CLM09
R
Release of Information Code
1
1
ID
Valid Values: I (Informed Consent to
Release), Y (Yes, Provider has signed
statement permitting release)
I (Informed Consent to Release), Y (Yes,
Provider has signed statement permitting
release)
CLM10
S
Patient Signature Source
1
1
ID
CLM11
S
Related Causes Information
Composite
*
*
*
Valid Values: P (Signature generated by
provider),
SEE BELOW CLM11-___
CLM1101
R
Related Causes Code
2
3
ID
Valid Values: AA (Auto Accident), EM
(Employment), OA (Other Accident)
Plave of Service
Y = Yes
A (Assigned), B (Lab Services), C (Not
Assigned)
P
AA (Auto Accident), EM (Employment), OA
(Other Accident)
25
DTP
S
CLM1102
S
Related Causes Code
2
3
ID
Valid Values: AA (Auto Accident), EM
(Employment), OA (Other Accident)
CLM1103
NU
Related Causes Code
2
3
ID
Not Used
CLM1104
S
Auto Accident State
2
2
ID
State or Province Code; Required if
CLM11-1, -2, or -3 = AA to identify state
where automobile accident occurred. Use
state postal code (i.e. CA = California)
Auto Accident State
CLM1105
S
Country Code
2
3
ID
Required if auto accident occurred out of
the USA to identify country in which
accident occurred.
Leave blank
CLM12
S
Special Program Code
2
3
ID
Required if services rendered under the
following Valid Values: 02 ( Physically
Handicapped Children's Program), 03
(Spec Fed'l Funding), 05 (Disability), 09
(Second Opinion or Surgery)
02 ( Physically Handicapped Children's
Program), 03 (Spec Fed'l Funding), 05
(Disability), 09 (Second Opinion or Surgery)
CLM13
CLM14
CLM15
CLM16
CLM17
CLM18
CLM19
CLM20
NU
NU
NU
NU
NU
NU
NU
S
Yes No condition or Resp
Level of Service Code
Yes/No Condition
Participation Agreement
Claim Status Code
Yes/No Condition
Claim Submission Reason
Delay Reason Code
1
1
1
1
1
1
2
1
1
3
1
1
2
1
2
2
ID
ID
ID
ID
ID
ID
ID
ID
Not Used
Not Used
Not Used
Valid Value: P (Participation agreement)
Not Used
Not Used
Not Used
Valid Values: 1 (Proof of Eligibility
Unknown/Unavailable), 2 (Litigation), 3
(Authorization Delays), 4 (Delay in
Certifying Provider), 5 (Delay in Supplying
Billing Forms), 6 (Delay in Delivery of
Custom Appliances), 7 (Third Party
Processing Delay), 8 (Delay in Eligibility
Determination), 9 (Original Claim Rejected
or Denied unrelated to Billing Limitation
Rules), 10 (Administration Delay in Prior
Approval Process), 11 (Other)
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Onset of Current Illness of Symptom required for the initial medical service or
visit performed in response to a medical
emergency when that date is available or
the date is different fro the service date.
DTP
Valid Value: 431 (Onset of Current Illness
of Symptom)
431
1
Onset of Current Illness or
Symptom
DTP01
R
Date/Time Qualifier
3
3
ID
Leave blank
AA (Auto Accident), EM (Employment), OA
(Other Accident)
26
DTP
DTP
DTP
DTP
DTP
S
S
S
S
S
DTP02
R
Qualifier
2
3
ID
Valid Value: D8
DTP03
R
Symptom Date
1
35
AN
CCYYMMDD
DTP01
DTP02
R
R
3
2
3
3
ID
ID
Initial Treatment Date
Valid Value: 454 (Initial Treatment)
Valid Value: D8
DTP03
R
Symptom Date
1
35
AN
CCYYMMDD
Date Last Seen
6
41
1
1
Date/Time Qualifier
Qualifier
D8
CCYYMMDD
DTP
454
D8
CCYYMMDD
Date Last Seen - Required when claims
involve services from independent physical
or occupational therapist, or phys services
of routine foot care and known to impact
payer adjudication
DTP01
R
Date/Time Qualifier
3
3
ID
DTP02
R
Qualifier
2
3
ID
Valid Value: 304 (Latest Visit or
Consultation)
Valid Value: D8
DTP03
R
Date Last Seen
1
35
AN
Format: CCYYMMDD
Acute Manifestation Required when loop
2300 CR208 = "A" or "M", claim involves
spinal manipulation, and payer is Medicare
1
Acute Manifestation
DTP01
R
Date/Time Qualifier
3
3
ID
Valid Value: 453 (Acute Manifestation of a
Chronic Condition)
DTP02
R
Qualifier
2
3
ID
Valid Value: D8
DTP03
R
Acute Manifestation
1
35
AN
Format: CCYYMMDD
DTP01
DTP02
R
R
Accident
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 439 (Accident)
Valid Values: D8 (CCYYMMDD), DT
(CCYYMMDDHHMM)
DTP03
R
Accident
1
35
AN
Formats: CCYYMMDD or
CCYYMMDDHHMM
DTP01
R
Last Menstrual Period
Date/Time Qualifier
3
3
ID
Valid Value: 484 (Last Menstrual Period)
1
1
DTP
439
D8
CCYYMMDD
27
DTP
DTP
DTP
DTP
DTP
S
S
S
S
S
DTP02
R
Qualifier
2
3
ID
Valid Value: D8
DTP03
R
Last Menstrual Period
1
35
AN
Format: CCYYMMDD
DTP01
DTP02
R
R
Last X-Ray
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 455 (Last X-Ray)
Valid Value: D8
DTP03
R
Last X-Ray
1
35
AN
Format: CCYYMMDD
1
1
Hearing and Vision
Prescription
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Hearing and Vision Prescription Required
where prescription written for
hearing/vision and being billed on this
claim
Valid Value: 471 (Prescription)
Valid Value: D8
DTP03
R
Hearing and Vision
Prescription
1
35
AN
Format: CCYYMMDD
DTP01
R
3
3
ID
Valid Value: 314(Disability), 360 (Disability
Begin), 361 (Disability End)
DTP02
R
Qualifier
2
3
ID
DTP03
R
Disability Begin Date
1
35
AN
Valid Value: D8 (CCYYMMDD, if 360 or
361), RD8 (CCYYMMDD-CCYYMMDD, if
314)
Format: CCYYMMDD
DTP01
DTP02
R
R
Last Worked Date
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 297 (Date Last Worked)
Format: D8
DTP03
R
Last Worked Date
1
35
AN
Format: CCYYMMDD
5
1
1
Disability Dates
Date/Time Qualifier
Authorized Return to Work
Date
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 296 (Return to Work)
Valid Value: D8
DTP03
R
Authorized Return to work
date
1
35
AN
Format: CCYYMMDD
28
DTP
DTP
DTP
DTP
DTP
S
S
S
S
S
1
Admission Date
Admission Date Required on all ambulance
claims/encounters when patient admitted
to hospital. Required on inpatient medical
visits/encounters.
DTP
435
D8
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 435 (Admission)
Valid Value: D8
DTP03
R
Admission Date
1
35
AN
Format: CCYYMMDD
1
Discharge Date
Discharge Date Required for inpatient
claims when patient discharged from
facility and discharge date known
DTP
096
D8
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 096 (Discharge)
Valid Value: D8
DTP03
R
Discharge Date
1
35
AN
Format: CCYYMMDD
2
Assumed Relinquished Care
CCYYMMDD
CCYYMMDD
Assumed and Relinquished Care Required
on Medicare claims where providers share
post-op care
DTP01
R
Date/Time Qualifier
3
3
ID
Valid Values: 090 (Report Start), 091
(Report End)
DTP02
R
Qualifier
2
3
ID
Valid Value: D8
DTP03
R
Assumed and Relinquished
Care
1
35
AN
Format: CCYYMMDD
Required for Property and Casualty claims
when state mandated.
1
Property and Casual Date of
First Contact
DTP01
R
Date/Time Qualifier
3
3
ID
DTP02
R
Qualifier
2
3
ID
Valid Values: 444 (First Visit or
Consultation)
Valid Value: D8
DTP03
R
Care
1
35
AN
Format: CCYYMMDD
Required when a repricer is passing the
claim onto the payer.
Valid Values: 050 (Received)
1
Repricer Received Date
DTP01
R
Date/Time Qualifier
3
3
ID
29
PWK
S
DTP02
R
Qualifier
2
3
ID
Valid Value: D8
DTP03
R
Care
1
35
AN
Format: CCYYMMDD
2
ID
Valid Values: 03 (Report Justifying
Treatment Beyond Utilization Guidelines),
04 (Drugs Administered), 05 (Treatment
Diagnosis), 06 (Initial Assessment), 07
(Functional Goals), 08 (Plan of Treatment),
09 (Progress Report), 10 (Continued
Treatment), 11 (Chemical Analysis), 15
(Justification for Admissions), 21 (Recovery
Plan), A4 (Allergies/Sensitivities
Document), A4 (Autopsy Report), AM
(Ambulance Certification), AS (Admission
Summary), B2 (Prescription), B3 (Physician
Order), B4 (Referral Form), BR (Benchmark
Testing Results), BS (Baseline), BT (Blanket
Test Results), CB (Chiropractic
Justification), CK (Consent Form), CT
(Certification), D2 (Drug Profile
Document), DA (Dental Models), DB
(Durable Medical Equipment Prescription),
DG (Diagnostic Report), DJ (Discharge
Monitoring Report), DS (Discharge
Summary), EB (Explanation of Benefits
(Coordination of Benefits or Medicare
Secondary Payor), HC (Health Certificate),
HR (Health Clinic Records), I5
(Immunization Record),
10
Claim Supplemental
Information
PWK01
R
Attachment Report Type Code
2
03 (Report Justifying Treatment Beyond
Utilization Guidelines), 04 (Drugs
Administered), 05 (Treatment Diagnosis), 06
(Initial Assessment), 07 (Functional Goals), 08
(Plan of Treatment), 09 (Progress Report), 10
(Continued Treatment), 11 (Chemical
Analysis), 15 (Justification for Admissions), 21
(Recovery Plan), A4 (Allergies/Sensitivities
Document), A4 (Autopsy Report), AM
(Ambulance Certification), AS (Admission
Summary), B2 (Prescription), B3 (Physician
Order), B4 (Referral Form), BR (Benchmark
Testing Results), BS (Baseline), BT (Blanket
Test Results), CB (Chiropractic Justification),
CK (Consent Form), CT (Certification), D2
(Drug Profile Document), DA (Dental Models),
DB (Durable Medical Equipment Prescription),
DG (Diagnostic Report), DJ (Discharge
Monitoring Report), DS (Discharge Summary),
EB (Explanation of Benefits (Coordination of
Benefits or Medicare Secondary Payor), HC
(Health Certificate), HR (Health Clinic
Records), I5 (Immunization Record),
30
CN1
S
PWK02
R
PWK03
PWK04
PWK05
IR (State School Immunization Records),
LA (Laboratory Results), M1 (Medical
Record Attachment), MT (Models), NN
(Nursing Notes), OB (Operative Notes), OC
(Oxygen Content Averaging Report), PD
(Orders and Treatments Document), OE
(Objective Physical Examination (including
vital signs) Document), OX (Oxygen
Therapy Certification), OZ (Support Data
for Claim), P4 (Pathology Report), P5
(Patient Medical History Document), PE
(Parenteral or Enteral Certification), PN
(Physical Therapy Notes), PO (Prosthetics
or Orthotic Certification), PY (Physician’s
Report), PZ (Physical Therapy
Certification), RB (Radiology Films), RR
(Radiology Reports), RT (Report of Test
and Analysis Report), RX (Renewable
Oxygen Content Averaging Report), SG
(Symptoms Document), V5 (Death
Notification, XP (Photographs)
IR (State School Immunization Records), LA
(Laboratory Results), M1 (Medical Record
Attachment), MT (Models), NN (Nursing
Notes), OB (Operative Notes), OC (Oxygen
Content Averaging Report), PD (Orders and
Treatments Document), OE (Objective Physical
Examination (including vital signs) Document),
OX (Oxygen Therapy Certification), OZ
(Support Data for Claim), P4 (Pathology
Report), P5 (Patient Medical History
Document), PE (Parenteral or Enteral
Certification), PN (Physical Therapy Notes), PO
(Prosthetics or Orthotic Certification), PY
(Physician’s Report), PZ (Physical Therapy
(Radiology Reports), RT (Report of Test and
Analysis Report), RX (Renewable Oxygen
Content Averaging Report), SG (Symptoms
Document), V5 (Death Notification, XP
(Photographs)
AA (Available on Request at Provider Site), BM
(By Mail), EL (Electronically Only), EM (E-Mail),
FT (File Transfer), FX (By Fax)
Attachment Transmission
Code
1
2
ID
Valid Values: AA (Available on Request at
Provider Site), BM (By Mail), EL
(Electronically Only), EM (E-Mail), FT (File
Transfer), FX (By Fax)
NU
NU
S
Report Copies Needed
1
2
1
2
3
2
N0
ID
ID
Not Used
Not Used
Valid Value: AC (Attachment Control
Number). Required if PWK02 = BM, EL,
EM, FT, or FX
Leave blank
Leave blank
Required if PWK02 = BM, EL, EM, FT, or FX
PWK06
PWK07
PWK08
S
NU
NU
Attachment Control Code
Description
Actions Indicated
2
1
***
80
80
***
AN
AN
***
Not Used
Not Used
Leave blank
Leave blank
PWK09
NU
Request Category Code
1
2
ID
Not Used
CN101
R
Contract information
Contract Type Code
2
2
ID
Valid Values: 01 (Diagnosis Related Group
(DRG), 02 (Per Diem), 03 (Variable Per
Diem), 04 (Flat), 05 (Capitated), 06
(Percent), 09 (Other)
CN102
S
Monetary Amount
1
18
R
Contract Amount
1
Leave blank
31
CN103
CN104
CN105
CN106
AMT
S
1
REF
S
S
Percent
Terms Discount Percentage
Version Identifier
1
1
1
1
6
50
6
30
R
AN
R
AN
Patient Amount Paid
AMT01
AMT02
AMT03
REF
S
S
S
S
R
R
NU
1
Amount Qualifier Code
Monetary Amount
Credit/Debit Flag Code
1
1
1
3
18
1
ID
R
ID
Service Authorization
Exception Code
Contract Percent
Contract Code
Contract Version ID
Patient Amount Paid - Required when
patient made pymt specifically toward this
claim
Valid Value: F5 (Patient Amount Paid)
Patient Amount Paid
Not Used
Service Authorization Exception Code
Required when providers required by state
law to obtain authorization for specific
services
REF01
R
Qualifier
2
3
ID
Valid Value: 4N (Special Payment
Reference Number)
REF02
R
Service Authorization
Exception Code
1
50
AN
REF03
REF04
NU
NU
Description
1
***
80
***
AN
***
Valid Values: 1 (Immediate/Urgent Care), 2
(Services rendered in retroactive period), 3
(Emergency Care), 4 (Client as temporary
Medicaid), 5 (Request from County for
Second Opinion to Recipient can Work), 6
(Request for Override Pending), 7 (Special
Handling)
Not Used
Not Used
Mandatory Medicare (Section 4081)
Crossover Indicator Required for Medicare
COB crossover claims when Beneficiary
Assignment for mandatory Medicare
Section 4081 claim applies
1
Mandatory Medicare (Section
4081) Crossover Indicator
REF01
R
Qualifier
2
3
ID
Valid Value: F5 (Medicare Version Code)
REF02
R
1
50
AN
Medicare Section 4081 Indicator Valid
Values: Y (4081), N (Regular Crossover)
REF03
REF04
NU
NU
1
***
80
***
AN
***
Not Used
Not Used
Description
32
REF
REF
REF
REF
S
S
S
S
1
Mammography Certification
Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
ID
AN
AN
***
Referral Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
ID
AN
AN
***
Prior Authorization
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
REF01
R
2
3
REF02
REF03
REF04
R
NU
NU
1
1
***
50
80
***
1
Payer Claim Control Number
Qualifier
Description
ID
AN
AN
***
ID
AN
AN
***
Mammography Certification Number Required when mammography services
rendered by certified mammography
provider
Valid Value: EW (Mammography
Certification Number)
Mammography Certification Number
Not Used
Not Used
Referral Number Required when a referral
number is assigned by the payer or
Utilization Management Organization
(UMO)
Valid Values: 9F (Referral Number)
Referral Number
Not Used
Not Used
REF
9F
Referral Number
Leave blank
Leave blank
Prior Authorization Required when an
authorization number is assigned by the
payer or UMO
REF
Valid Values: G1 (Prior Authorization
Number)
G1
Prior Authorization
Not Used
Not Used
Prior Authorization Number
Leave blank
Leave blank
Valid Value: F8 (Original Reference
Number)
Not Used
Not Used
33
REF
REF
REF
REF
S
S
S
S
1
Clinical Laboratory
Improvement Amendment
(CLIA) Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
REF01
R
Repriced Claim Number
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
1
ID
AN
AN
***
ID
AN
AN
***
Adjusted Repriced Claim
Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
ID
AN
AN
***
Investigational Device
Exemption Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
ID
AN
AN
***
Clinical Laboratory Improvement
Amendment (CLIA) Number Required on
Medicare and Medicaid claims for
laboratory performing tests covered by
CLIA Act
Valid Value: X4 (Clinical Laboratory
Improvement Amendment Number)
Not Used
Not Used
Valid Value: 9A (Repriced Claim Reference
Number)
Repriced Claim Reference #
Not Used
Not Used
Adjusted Repriced Claim Number
Valid Value: 9C (Adjusted Repriced Claim
Reference Number)
Adjusted Repriced claim #
Not Used
Not Used
Investigational Device Exemption Number
Required when claim involves FDA
assigned investigational device exemption
(IDE) number
Valid Value: LX (Qualified Products List)
Investigational Device Exemption Identifier
Not Used
Not Used
34
REF
REF
REF
REF
K3
S
S
S
S
S
1
Claim Identification Number
for Clearing Houses and Other
Transmission Intermediaries
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
REF01
R
Medical Record Number
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
1
ID
AN
AN
***
ID
AN
AN
***
Demonstration Project
Identifier
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
10
Claim Identification Number for Clearing
Houses and Other Transmission
Intermediaries
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
File Information
Clearinghouse Trace Number
Not Used
Not Used
Valid Value: EA (Medical Record
Identification Number)
Not Used
Not Used
D9
Trace number assigned by submitter
Leave blank
Leave blank
REF
EA
Leave blank
Leave blank
Demonstration Project Identifier Required
on claims/encounters where
demonstration project is billed/reported
Valid Value: P4 (Project Code)
Demonstration Project Identifier
Not Used
Not Used
Care Plan Oversight Required then the
physical is billing Medicare for Care Plan
Oversight (CPO)
ID
AN
AN
***
Care Plan Oversight Number
Not Used
Not Used
File Information
ID
AN
AN
***
Care Plan Oversight
REF01
Valid Value: D9 (Claim Number)
REF
***Colorado Access does not require this
information, but it will return it in the
acknowledgement report if it is present. ***
35
K301
K302
K303
NTE
CR1
S
S
R
NU
NU
1
Fixed Format Information
Record Format Code
Composite Unit of Measure
1
1
*
80
2
*
AN
ID
*
Claim Note
Claim Note Required when <1> State
regulations mandate, or <2> in opinion of
provider information is needed to
substantiate medical treatment
NTE01
R
Note Reference Code
3
3
ID
NTE02
R
Description
1
80
AN
1
Not Used
Not Used
Ambulance Transport
Information
Valid Values: ADD (Additional
Information), CER (Certification Narrative),
DCP (Goals, Rehabilitation Potential, or
Discharge Plans), DGN (Diagnosis
Description), TPO (Third Party
Organization Notes)
Claim Note Text
ADD (Additional Information), CER
(Certification Narrative), DCP (Goals,
Rehabilitation Potential, or Discharge Plans),
DGN (Diagnosis Description), TPO (Third Party
Organization Notes)
Ambulance Transport Information
Required on all claims involving ambulance
services
Valid Value: LB (Pound)
Patient Weight
Valid Values: I (Initial Trip), R (Return Trip,
T (Transfer Trip), X (Round Trip)
Claim Note Text
CR101
CR102
CR103
S
S
R
Unit or Basis of Measurement
Weight
Ambulance Transport Code
2
1
1
2
10
1
ID
R
ID
CR104
R
Ambulance Transport Reason
Code
1
1
ID
Valid Values: A (Transported to nearest
facility), B (Transported for the benefit of a
preferred physician), C (Transported for
nearness of family), D (Transported for the
care of a specialist or for availability of
specialized equipment), E (Transferred to
rehab facility)
CR105
CR106
CR107
CR108
CR109
R
R
NU
NU
S
Quantity
Address Info
Address Info
Description
2
1
1
1
1
2
15
55
55
80
ID
R
AN
AN
AN
Valid Value: DH (Miles)
Transport Distance
Not Used
Not Used
Round Trip Purpose Description Required
if CR103 = X
CR110
S
Stretcher Purpose Description
1
80
AN
Required if needed to justify usage of
stretcher
36
CR2
CRC
S
S
1
Spinal Manipulation Service
Information
Spinal Manipulation Service Information Required on chiro claims with spinal
manipulation and known to impact payer
adjudication
CR201
NU
Treatment Nu. Spinal
Manipulation
1
9
N0
Not Used
CR202
CR203
NU
NU
Treatment Count
Subluxation Level Code
1
2
15
3
R
ID
Not Used
C1, C2, C3, C4, C5, C6, C7, CO, IL, L1, L2, L3,
L4, L5. OC, SA, T1, T10, T11, T12, T2, T3,
T4, T5, T6, T7, T8, T9
CR204
NU
Subluxation Level Code
2
3
ID
C1, C2, C3, C4, C5, C6, C7, CO, IL, L1, L2, L3,
L4, L5. OC, SA, T1, T10, T11, T12, T2, T3,
T4, T5, T6, T7, T8, T9
CR205
CR206
CR207
CR208
NU
NU
NU
R
Treatment Period Count
Quantity
Patient Condition Code
2
1
1
1
2
15
15
1
ID
R
R
ID
CR209
CR210
CR211
CR212
NU
S
S
S
Complication Indicator
Patient Condition Description
Patient Condition Description
X-ray Availability Indicator
1
1
1
1
1
80
80
1
ID
AN
AN
ID
DA, MO, WK, YR
Not Used
Not Used
Valid Values: A (Acute Condition), C
(Chronic Condition), D (Non-acute), E
(Non-Life Threatening), F (Routine), G
(Symptomatic), M (Acute Manifestation of
Chronic Condition)
Y, N
Used at discretion of submitter
Used at discretion of submitter
Ambulance Certification Required on
ambulance claims/encounters
3
Ambulance Certification
CRC01
R
Patient Condition Info Ambulance
2
2
ID
Valid Value: 07 (Ambulance Certification)
CRC02
CRC03
R
R
Response Code
Condition Indicator
1
2
1
2
ID
ID
Valid Values: 01 (Patient admitted to
hospital), 04 (Patient was moved by
stretcher), 05 (Patient was unconscious or
in shock), 06 (Patient was transported in
an emergency situation), 07 (Patient had
to be physically restrained), 08 (Patient
had visible hemorrhaging), 09 (Ambulance
service was medically necessary), 12
(Patient is confined to a bed or chair)
CRC04
S
Condition Indicator
2
2
ID
Same as CRC03
37
CRC05
CRC06
CRC07
CRC
CRC
CRC
S
S
S
S
S
S
3
Condition Indicator
Condition Indicator
Condition Indicator
2
2
2
2
2
2
ID
ID
ID
Patient Condition Information:
Vision
Same as CRC03
Same as CRC03
Same as CRC03
Patient Condition Information: Vision
Required on vision claims/encounters
involving replacement lenses or frames
when info known to impact
reimbursement
Valid Values: E1 (Spectacle Lenses), E2
(Contact Lenses), E3 (Spectacle Frames)
CRC01
R
Patient Condition Info - Vision
2
2
ID
CRC02
CRC03
R
R
Response Code
Condition Indicator
1
2
1
2
ID
ID
Valid Values: L1 (General Standard of 20
Degree or .5 Diopter Sphere or Cylinder
Change Met), L2 (Replacement Due to Loss
or Theft), L3 (Replacement Due to
Breakage or Damage), L4 (Replacement
Due to Patient Preference), L5
(Replacement Due to Medical Reason)
CRC04
CRC05
CRC06
CRC07
S
S
S
S
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
2
2
2
2
2
2
2
2
ID
ID
ID
ID
Same as CRC03
Same as CRC03
Same as CRC03
Same as CRC03
CRC01
CRC02
CRC03
CRC04
CRC05
CRC06
CRC07
R
R
R
NU
NU
NU
NU
Homebound Indicator
Code Category
Response Code
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
2
1
2
2
2
2
2
2
1
2
2
2
2
2
ID
ID
ID
ID
ID
ID
ID
Homebound Indicator
Valid Value: 75 (Functional Limitations)
Valid Value: IH (Independent at Home)
Not Used
Not Used
Not Used
Not Used
1
1
EPSDT Referral
CRC Required on Early and Periodic
screening, diagnosis and treatment
(EPSDT) claims/encounters
CRC
CRC01
R
Code Category
2
2
ID
Valid Value: ZZ (Mutually Defined). EPSDT
Screening Referral information
ZZ
CRC02
R
Response Code
1
1
ID
Valid Values: Y (Yes -EPSDT Referral given
to patient), N (No) (choose NU for CRC03)
Y (Yes -EPSDT Referral given to patient), N
(No) (choose NU for CRC03)
38
HI
R
CRC03
R
Condition Indicator
2
2
ID
Valid Values: AV (Available-not used patient refused referral), NU (Not Used Use with "N" in CRC02), S2 (Under
Treatment), ST (New Services Requested)
AV (Available-not used - patient refused
referral), NU (Not Used - Use with "N" in
CRC02), S2 (Under Treatment), ST (New
Services Requested)
CRC04
S
Condition Indicator
2
2
ID
Required if additional condition codes are
needed; use list of codes from CRC03
Leave blank
CRC05
S
Condition Indicator
2
2
ID
Required if additional condition codes are
needed; use list of codes from CRC03
Leave blank
CRC06
CRC07
NU
NU
Condition Indicator
Condition Indicator
2
2
2
2
ID
ID
Not Used
Not Used
Leave blank
Leave blank
1
Health Care Diagnosis Code
Health Care Diagnosis Code Note: Do not
transmit decimal points in diagnosis codes.
Decimal point is assumed.
HI
HI01
HI0101
R
R
Health Care Code Information
Principal Diagnosis Qualifier
*
1
*
3
*
ID
HI0102
HI0103
R
Industry Code
1
30
AN
See HI01-___ BELOW
Valid Value: ABK (ICD-10-CM Principal
Diagnosis), BK (ICD-9-CM Principal
Diagnosis)
Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
HI02
HI0201
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
See HI02-___ BELOW
Valid Value: ABF (Diagnosis ICD-10-CM
Codes, BF (Diagnosis ICD-9 Codes)
HI0202
HI0203
R
Industry Code
1
30
AN
Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
HI0204
ABK (ICD-10-CM Principal Diagnosis), BK (ICD9-CM Principal Diagnosis)
Diagnosis Code 1
ABF (Diagnosis ICD-10-CM Codes, BF
(Diagnosis ICD-9 Codes)
Diagnosis Code 2
39
HI0205
HI0206
HI0207
HI0208
HI0209
HI03
HI0301
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
See HI03-___ BELOW
Codes), BF (Diagnosis ICD-9-CM Codes)
HI0302
HI0303
R
Industry Code
1
30
AN
Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
HI04
HI0401
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
See HI04-___ BELOW
HI0402
HI0403
R
Industry Code
1
30
AN
Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
HI0404
HI0405
HI0406
HI0407
HI04-
Diagnosis Code 3
Diagnosis Code 4
40
08
HI0409
HI05
HI0501
Yes or No Condition
1
1
ID
Not Used
S
R
*
1
*
3
*
ID
See HI05-___ BELOW
R
Industry Code
1
30
AN
Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
HI06
HI0601
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
See HI06-___ BELOW
HI0602
HI0603
R
Alias Diagnosis Code
1
30
AN
Use standard ICD9 Codes
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
*
1
*
3
*
ID
See HI07-___ BELOW
HI0502
HI0503
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
HI07
HI0701
NU
S
R
Leave blank
Diagnosis Code 5
Diagnosis Code 6
41
HI0702
HI0703
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
HI08
HI0801
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
See HI08-___ BELOW
HI0802
HI0803
R
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0804
HI0805
HI0806
HI0807
HI0908
HI0809
HI09
HI0901
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
5
R
*
1
*
3
*
ID
See HI09-___ BELOW
HI0902
HI0903
R
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
HI0904
HI09-
R
Diagnosis Code 7
Diagnosis Code 8
Diagnosis Code 9
42
05
HI0906
HI0907
HI0908
HI0909
HI10
HI1001
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
5
R
*
1
*
3
*
ID
See HI010-___ BELOW
R
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1004
HI1005
HI1006
HI1007
HI1008
HI1009
HI11
HI1101
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
5
R
*
1
*
3
*
ID
See HI010-___ BELOW
HI1102
HI1103
R
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
HI1002
HI1003
HI1104
HI1105
HI1106
HI1107
HI1108
Diagnosis Code 10
Diagnosis Code 11
43
HI1109
HI12
HI1201
NU
HI1202
HI1203
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
HI
S
Yes or No Condition
1
1
ID
Not Used
5
R
*
1
*
3
*
ID
See HI010-___ BELOW
R
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
1
Anesthesia Related Procedure
Leave blank
Diagnosis Code 12
Required on claims where anesthesiology
services are being billed or reported when
the provider knows the surgical code and
knows the adjudication of the claim will
depend on provision of the surgical code.
HI01
HI0101
R
R
*
1
*
3
*
ID
HI0102
HI0103
R
Industry Code
1
30
AN
See HI01-___ BELOW
Valid Value: BP (Health Care Financing
Administration Common Procedural
Coding System Principal Procedure
(HCPCS)
Anesthesia Related Surgical Procedure
NU
Qualifier
2
3
ID
Not Used
NU
Date Time Period
1
35
AN
Not Used
NU
Monetary Amount
1
18
R
Not Used
NU
Quantity
1
15
R
Not Used
NU
Version Identifier
1
30
AN
Not Used
HI0104
HI0105
HI0106
HI0107
44
HI0108
HI0109
HI02
HI0201
NU
Industry Code
1
30
AN
Not Used
NU
Yes or No Condition
1
1
ID
Not Used
S
R
*
1
*
3
*
ID
See HI02-___ BELOW
Valid Value: BO (Health Care Financing
Administration Common Procedural
Coding System Principal Procedure
(HCPCS))
HI0202
HI0203
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
NU
Date Time Period
1
35
AN
Not Used
NU
Monetary Amount
1
18
R
Not Used
NU
Quantity
1
15
R
Not Used
NU
Version Identifier
1
30
R
Not Used
NU
Industry Code
1
30
AN
Not Used
NU
Yes or No Condition
1
1
ID
Not Used
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
HI0204
HI0205
HI0206
HI0207
HI0208
HI0209
HI03
HI-404
HI05
HI06
HI07
HI08
HI09
HI10
HI11
HI12
HI
S
2
Condition Information
HI01
HI0101
HI0102
Required when condition information
applies to the claim.
R
R
*
1
*
3
*
ID
See HI01-___ BELOW
Valid Value: BG (Condition)
R
Industry Code
1
30
AN
Condition Code
HI
BG
Condition Code
45
HI0103
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
HI02
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0201
HI0202
HI0203
R
1
3
ID
Required when it is necessary to report an
additional condition and the preceding HI
data elements have been used to report
other condition codes. See HI02-___
BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0204
HI0205
HI0206
HI0207
HI0208
HI0209
HI03
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0301
HI0302
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
BG
Condition Code
BG
Condition Code
46
HI0303
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
HI04
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0401
HI0402
HI0403
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0404
HI0405
HI0406
HI0407
HI0408
HI0409
HI05
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0501
HI0502
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
BG
Condition Code
BG
Condition Code
47
HI0503
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
HI06
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0601
HI0602
HI0603
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
HI07
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0701
HI0702
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
BG
Condition Code
BG
Condition Code
48
HI0703
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
HI08
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0801
HI0802
HI0803
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0804
HI0805
HI0806
HI0807
HI0808
HI0809
HI09
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI0901
HI0902
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
BG
Condition Code
BG
Condition Code
49
HI0903
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0904
HI0905
HI0906
HI0907
HI0908
HI0909
HI10
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI1001
HI1002
HI1003
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1004
HI1005
HI1006
HI1007
HI1008
HI1009
HI11
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI1101
HI1102
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
BG
Condition Code
BG
Condition Code
50
HI1103
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1104
HI1105
HI1106
HI1107
HI1108
HI1109
HI12
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
S
*
*
*
HI1201
HI1202
HI1203
R
1
3
ID
BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
R
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Yes or No Condition
1
1
ID
Not Used
Leave blank
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
HCP
S
1
Claim Pricing/Repricing
Information
Claim Pricing/Repricing Information
BG
Condition Code
51
HCP01
R
Pricing Methodology
2
2
ID
Valid Values: 00 (Zero Pricing Not Covered
Under Contract), 01 (Priced as Billed at
100%), 02 (Priced at the Standard Fee
Schedule), 03 (Priced at a Contractual
Percentage), 04 (Bundled Pricing), 05 (Peer
Review Pricing), 07 (Flat Rate Pricing), 08
(Combination Pricing), 09 (Maternity
Pricing), 10 (Other Pricing), 11 (Lower of
Cost), 12 (Ratio of Cost), 13 (Cost
Reimbursed), 14 (Adjustment Pricing)
HCP02
HCP03
HCP04
HCP05
HCP06
R
S
S
S
S
Monetary Amount
Monetary Amount
Rate
1
1
1
1
1
18
18
50
9
30
R
R
AN
R
AN
Repriced Allowed Amount
Repriced Saving Amount
Repricing Organization Identifier
Repricing Per Diem or Flat Rate Amount
Repriced Approved Ambulatory Patient
Group Code
HCP07
S
Monetary Amount
1
18
R
Group Amount
HCP08
HCP09
HCP10
HCP11
HCP12
HCP13
NU
NU
NU
NU
NU
S
Product/Service ID
Product/Service ID Qualifier
Product/Service ID
Quantity
Reject Reason Code
1
2
1
2
1
2
48
2
48
2
15
2
AN
ID
AN
ID
R
ID
HCP14
S
Policy Compliance Code
1
2
ID
Not Used
Not Used
Not Used
Not Used
Not Used
Valid Values: T1 (Cannot Identify Provider
as TPO Participant), T2 (Cannot Identify
Payer as TPO Participant), T3 (Cannot
Identify Insured as TPO Participant), T4
(Payer Name or Identifier Missing), T5
(Certification Information Missing), T6
(Claim does not contain enough
information for repricing)
Valid Values: 1 (Procedure FollowedCompliance), 2 (Not Followed - Call Not
Made - Non-Compliance Call Not Made), 3
(Not Medically Necessary - NonCompliance Non-Medically Necessary), 4
(Not Followed Other - Non-Compliance
Other), 5 (Emergency Admit to NonNetwork Hospital)
52
HCP15
2310A
2
S
NM1
REF
2310B
1
S
S
S
S
1
2
ID
Referring Provider Name
1
Valid Values: 1 (Non-Network Professional
Provider in Network Hospital), 2
(Emergency Care), 3 (Services or Specialist
not in Network), 4 (Out-of-Service Area), 5
(State Mandates), 6 (Other)
Referring Provider Name Required if
claim involved a referral
NM101
R
2
3
ID
Valid Values: DN (Referring Provider), P3
(Primary Care Provider)
NM102
NM103
R
R
Name
1
1
1
60
ID
AN
Valid Values: 2 (Person)
Referring Provider Last Name
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
S
S
NU
S
S
S
NU
NU
Referring Provider First Name
Referring Provider Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
35
25
10
10
2
80
2
3
AN
AN
AN
AN
ID
AN
ID
ID
Required if NM102=1
Not Used
Referring Provider Name Suffix
Valid Values: 24 (EIN), 34 (SSN), XX (NPI)
Referring Provider ID
Not Used
Not Used
Referring Provider Secondary
Identification
3
Identification
REF01
R
Qualifier
2
3
ID
Valid Values: 0B (State License #), 1G
(Provider UPIN Number), G2 (Provider
Commercial #)
REF02
R
1
50
AN
REF03
REF04
NU
NU
1
***
80
***
AN
***
Identification
Not Used
Not Used
S
NM1
Exception Code
Description
Rendering Provider Name
1
NM101
R
2
3
ID
Rendering Provider Name Required when
Rendering Provider information is
different than that in Billing Provider
(2010AA) or Pay-To Provider (2010AB)
loops
Valid Value: 82 (Rendering Provider)
NM1
82
53
PRV
REF
2310C
1
S
S
NM102
R
1
1
ID
NM103
R
Name
1
60
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
S
S
NU
S
R
R
NU
NU
Rendering Provider First Name
Rendering Provider Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
35
25
10
10
2
80
2
3
Rendering Provider Specialty
Information
9
41
Provider Code
Qualifier
1
2
3
3
1
2
***
30
2
***
3
3
1
PRV01
PRV02
R
R
PRV03
PRV04
PRV05
R
NU
NU
State or Province code
PRV06
NU
4
S
Rendering Provider Last Name
AN
AN
AN
ID
ID
AN
ID
ID
Required if NM102=1
Not Used
Rendering Provider Generation
Rendering Provider Identifier
Not Used
Not Used
Leave blank
Leave blank
Leave blank
XX
Rendering Provider NPI
Leave blank
Leave blank
ID
ID
AN
ID
***
ID
Rendering Provider Secondary
Identification
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
ID
AN
AN
***
Service Facility Location
1
NM101
NM102
R
R
Valid Value: PE (Performing)
Taxonomy Code)
Not Used
Not Used
Not Used
Commercial #)
Rendering Provider Secondary Identifier
Not Used
Not Used
2
1
3
1
ID
ID
1
Rendering Provider Specialty Information Required when adjudication known to be
impacted by provider taxonomy code
Identification
REF01
S
NM1
AN
Entity)
Valid Values: 77 (Service Location)
REF
0B (State License #), 1G (Provider UPIN
Number), G2 (Provider Commercial #)
Rendering Provider Tax ID
Leave blank
Leave blank
NM1
77
2
54
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
N3
R
1
REF
PER
R
S
S
Laboratory or Facility Name
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
1
2
2
2
1
35
25
25
10
10
2
80
2
3
80
AN
AN
AN
AN
AN
ID
AN
ID
ID
An
Address
N301
N302
N4
S
NU
NU
NU
NU
S
S
NU
NU
NU
R
S
1
Address Information
Address Information
Service Facility Location Address
1
1
55
55
AN
AN
City/State/ZIP
N401
N402
N403
R
R
R
N404
N405
N406
N407
S
NU
NU
S
3
City Name
Postal Code
2
2
3
30
2
15
AN
ID
ID
Laboratory Country Code
Location Qualifier
Location Identifier
County Subdivision Code
2
1
1
1
3
2
30
3
ID
ID
AN
ID
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
ID
AN
AN
***
Service Facility Contact
Information
PER01
R
Laboratory or Facility Address Line 1
Service Facility Location City/State/ZIP
Secondary Identification
1
Not Used
Not Used
Not Used
Not Used
Laboratory or Facility ID
Not Used
Not Used
Not Used
2
2
ID
Laboratory Facility City
Laboratory Facility State
Facility Zip Code (the full nine digit must
be used)
Not Used
Not Used
Not Used
Facility Location Name
Leave blank
Leave blank
Leave blank
Leave blank
XX
Facility NPI
Leave blank
Leave blank
Leave blank
N3
Facility Address Line 1
Facility Address Line 2
N4
Facility City
Facility State
Facility Zip Code
Facility Country Code
Leave blank
Leave blank
Leave blank
Service Facility Location Secondary
Identification
Valid Values: 0B (State License #), G2
(Provider Commercial #), LU (Location #)
Lab or Facility Secondary ID
Not Used
Not Used
Service Facility Contact Information
55
2310D
1
PER02
S
Name
1
60
AN
Required when the name is different than
the name in the Loop ID-1000A Submitter
DI Contact information PER segment and
in the Loop ID-2010AA Billing Provider
Contact Information PER.
PER03
R
Qualifier
2
2
ID
Valid Value: TE (Telephone)
PER04
PER05
R
S
Qualifier
1
2
256
2
AN
ID
Valid Value: EX (Extension)
PER06
PER07
S
NU
Qualifier
1
2
256
2
AN
ID
Not Used
PER08
PER09
NU
NU
1
1
256
20
AN
AN
S
NM1
REF
S
S
Supervising Provider Name
1
NM101
NM102
NM103
R
R
R
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
R
S
NU
S
S
S
NU
NU
NU
4
Not Used
Supervising Provider Name Required
when rendering provider is supervised by a
physician
Name
2
1
1
3
1
60
ID
ID
AN
Valid Value: DQ (Supervising Physician)
Supervising Provider Last Name
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
80
AN
AN
AN
AN
ID
AN
ID
ID
An
Supervising Provider First
Supervising Provider Middle
Not Used
Supervising Provider Identifier
Not Used
Not Used
Not Used
Supervising Provider Secondary
Identification
Supervising Provider
REF01
R
Qualifier
2
3
ID
Commercial #), LU (Location #)
REF02
R
1
50
AN
Identification
56
REF03
REF04
2310E
1
S
NM1
N3
S
R
N4
1
R
NM1
S
80
***
AN
***
Not Used
Not Used
Ambulance Pick-up Location
Required when billing for ambulance or
non-emergency transportation services.
NM1
R
R
NU
Name
2
1
1
3
1
60
ID
ID
AN
Valid Value: PW (Pick-up Address)
Valid Value: 2 (Non-Person)
Not Used
PW
2
Leave blank
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
NU
NU
NU
NU
NU
NU
NU
NU
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
ID
AN
ID
ID
An
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Address
R
R
1
1
1
***
NM101
NM102
NM103
1
S
Description
1
N301
N302
2310F
NU
NU
Ambulance Pick-up Address 1
1
1
55
55
AN
AN
City/State/ZIP Code
N401
N402
N403
N404
R
S
S
S
N405
N406
N407
NU
NU
S
2
2
3
2
30
2
15
3
AN
ID
ID
ID
Location Qualifier
Location Identifier
1
1
1
2
30
3
ID
AN
ID
Ambulance Drop-off Location
Ambulance Pick-up City Name
Ambulance Pick-up State
Ambulance Pick-up Zip Code
Country Code
N3
US
Not Used
Not Used
Not Used
Required when billing for ambulance or
non-emergency transportation services.
N4
Ambulance Pick-up City Name
Ambulance Pick-up Zip Code
Ambulance Pick-up Country Code
Leave blank
Leave blank
Leave blank
NM1
57
N3
R
NM101
NM102
NM103
R
R
S
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
NU
NU
NU
NU
NU
NU
NU
NU
1
2320
10
R
SBR
S
R
R
1
S
1
2
1
1
3
1
60
ID
ID
AN
Valid Value: 45 (Drop-off Address)
Valid Value: 2 (Non-Person)
Required when drop-off-location is known
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
ID
AN
ID
ID
An
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Address
N301
N302
N4
Name
Ambulance Drop-off Address 1
1
1
55
55
AN
AN
City/State/ZIP Code
N401
R
N402
N403
N404
S
S
S
N405
N406
N407
NU
NU
S
45
2
Required when drop-off-location is known
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
N3
N4
Ambulance Drop-off City
Name
Ambulance Drop-off State
Ambulance Drop-off Zip Code
Ambulance Drop-offCountry
Code
2
30
AN
Ambulance Drop-off City Name
2
3
2
2
15
3
ID
ID
ID
Ambulance Drop-off State
Ambulance Drop-off Zip Code
Ambulance Drop-offCountry Code
Location Qualifier
Location Identifier
1
1
1
2
30
3
ID
AN
ID
11
102
Other Subscriber Information
US
Not Used
Not Used
Not Used
Other Subscriber Information Required if
other payers known to potentially be
involved in paying on this claim
Leave blank
Leave blank
Leave blank
SBR
58
SBR01
R
Number Code
1
1
ID
Valid Values: A (Payer Responsibility Four),
B (Payer Responsibility Five), C (Payer
Responsibility Six), D (Payer Responsibility
Seven), E (Payer Responsibility Eight), F
(Payer Responsibility Nine), G (Payer
Responsibility Ten), H (Payer Responsibility
Eleven), P (Primary), S (Secondary), T
(Tertiary), U (Unknown)
A (Payer Responsibility Four), B (Payer
Responsibility Five), C (Payer Responsibility
Six), D (Payer Responsibility Seven), E (Payer
Responsibility Eight), F (Payer Responsibility
Nine), G (Payer Responsibility Ten), H (Payer
Responsibility Eleven), P (Primary), S
(Secondary), T (Tertiary), U (Unknown)
SBR02
R
2
2
ID
Valid Values: 01 (Spouse) 18 (Self), 19
(Child), 20 (Employee), 21 (Unknown), 39
(Organ Donor), 40 (Cadaver Donor), 53
(Life Partner), G8 (Other Relationship)
01 (Spouse) 18 (Self), 19 (Child), 20
(Employee), 21 (Unknown), 39 (Organ Donor),
40 (Cadaver Donor), 53 (Life Partner), G8
(Other Relationship)
SBR03
SBR04
SBR05
R
S
R
Name
Insurance Type Code
1
1
1
50
60
3
AN
AN
ID
Other Insured Group Name
Valid Values: 12 (Medicare Secondary
Working Aged Beneficiary or Spouse with
Employer Group[ Health Plan), 13
(Medicare Secondary End-State Renal
Disease Beneficiary in the Mandated
Coordination Period with an Employer
Group health Plan), 14 Medicare
Secondary, No-fault Insurance including
Auto is Primary), 15 (Medicare Secondary
Worker's Compensation), 16 Medicare
Secondary Public Health Service (PHS) or
Other Federal Agency), 41 (Medicare
Secondary Black Lung), 42 Medicare
Secondary Veteran's Administration), 43
(Medicare Secondary Disabled Beneficiary
Under Age 65 with Large Group Health
Plan (LGHP)), 47 (Medicare Secondary,
Other Liability Insurance is primary)
12 (Medicare Secondary Working Aged
Beneficiary or Spouse with Employer Group[
Health Plan), 13 (Medicare Secondary EndState Renal Disease Beneficiary in the
Mandated Coordination Period with an
Employer Group health Plan), 14 Medicare
Secondary, No-fault Insurance including Auto
is Primary), 15 (Medicare Secondary Worker's
Compensation), 16 Medicare Secondary Public
Health Service (PHS) or Other Federal Agency),
41 (Medicare Secondary Black Lung), 42
Medicare Secondary Veteran's
Administration), 43 (Medicare Secondary
Disabled Beneficiary Under Age 65 with Large
Group Health Plan (LGHP)), 47 (Medicare
Secondary, Other Liability Insurance is
primary)
SBR06
SBR07
SBR08
NU
NU
NU
Yes No Condition or Resp
1
1
2
1
1
2
ID
ID
ID
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
59
CAS
S
SBR09
S
1
2
ID
CAS01
R
Claim Level Adjustments
Claim Adjustment Group Code
1
2
ID
CAS02
R
Claim Adjustment Reason
Code
1
5
ID
CAS03
CAS04
CAS05
R
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
Adjusted Amount - Claim Level
Adjusted Units - Claim Level
Adjustment Reason Code - Claim Level
CAS06
CAS07
CAS08
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
CAS09
CAS10
CAS11
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
CAS12
CAS13
CAS14
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
5
Maintenance Organization-Medicare Risk),
17 (Dental Maintenance Organization),
AM (Automobile Medical), BL (Blue
Cross/Blue Shield), CH (Champus), CI
(Commercial Insurance Co.), DS
(Disability), FI (Federal Employees
Program), HM (Health Maintenance
Organization), LM (Liability Medical), MA
(Medicare Part A), MB (Medicare Part B),
MC (Medicaid), OF (Other Federal
Program), TV (Title V), VA (VA Plan), WC
(Workers' Comp Health Claim), ZZ
(Mutually Defined)
11 (Other Non-Federal Programs), 12
(Preferred Provider Organization), 13 (Point of
Service), 14 (Exclusive Provider Organization),
15 (Indemnity Insurance), 16 (Health
Maintenance Organization-Medicare Risk), 17
(Automobile Medical), BL (Blue Cross/Blue
Shield), CH (Champus), CI (Commercial
Insurance Co.), DS (Disability), FI (Federal
Employees Program), HM (Health
Maintenance Organization), LM (Liability
Medical), MA (Medicare Part A), MB
Federal Program), TV (Title V), VA (VA Plan),
WC (Workers' Comp Health Claim), ZZ
(Mutually Defined)
Claim Level Adjustments
Valid Values: CO (Contractual Obligations),
CR (Correction and Reversals), OA (Other
adjustments), PI (Payor Initiated
Reductions), PR (Patient Responsibility)
60
AMT
S
CAS15
CAS16
CAS17
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
CAS18
CAS19
S
S
Monetary Amount
Quantity
1
1
18
15
R
R
1
Coordination of Benefits (COB)
Payer Paid Amount
AMT01
AMT02
AMT03
AMT
AMT
OI
S
S
R
R
R
NU
1
Monetary Amount
AMT
1
1
1
3
18
1
ID
R
ID
Total Non-Covered Amount
AMT01
R
1
3
ID
AMT02
AMT03
R
NU
Monetary Amount
1
1
18
1
R
ID
AMT01
R
Remaining Patient Liability
1
3
ID
AMT02
R
Monetary Amount
1
18
R
AMT03
NU
1
1
ID
Other Insurance Coverage
Information
7
8
Claim Submission Reason Code
Yes/No Condition
1
2
1
2
2
1
1
1
OI01
OI02
OI03
NU
NU
R
ID
ID
ID
Valid Value: D (Payor Amount Paid)
Payer Paid Amount
Not Used
D
Other Insurance Paid Amount
Leave blank
Coordination of Benefits (COB) Total NonCovered Amount
Valid Values: AB ( Total Non-Covered
Amount)
Approved Amount
Not Used
Valid Value: EAF (Remaining Patient
Liability)
Other Payer Patient Responsibility Amount
This is crosswalked from CLP05 in 835
when doing COB.
Not Used
Other Insurance Coverage Information
Not Used
Not Used
Valid Values: N (No), W (Not Applicable, Y
(Yes). This is a crosswalk from CLM08
when doing COB.
61
MOA
S
OI04
S
OI05
OI06
NU
R
1
MOA01
MOA02
MOA03
MOA04
MOA05
MOA06
MOA07
MOA08
MOA09
2330A
1
S
S
S
S
S
S
S
S
S
S
NM1
R
Patient Signature Source Code
1
1
ID
Provider Agreement Code
1
1
1
1
ID
ID
Medicare Outpatient
Adjudication Information
9
214
Percent
Monetary Amount
Monetary Amount
Monetary Amount
1
1
1
1
1
1
1
1
1
10
18
50
50
50
50
50
18
18
R
R
AN
AN
AN
AN
AN
R
R
Other Subscriber Name
1
Valid Values: B (Signed signature Auth
form for HCFA1500 block 12 and 13), C
(Signed HCFA 1500 on file), M (Signed
signature auth form HCFA1500 block 13), P
(Signature generated by provider), S
(Signed signature auth form HCFA1500
block 12) Required except when OI06 is
N.
Not Used
Valid Values: I (Informed Consent to
Release), Y (Yes, Provider has a Signed
Statement Permitting Release of Medical
Billing Data Related to a Claim)
Medicare Outpatient Adjudication
Information Required if returned in the
electronic remittance advice (835).
Reimbursement Rate
HCPCS Payable Amt
Remarks Code
Remarks Code
Remarks Code
Remarks Code
Remarks Code
End Stage Renal Disease Payment Amount
Non-Payable Professional Component
Billed Amount
NM101
NM102
R
R
2
1
3
1
ID
ID
NM103
R
Name
1
60
NM104
NM105
NM106
NM107
S
S
NU
S
Other Insured First Name
Other Insured Middle Name
Name Prefix
Name Suffix
1
1
1
1
35
25
10
10
AN
Entity)
Other Insured Last Name
AN
AN
AN
AN
Required if NM102=1
Not Used
Other Insured Name Suffix
62
N3
S
NM108
R
NM109
NM110
NM111
NM112
R
NU
NU
NU
1
N301
N302
N4
S
1
2330B
1
S
NM1
R
S
S
S
S
NU
NU
NU
1
S
1
1
2
ID
Identifier for each Individual in the US), MI
(Member Identification Number)
Identification Code
Name
2
2
2
1
80
2
3
80
AN
ID
ID
ID
Other Insured Identification Code
Not Used
Not Used
Not Used
1
1
55
55
AN
AN
Other Subscriber Address
Other Insured Address 1
Other Insured Address 2
Other Subscriber City/State/ZIP Code
Other Insured City Name
Other Insured State Code
Other Insured postal code
Address Information
Address Information
Other Subscriber
City/State/ZIP Code
N401
N402
N403
N404
N405
N406
N407
REF
R
S
City Name
Postal Code
Location Qualifier
Location Identifier
2
2
3
2
1
1
1
30
2
15
3
2
30
3
AN
ID
ID
ID
ID
AN
ID
Other Subscriber Secondary
Identification
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
Other Payer Name
Other Payer Name
Not Used
Not Used
US, including its territories, or Canada, and
subdivisions such as but limited to state
provinces, cantons, etc. If not required, do
not send.
Other Subscriber Secondary Identification
ID
AN
AN
***
Other Subscriber Secondary Identification
Not Used
Not Used
Other Payer Name
Other Payer Name
63
N3
S
NM101
NM102
NM103
R
R
R
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
DTP
R
S
2
1
1
3
1
60
ID
ID
AN
Other Payer Last or Org Name
NU
NU
NU
NU
R
Name First
Name Middle
Name Prefix
Name Suffix
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Not Used
Not Used
Not Used
Not Used
(Health Care Financing Administration
National Plan ID)
R
NU
NU
NU
Identification Code
Name
2
2
2
1
80
2
3
60
AN
ID
ID
AN
Other Payer Primary ID
Not Used
Not Used
Not Used
Other Payer Address
1
1
55
55
AN
AN
Other Payer Cit, State, ZIP Code
1
N301
N302
N4
Name
R
R
1
Other Payer Address
Other Payer Address Line 1
Other Payer Cit/ State/ ZIP
Code
N401
N402
R
S
N403
N404
N405
N406
N407
S
S
NU
NU
S
DTP01
R
1
Other Payer City Name
Other Payer State or Province
Code
2
2
30
2
AN
ID
Other Payer State or Province Code
Other Payer ZIP Code
Other Payer Country Code
Location Qualifier
Location Identifier
3
2
1
1
1
15
3
2
30
3
ID
ID
ID
AN
ID
Other Payer ZIP Code
Required is address is outside the US
Not Used
Not Used
not send.
Claim Adjudication Date
Date/Time Qualifier
3
3
ID
Valid Value: 573 (Date Claim Paid)
64
REF
REF
REF
REF
S
S
S
S
DTP02
R
Qualifier
2
3
ID
DTP03
R
Adjudication or Payment Date
1
35
AN
Format: CCYYMMDD
Other Payer Secondary Identifier
Valid Value: 2U (Payer Identification
Number), EI (Employer's Identification
(National Associate of Insurance
Commissioners)
Other Payer Secondary Identifier
Not Used
Not Used
Other Payer Prior Authorization Number
Number)
Other Payer Prior Authorization Number
Not Used
Not Used
Other Payer Referral Number
Not Used
Not Used
Other Payer Claim Adjustment Indicator
2
Other Payer Secondary
Identifier
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
ID
AN
AN
***
Other Payer Prior
Authorization Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
REF01
R
2
3
REF02
REF03
REF04
R
NU
NU
1
1
***
50
80
***
1
1
Qualifier
Description
ID
AN
AN
***
ID
AN
AN
***
Other Payer Claim Adjustment
Indicator
REF01
R
Qualifier
2
3
ID
Valid Value: T4 (Signal Code)
REF02
R
1
50
AN
Other Payer Claim Adjustment Indicator.
Valid Value: Y
REF03
NU
Description
1
80
AN
Not Used
65
REF04
REF
2330C
2
S
NU
1
REF
S
R
***
***
***
Not Used
Other Payer Claim Control Number
ID
Valid Value: F8 (Original Reference
Number)
AN
AN
***
Not Used
Not Used
Other Payer Claim Control
Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
S
NM1
Other Payer Referring
Provider
Other Payer Referring Provider
1
NM101
R
NM102
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
2
3
ID
Valid Values: DN (Referring provider), P3
R
NU
Name
1
1
1
60
ID
AN
Not Used
NU
NU
NU
NU
NU
NU
NU
NU
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
2
2
2
345
25
10
10
2
80
2
3
AN
AN
AN
AN
ID
AN
ID
ID
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Identification
3
Identification
REF01
R
Qualifier
2
3
ID
Valid Values: 0B (State License Number),
1G (Provider UPIN Number), G2 (Provider
Commercial #)
REF02
R
1
50
AN
REF03
REF04
NU
NU
1
***
80
***
AN
***
Identification
Not Used
Not Used
Description
66
2330D
1
S
NM1
REF
2330E
1
S
R
1
NM101
NM102
R
R
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
S
Other Payer Rendering Provider
Other Payer Rendering
Provider
2
1
3
1
ID
ID
NU
Name
1
60
AN
Entity)
Not Used
NU
NU
NU
NU
NU
NU
NU
NU
NU
Name First
Name Middle
Name prefix
Name Suffix
Identification Code
Name
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
ID
AN
ID
ID
AN
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Other Payer Rendering Provider Secondary
Identification
3
Provider Secondary
Identification
REF01
R
Qualifier
2
3
ID
Valid Values: 0B (Provider License
Number), 1G (Provider UPIN Number), G2
(Provider Commercial #), LU (Location #)
REF02
R
1
50
AN
Other Payer Rendering Provider Secondary
Identifier
REF03
REF04
NU
NU
1
***
80
***
AN
***
Not Used
Not Used
S
NM1
Provider
1
Description
Other Payer Service Facility
Location
Other Payer Service Facility Location
Location
NM101
NM102
NM103
R
R
NU
Name
2
1
1
3
1
60
ID
ID
AN
Valid Values: 77 (Service Location)
Not Used
NM104
NU
Name First
1
35
AN
Not Used
67
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
REF
2330F
1
R
NU
NU
NU
NU
NU
NU
NU
NU
3
S
1
1
1
1
2
2
2
1
25
10
10
2
80
2
3
60
AN
AN
AN
ID
AN
ID
ID
An
Location Identification
REF01
R
Qualifier
2
3
ID
REF02
R
1
50
AN
REF03
REF04
NU
NU
1
***
80
***
AN
***
S
NM1
Name Middle
Name Prefix
Name Suffix
Identification Code
Name
1
Description
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Identification
Valid Values: 0B (Provider License
Number), G2 (Provider Commercial #), LU
(Location #)
Identifier
Not Used
Not Used
Other Payer Supervising
Provider
Other Payer Supervising Provider
Provider
NM101
NM102
NM103
R
R
NU
Name
2
1
1
3
1
60
ID
ID
AN
Not Used
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
NU
NU
NU
NU
NU
NU
NU
NU
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
ID
AN
ID
ID
AN
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
68
REF
2330G
1
REF
50
3
S
R
LX
R
113
Qualifier
2
3
ID
REF02
R
1
50
AN
REF03
REF04
NU
NU
1
***
80
***
AN
***
Description
Other Payer Billing Provider
NM101
NM102
R
R
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
2
1
4
R
1
R
Provider Identification
REF01
S
NM1
2400
R
2
1
3
1
ID
ID
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
1
1
1
1
1
1
2
2
2
1
60
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
AN
ID
AN
ID
ID
AN
REF01
R
Qualifier
2
3
ID
REF02
R
Qualifier
1
50
AN
REF03
REF04
NU
NU
1
***
80
***
AN
***
Description
Service Line
Service Line
Identification
Valid Values: 0B (provider License
Number), 1G (Provider UPIN #), G2
(Provider Commercial #), LU (Location
Number)
Identification
Not Used
Not Used
Valid Value : 85 (Billing Provider)
Valid Value: 1 (Person), 2 (non-Person
Entity)
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Other Payer Billing Provider Secondary
Identification
Valid Value: G2 (Provider Commercial
Not Used
Not Used
Service Line
Service Line
LX
69
SV1
R
LX01
R
Assigned Number
1
6
N0
SV101
R
Professional Service
Composite Medical Procedure
Identifier
*
*
*
SV10101
R
2
2
ID
Valid Values: ER (Jurisdiction Specific
Procedure and Supply Code), HC (HCPCs
codes), IV (Home Infusion), WK (Advanced
Billing Concepts (ABC) Codes)
SV10102
R
Product/Service ID
1
48
AN
Procedure Code
SV10103
S
Procedure Modifier 1
2
2
AN
SV10104
S
2
2
AN
SV10105
S
2
2
AN
SV10106
S
2
2
AN
SV10107
NU
Description
1
80
AN
Not Used
Leave blank
SV10108
NU
Product/Service ID
1
48
AN
Not Used
Leave blank
SV102
R
Line Item Charge Amount
1
18
R
SV103
R
2
2
ID
SV104
R
Service Units or Minutes
1
15
R
SV105
SV106
SV107
S
NU
S
Place of Service Code
Service Type Code
Composite Diagnosis Code
Identifier
1
1
*
2
2
*
AN
ID
*
Refer to Code Source 237
Not Used
SEE SV107-___ BELOW
SV10701
R
Diagnosis Code Pointer
1
2
N0
Use this pointer for the 1st diagnosis code
pointer (primary diagnosis for this service
line)
SV10702
S
1
2
N0
Diagnosis Code Pointer 2
SV10703
S
1
2
N0
1
Service line incremented by one for each
line
Service line incremented by one for each line
Professional Service
SEE SV101-___ BELOW
For encounter transmissions, (0) ZERO is
valid
Valid Values: MJ (Minutes: REQUIRED for
anesthesia claims), UN (Unit)
If a decimal is needed to report units,
include it in this element
HC
Procedure Code
MJ (Minutes: REQUIRED for anesthesia
claims), UN (Unit)
Units of service or minutes for anesthesia
Place of Service Code - Appendix A
Leave blank
70
SV5
S
SV10704
S
1
2
N0
SV108
SV109
NU
S
Monetary Amount
Emergency Indicator
1
1
18
1
R
ID
Not Used
Valid Value: Y (Yes) Required when service
known to be an emergency by provider
Leave blank
Y (Yes) Required when service known to be an
emergency
SV110
SV111
NU
S
Multiple Procedure Code
EPSDT Indicator
1
1
2
1
ID
ID
Not Used
Valid Value: Y (Yes)
Leave blank
Y (Yes) Required when service known to be an
related to EPSDT
SV112
SV113
SV114
S
NU
NU
Family Planning Indicator
Review Code
National or Local Assigned
Review Value
1
1
1
1
2
2
ID
ID
AN
Valid Value: Y (Yes)
Not Used
Not Used
Leave blank
Leave blank
Leave blank
SV115
SV116
S
NU
Co-Pay Status Code
Health Care Professional
Shortage Area Code
1
1
1
1
ID
ID
Valid Value: 0 (Copay exempt)
Not Used
Leave blank
Leave blank
SV117
SV118
SV119
SV120
SV121
NU
NU
NU
NU
NU
Postal Code
Monetary Amount
Level of Care Code
1
3
1
1
1
30
15
18
1
1
AN
ID
R
ID
ID
Not Used
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
1
Durable Medical Equipment
Service
Durable Medical Equipment Service
SV501
R
Composite Medical Procedure
Identifier
*
*
*
SEE SV501-___ BELOW
SV50101
R
2
2
ID
Valid Values: HC (HCPC)
SV50102
R
Product/Service ID
1
48
AN
Must be same value as reported in SV1012
SV50103
NU
Procedure Modifier
2
2
AN
Not Used
SV50104
NU
Procedure Modifier
2
2
AN
Not Used
SV50105
NU
Procedure Modifier
2
2
AN
Not Used
SV50106
NU
Procedure Modifier
2
2
AN
Not Used
SV50107
NU
Description
1
80
AN
Not Used
SV502
R
2
2
ID
Valid Value: DA (Days)
71
PWK
S
SV503
SV504
SV505
SV506
R
S
S
S
SV507
NU
10
Quantity
Monetary Amount
Monetary Amount
Frequency Code
1
1
1
1
15
18
18
1
R
R
R
ID
Prognosis Code
1
1
ID
Line Supplemental Information
- DMERC CMN Indicator
PWK01
R
2
2
Length of Medical Necessity
DME Rental Price
DME Purchase Price
Valid Values: 1 (Weekly), 4 (Monthly), B
(Daily)
Not Used
Line Supplemental Information - DMERC
CMN Indicator
ID
Valid Values: 03 (Report Justifying
Treatment Beyond Utilization Guidelines),
04 (Drugs Administered), 05 (Treatment
Diagnosis), 06 (Initial Assessment), 07
(Functional Goals), 08 (Plan of Treatment),
09 (Progress Report), 10 (Continued
Treatment), 11 (Chemical Analysis), 13
(Certified Test Report), 15 (Justification for
Admission), 21 (Recovery Plan), A3
(Allergies/Sensitivities Document), A4
(Autopsy Report), AM (Ambulance
Certification), AS (Admission Summary),
B2 (Prescription), B3 (Physician Order), B4
(Referral Form), BR (Benchmark Testing
Results), BS (Baseline), BT (Blanket Test
Results), CB (Chiropractic Justification), CK
(Consent Form(s)), CT (Certification), D2
(Drug Profile Document), DA (Dental
Models), DB (Durable Medical Equipment
Prescription), DG (Diagnosis Report), DJ
(Discharge Monitoring Report), DS
(Discharge Summary),
72
PWK
S
PWK02
R
PWK03
PWK04
PWK05
PWK06
PWK07
PWK08
NU
NU
NU
NU
NU
NU
Identification Code
Description
Actions Indicated
PWK09
NU
1
Attachment Transmission
Code
1
2
1
2
1
2
1
***
2
3
2
80
80
***
1
2
EB (Explanation of Benefits, Coordination
of Benefits or Medicate Secondary Payer),
HC (Health Certificate), HR (Health Clinic
Records), I5 (Immunization Record), IR
(State School Immunization Records), LA
(Laboratory Results), M1 (Medical Record
Attachment), MT (Models), NN (Nursing
Notes), OB (Operative Notes), OC (Oxygen
Content Averaging Report), OD (Orders
and Treatments Document), OE (Objective
Physical Examination (including vital signs)
Document), OX (Oxygen Therapy
Certification), OZ (Support Data for Claim),
P4 (Pathology Report), P5 (Patient Medical
History Document), PE (Parenteral or
Enteral Certification), PN (Physical Therapy
Notes), PO (Prosthetics or Orthotics
Certification), PQ (paramedical Results), PY
(Physician’s Report), PZ (Physical Therapy
(Radiology Reports), RT (Report of Tests
and Analysis Report), RX (Renewable
Oxygen Content Averaging Report), SG
(Symptoms Document), V5 (Death
Notification), XP(Photographs)
Valid Values: AA (Available on Request at
Provider Site), BM (By Mail), EL
(Electronically Only), EM (E-Mail), FT (File
Transfer), FX (By Fax)
N0
ID
ID
AN
AN
***
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
ID
Not Used
Durable Medical Equipment Certificate of
Medical Necessity Indicator
Valid Value: CT (Certification)
ID
Certificate of Medical
Necessity Indicator
PWK01
R
Report Type Code
2
2
ID
73
CR1
CR3
S
S
PWK02
R
PWK03
PWK04
PWK05
PWK06
PWK07
PWK08
NU
NU
NU
NU
NU
NU
Identification Code Qualified
Identification Code Qualified
Description
Action Indicated
PWK09
NU
1
Report Transmission Code
2
2
1
2
1
2
1
***
2
3
2
80
80
***
1
2
ID
Valid Value: AB (Previously Submitted to
Payer), AD (Certification Included in this
Claim), AF (Narrative Segment Included in
this Claim), AG (No Documentation is
Required), NS (Not Specified)
ID
ID
ID
ID
AN
***
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
ID
Not Used
Ambulance Transport Information
More ambulance segments to be discussed.
Ambulance Transport
Information
CR101
CR102
CR103
CR104
S
S
nu
R
Weight
Ambulance Transport Code
Ambulance Transport Reason
Code
2
1
1
1
2
10
1
1
ID
R
ID
ID
Valid Value: LB (Pound)
Patient Weight
Not Used
Valid Values: A (Transported to nearest
facility), B (Transported for the benefit of a
preferred physician), C (Transported for
nearness of family), D (Transported for the
care of a specialist or for availability of
specialized equipment), E (Transferred to
Rehabilitation Facility)
CR105
CR106
CR107
CR108
CR109
CR110
R
R
NU
NU
S
S
Quantity
Address Info
Address Info
Description
Description
2
1
1
1
1
1
2
15
55
55
80
80
ID
R
AN
AN
AN
AN
Valid Value: DH (Miles)
Transport Distance
Not Used
Not Used
Round Trip Purpose Description
Stretcher Purpose Description
Durable Medical Equipment Certification
1
Certification
CR301
R
CR302
CR303
CR304
R
R
NU
Certification Type Code
1
1
ID
Valid Values: I (Initial), R (Renewal), S
(Revised)
DME Duration
Insulin Dependent Code
2
1
1
2
15
1
ID
R
ID
Valid Value: MO (Months)
Length of time DME equipment is needed
Not Used
74
CR305
CRC
CRC
CRC
S
S
S
NU
3
Description
1
80
AN
Not Used
More ambulance segments to be discussed.
CRC01
R
Code Category
2
2
ID
Valid Value: 07 (Ambulance Certification)
Required on all service lines which report
ambulance services
CRC02
R
Yes/No Condition or Response
Code
1
1
ID
Valid Values: N (No), Y (Yes)
CRC03
R
Condition Indicator
2
2
ID
Valid Values: 01 (Patient admitted to
hospital), 04 (Patient was moved by
stretcher), 05 (Patient was unconscious or
in shock), 06 (Patient was transported in
an emergency situation), 07 (Patient had
to be physically restrained), 08 (Patient
had visible hemorrhaging), 09 (Ambulance
service was medically necessary), 12
(Patient is confined to a bed or chair)
CRC04
CRC05
CRC06
CRC07
S
S
S
S
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
2
2
2
2
2
2
2
2
ID
ID
ID
ID
Same as CRC03
Same as CRC03
Same as CRC03
Same as CRC03
Hospice Employee Indicator Required on
all Medicare claims involving physician
services to hospice patients
1
Hospice Employee Indicator
CRC01
CRC02
R
R
CRC03
CRC04
CRC05
CRC06
CRC07
R
NU
NU
NU
NU
1
Code Category
Hospice Employed Provider
Indicator
2
1
2
1
ID
ID
Valid Value: 70 (Hospice)
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
2
2
2
2
2
2
2
2
2
2
ID
ID
ID
ID
ID
Valid Value: 65 (Open)
Not Used
Not Used
Not Used
Not Used
DMERC Condition Indicator Required on
all oxygen therapy and DME claims that
require a certificate of medical necessity
(CMN)
Valid Values: 09 (Durable Medical
Equipment Certification)
DMERC Condition Indicator
CRC01
R
Code Category
2
2
ID
75
DTP
DTP
DTP
DTP
R
S
S
S
CRC02
R
Certification Condition
Indicator
1
1
ID
CRC03
R
Condition Indicator
2
2
ID
Valid Values: 38 (Certification signed by
the physician is on file at the supplier's
office), ZV (Replacement Item)
CRC04
CRC05
CRC06
CRC07
S
S
S
S
Condition Indicator
Condition Indicator
Condition Indicator
Condition Indicator
2
2
2
2
2
2
2
2
ID
ID
ID
ID
Same as CRC03
Same as CRC03
Same as CRC03
Same as CRC03
DTP01
DTP02
R
R
Service Date
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
DTP03
R
Date Time Period
1
35
AN
Service Date
Valid Value: 472 (Service)
Valid Value: D8 (CCYYMMDD), RD8 (Range
of dates Expressed as CCYYMMDDCCYYMMDD)
Service Date
DTP01
DTP02
R
R
Prescription Date
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Prescription Date
Valid Value: 471 (Prescription)
DTP03
R
Date Time Period
1
35
AN
Certification Revision Date
Certification Revision Date Required if
CR301 (DMERC Certification) = "R" or "S"
1
1
1
DTP
472
D8
Date of Service
CCYYMMDD
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 607 (Certification Revision)
DTP03
R
Date Time Period
1
35
AN
Begin Therapy Date Required if it is
necessary to included documentation for
DMERC
1
Begin Therapy Date
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 463 (Begin Therapy)
DTP03
R
Date Time Period
1
35
AN
Begin Therapy Date
76
DTP
DTP
DTP
DTP
S
S
S
S
1
Last Certification Date
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Last Certification Date Required if
necessary to include documentation for
Medicare DMERC where provider required
to obtain CMN from physician. Required
on oxygen therapy certificates of medical
necessity.
Valid Value: 461 (Last Certification)
DTP03
R
Date Time Period
1
35
AN
Last Certification Date
DTP01
R
Date Last Seen
Date/Time Qualifier
3
3
ID
Date Last Seen
Valid Value: 304 (Latest Visit or
Consultation) Required when claim
involves services of independent physical
or occupational therapist, or phys service
involving routine foot care and different
than date at claim level and known to
impact payer adjudication
DTP02
R
Qualifier
2
3
ID
DTP03
R
Date Time Period
1
35
AN
Last Seen Date
Test Date Required on initial EPO claims
service lines where test results are being
billed/reported
1
2
Test Date
DTP01
R
Date/Time Qualifier
3
3
ID
Valid Values: 738 (Most Recent
Hemoglobin or Hematocrit or Both), 739
(Most Recent Serum Creatine)
DTP02
R
Qualifier
2
3
ID
DTP03
R
Date Time Period
1
35
AN
Test Performed Date
Shipped Date Required when
billing/reporting shipped products
1
Shipped Date
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 011 (Shipped)
DTP03
R
Date Time Period
1
35
AN
Shipped Date
77
DTP
DTP
QTY
QTY
MEA
S
S
S
S
S
1
Last X-Ray Date
Last X-Ray Date Required for spinal
manipulation certifications if different
than loop 2300.
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 455 (Last X-Ray)
DTP03
R
Date Time Period
1
35
AN
Last X-Ray Date
Initial Treatment Date Required for
spinal manipulation certifications if
different than loop 2300
1
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 454 (Initial Treatment)
DTP03
R
Date Time Period
1
35
AN
QTY01
QTY02
QTY03
R
R
NU
Ambulance Patient Count
Quantity Qualifier
Quantity
2
1
***
2
15
***
ID
R
***
Valid Value: PT (Patients)
Not Used
QTY04
NU
Free Form Message
1
30
AN
Not Used
Obstetric Anesthesia Additional
Valid Value: FL (Units)
1
1
Obstetric Anesthesia
Additional
QTY01
QTY02
R
R
QTY03
NU
QTY04
NU
Free Form Message
5
Quantity Qualifier
Obstetric Anesthesia
Additional
2
1
2
15
ID
R
***
***
***
Not Used
1
30
AN
Not Used
Test Results - Required for Dialysis for
ESRD, on Oxygen Therapy (saturation,
arterial blood gas), DMERC for height
Test Results
MEA01
R
Measurement Reference ID
Code
2
2
ID
Valid Values: OG (Original Starting
dosage), TR (Test Results)
MEA02
R
Measurement Qualifier
1
3
ID
Valid Values: HT (Height), R1
(Hemoglobin), R2 (Hematocrit), R3
(Epoetin Starting Dosage), R4 (Creatin)
78
CN1
REF
REF
S
S
S
MEA03
MEA04
MEA05
MEA06
MEA07
R
NU
NU
NU
NU
Measurement Value
Range Minimum
Range Maximum
Measurement Significance
Code
1
*
1
1
2
20
*
20
20
2
R
*
R
R
ID
Test Results
Not Used
Not Used
Not Used
Not Used
MEA08
MEA09
MEA10
NU
NU
NU
Measurement Attribute Code
Surface/Layer/Position Code
Measurement Method or
Device
2
2
2
2
2
4
ID
ID
ID
Not Used
Not Used
Not Used
MEA
11
MEA12
NU
1
3
ID
Not Used
NU
Industry Code
1
30
AN
Not Used
CN101
R
Contract Information
Contract Type Code
2
2
ID
Valid Values: 01 (Diagnosis Related GroupDRG), 02 (Per Diem), 03 (Variable Per
Diem), 04 (Flat), 05 (Capitated), 06
(Percent), 09 (Other)
CN102
CN103
CN104
CN105
CN106
S
S
S
S
S
Monetary Amount
Percent
Version Identifier
1
1
1
1
1
18
6
50
6
30
R
R
AN
R
AN
Contract Amount
Contract Percentage
Contract Code
Contract Version Identifier
Repriced Line Item Reference Number
Valid Value: 9B (Repriced Line Item
Reference Number)
Repriced Line Item Reference Number
Not Used
Not Used
Adjusted Repriced Line Item Reference
Number
1
1
Repriced Line Item Reference
Number
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
ID
AN
AN
***
Adjusted Repriced Line Item
Reference Number
REF01
R
Qualifier
2
3
ID
Valid Value: 9D (Adjusted Repriced Line
Item Reference Number)
REF02
R
1
50
AN
Number
79
REF03
REF04
REF
REF
REF
S
S
S
NU
NU
5
1
***
80
***
AN
***
Prior Authorization Number Required if
service line involved a prior authorization
number
Number)
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
S
Description
1
1
***
50
80
***
REF401
R
Qualifier
2
3
ID
Number)
REF402
R
1
50
AN
REF403
NU
Qualifier
2
3
ID
The payer identifier reporting this field
must match the corresponding payer
identifier reported in Loop ID-2330B
NM109)
Not Used
REF404
REF405
NU
1
50
AN
Not Used
NU
Qualifier
2
3
ID
Not Used
REF406
NU
1
50
AN
Not Used
REF01
R
Line Item Control Number
Qualifier
2
3
ID
Valid Value: 6R (Provider Control Number)
REF02
REF03
REF04
R
NU
NU
1
1
***
50
80
***
Description
Mammography Certification
Number
ID
Not Used
Not Used
REF01
1
1
Description
AN
AN
***
AN
AN
***
Not Used
Required when the Prior Authorization
Number reported in REF02 of this segment
is for a non-destination payer.
Not Used
Not Used
Required when mammography services
rendered by certified mammography
provider
6R
Not Used
Not Used
80
REF
REF
REF
REF
S
S
S
S
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
AN
AN
***
Clinical Laboratory
(CLIA) Number
Valid Value: EW (Mammography
Certification Number)
Not Used
Not Used
Amendment (CLIA) Number Required for
all CLIA certified facilities performing CLIA
covered lab services
REF01
R
Qualifier
2
3
ID
Valid Value: X4 (Clinical Laboratory
Improvement Amendment Number)
REF02
R
1
50
AN
Amendment Number
REF03
REF04
NU
NU
1
***
80
***
AN
***
Not Used
Not Used
Referring Clinical Laboratory Improvement
Amendment (CLIA) Facility Identification
Required for Medicare claims for any
laboratory that referred tests to another
lab covered by CLIA Act billed on this line
Valid Value: F4 (Facility Certification
Number)
Referring CLIA Number
Not Used
Not Used
Immunization Batch Number
Valid Value: BT (Batch Number)
Not Used
Not Used
Referral Number
1
Description
Referring Clinical Laboratory
(CLIA) Facility Identification
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
REF01
R
2
3
REF02
REF03
REF04
R
NU
NU
1
1
***
50
80
***
1
5
ID
Qualifier
Description
Referral Number
ID
AN
AN
***
ID
AN
AN
***
81
AMT
AMT
K3
NTE
S
S
S
S
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
S
Description
1
1
***
50
80
***
REF0401
R
Qualifier
2
3
REF0402
R
1
REF0403
NU
Qualifier
REF0404
NU
REF0405
Valid Value: 9F (Referral Number)
Referral Number
Not Used
ID
Valid Value: 2U (Patient Identification
Number)
50
AN
Other payer Primary Identifier
2
3
ID
Not Used
1
50
AN
Not Used
NU
Qualifier
2
3
ID
Not Used
REF0406
NU
1
50
AN
Not Used
AMT01
AMT02
AMT03
R
R
NU
Sales Tax Amount
Monetary Amount
1
1
1
3
18
1
ID
R
ID
Sales Tax Amount
Valid Value: T (Tax)
Sales Tax Amount
Not Used
AMT01
AMT02
AMT03
R
R
NU
Postage Claimed Amount
Monetary Amount
1
1
1
3
18
1
ID
R
ID
Valid Value: F4 (Postage Claimed)
Not Used
R
NU
NU
File Information
Record Format Code
File Information
K301
K302
K303
1
1
*
80
2
*
AN
ID
*
NTE01
R
Line Note
Note Reference Code
3
3
ID
Line Note
Valid Values: ADD (Additional
Information), DCP (Goals, Rehabilitation
Potential, or Discharge Plans)
NTE02
R
Description
1
80
AN
Line Note Text
1
1
10
1
ID
AN
AN
***
Not Used
Not Used
Other payer Primary Identifier
82
NTE
PS1
S
S
1
NTE01
R
Third Party Organization Notes
Note Reference Code
3
3
ID
NTE02
R
Description
1
80
1
S
AN
R
ID
Purchased Service Information Required
on service lines when purchased service
chg amt necessary for processing; use on
vision claims when acquisition cost of
lenses known to impact adjudication or
reimbursement
Purchased Service Provider Identifier
Purchased Service Charge Amount
Not Used
Line Pricing/Repricing Information
Purchased Service Information
PS101
PS102
PS103
HCP
AN
Valid Values: TPO (Third Party
Organization)
Line Note Text
R
R
NU
1
Monetary Amount
1
1
2
50
18
2
Line Pricing/Repricing
Information
HCP01
R
Pricing / Repricing Method
2
2
ID
Under Contract), 01 (Priced As Billed at
100%), 02 (Priced at the Standard Fee
Schedule), 03 (Priced at a Contractual
Percentage), 04 (Bundling Pricing), 05
(Peer Review Pricing), 06 (Per Diem
Pricing), 07 (Flat Rate Pricing), 08
(Combination Pricing), 09 (Maternity
Pricing), 10 (Other Pricing), 11 (Lower of
Cost), 12 (Ratio of Cost), 13 (Cost
Reimbursed), 14 (Adjustment Pricing)
HCP02
HCP03
HCP04
HCP05
HCP06
R
S
S
S
S
Monetary Amount
Monetary Amount
Rate
1
1
1
1
1
18
18
50
9
50
R
R
AN
R
AN
Repriced Savings Amount
Repriced Organization Identifier
Group Code
HCP07
S
Monetary Amount
1
18
R
Group Amount
HCP08
HCP09
NU
S
Product/Service ID
1
2
48
2
AN
ID
Not Used
Procedure and Supply Codes), HC (HCPC),
IV (HIEC), WK (Advanced Billing Concepts)
HCP10
HCP11
HCP12
S
S
S
Product/Service ID
Quantity
1
2
1
48
2
15
AN
ID
R
Valid Values: DA (Days), UN (Units)
Repriced Approved Service Unit Count
83
2410
1
HCP13
S
Reject Reason Code
2
2
ID
HCP14
S
1
2
ID
HCP15
S
Exception Code
1
2
ID
S
S
Drug Identification
LIN
S
1
LIN01
LIN02
NU
R
LIN03
R
LIN04
LIN05
LIN06
LIN07
LIN08
LIN09
LIN10
LIN11
LIN12
NU
NU
NU
NU
NU
NU
NU
NU
NU
Valid Values: T1 (Cannot Identify Provider
as TPO Participant), T2 (Cannot Identify
Payer as TPO Participant), T3 (Cannot
Identify Insured as TPO Participant), T4
(Payer Name or Identifier Missing), T5
(Certification Information Missing), T6
(Claim does not contain enough
information for repricing)
Valid Values: 1 (Procedure Followed;
Compliance), 2 (Not Followed - Call Not
Made; Non-Compliance Call Not Made), 3
(Not Medically Necessary; NonCompliance Non-Medically Necessary), 4
(Not Followed Other; Non-Compliance
Other), 5 (Emergency Admit to NonNetwork Hospital)
Provider in Network Hospital), 2
(Emergency Care), 3 (Services or Specialist
not in Network), 4 (Out-of-Service Area), 5
(State Mandates), 6 (Other)
Required when NDC usage necessary to
further define service in SV101-2
Item Identification
Assigned identification
1
2
20
2
AN
ID
Product/Service ID
1
48
AN
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
2
1
2
1
2
1
2
1
2
2
48
2
48
2
48
2
48
2
ID
AN
ID
AN
ID
AN
ID
AN
ID
Not Used
Valid Value: N4 (National Drug Code 5-4-2
format), EN (EAN/UCC - 13), EO (EAN/USS 8), HI (HIBC (Health Care Car Code)
Supplier Labeling tatndard Primary data
Message), ON (Customer Order Number),
UK (GTIN14 - digit Data Structire), UP (UCC
- 12)
National Drug Code or Universal Product
Number
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
84
CTP
R
LIN13
LIN14
LIN15
LIN16
LIN17
LIN18
LIN19
LIN20
LIN21
LIN22
LIN23
LIN24
LIN25
LIN26
LIN27
LIN28
LIN29
LIN30
LIN31
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
Product/Service ID
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
48
2
48
2
48
2
48
2
48
2
48
2
48
2
48
2
48
2
48
AN
ID
AN
ID
AN
ID
AN
ID
AN
ID
AN
ID
AN
ID
AN
ID
AN
ID
AN
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
CTP01
CTP02
CTP03
CTP04
CTP05
CTP0501
NU
NU
NU
R
R
R
Drug Pricing
Class of Trade Code
Price Identifier Code
Unit Price
Quantity
2
3
1
1
*
2
2
3
17
15
*
2
ID
ID
R
R
*
ID
Not Used
Not Used
Not Used
National Drug Unit Count
SEE CTP05-___ BELOW
Valid Values: F2 (International Unit), GR
(Gram), ME (Milligram), ML (Milliliter), UN
(Unit)
CTP0502
NU
Exponent
1
15
R
Not Used
CTP0503
NU
Multiplier
1
10
R
Not Used
CTP0504
NU
2
2
ID
Not Used
CTP0505
NU
Exponent
1
15
R
Not Used
CTP0506
NU
Multiplier
1
10
R
Not Used
1
85
REF
2420A
1
S
CTP0507
NU
2
2
ID
Not Used
CTP0508
NU
Exponent
1
15
R
Not Used
CTP0509
NU
Multiplier
1
10
R
Not Used
CTP0510
NU
2
2
ID
Not Used
CTP0511
NU
Exponent
1
15
R
Not Used
CTP0512
NU
Multiplier
1
10
R
Not Used
CTP0513
NU
2
2
ID
Not Used
CTP0514
NU
Exponent
1
15
R
Not Used
CTP0515
NU
Multiplier
1
10
R
Not Used
CTP06
CTP07
CTP08
CTP09
CTP10
CTP11
NU
NU
NU
NU
NU
NU
Price Multiplier Qualifier
Multiplier
Monetary Amount
Basis of Unit Price Code
Condition Value
Multiple Price Quantity
3
1
1
2
1
1
3
10
18
2
10
2
ID
R
R
ID
AN
N0
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
REF01
R
Prescription Number
Qualifier
2
3
ID
Valid Value: VY (Link Sequence Number),
XZ (Pharmacy Prescription Number)
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
1
S
NM1
S
AN
AN
***
1
NM101
R
Prescription Number
Not Used
Not Used
2
3
ID
Valid Value: 82 (Rendering Provider).
Usage changed - Required when
adjudication is known to be impacted by
provider taxonomy code
82
86
PRV
REF
S
S
NM102
R
1
1
ID
NM103
R
Name
1
60
AN
Entity)
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
S
S
NU
S
R
R
NU
NU
NU
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
ID
AN
ID
ID
AN
Required if NM102=1
Not Used
Rendering Suffix
Rendering Provider Identifier
Not Used
Not Used
Not Used
1
Rendering Provider Specialty
Information
PRV01
PRV02
R
R
PRV03
PRV04
PRV05
R
NU
NU
PRV06
NU
20
Provider Code
Qualifier
Rendering Suffix
XX
Rendering Provider’s NPI
Rendering Provider Specialty Information.
Required when adjudication is known to
be impacted by provider taxonomy code.
1
2
3
3
1
2
***
30
2
***
3
3
ID
ID
AN
ID
***
ID
Identification
Valid Value: PE (Performing)
Taxonomy Code)
Not Used
Not Used
PE
PXC
Not Used
Identification
REF01
R
Qualifier
2
3
ID
REF02
REF03
REF04
R
NU
S
Description
1
1
***
50
80
***
REF041
R
Reference Identifier Qualifier
2
3
ID
Number)
REF042
R
Other Payer Primary Identifier
1
50
AN
AN
AN
***
Commercial #), LU (Location #)
Not Used
0B, IG, G2, LU
2U
87
2420B
1
REF043
NU
Qualifier
2
3
ID
Not Used
REF044
REF045
NU
1
50
AN
Not Used
NU
Qualifier
2
3
ID
Not Used
REF046
NU
1
50
AN
Not Used
S
NM1
REF
S
S
1
Purchased Service Provider
Name
Purchased Service Provider Name
Purchased Serviced Provider
Name
Purchased Serviced Provider Name
NM101
R
2
3
ID
NM102
R
1
1
ID
NM103
R
Name
1
60
AN
Valid Value: QB (Purchased Service
Provider
Entity)
Purchased Serviced Provider Last Name
NM104
S
First Name
1
35
AN
Required if NM102=1
NM105
S
Middle
1
25
AN
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
S
R
R
NU
NU
NU
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
2
2
2
1
10
10
2
80
2
3
60
AN
AN
ID
AN
ID
ID
AN
Not Used
Purchased Serviced Provider Name
Purchased Serviced Provider Identifier
Not Used
Not Used
Not Used
Purchased Service Provider Secondary
Identification
20
Purchased Service Provider
REF01
R
Qualifier
2
3
ID
Valid Values: QB (State License #), 1G
Commercial #)
REF02
R
1
50
AN
Purchased Service Provider Secondary
Identifier
REF03
NU
Description
1
80
AN
Not Used
88
2420C
1
REF04
S
***
***
REF041
R
2
3
REF042
REF043
R
1
NU
Qualifier
REF044
REF045
NU
REF046
Not Used
ID
Number)
50
AN
2
3
ID
Not Used
1
50
AN
Not Used
NU
Qualifier
2
3
ID
Not Used
NU
1
50
AN
Not Used
S
NM1
N3
S
R
***
1
NM101
R
2
3
ID
Valid Values: 77 (Service Location), FA
(Facility), LI (Independent Lab), TL (Testing
Laboratory)
NM102
NM103
R
S
Name
1
1
1
60
ID
AN
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
NU
NU
NU
S
S
NU
NU
NU
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
1
1
2
2
2
1
35
25
10
10
2
80
2
3
60
AN
AN
AN
AN
ID
AN
ID
ID
AN
Not Used
Not Used
Not Used
Not Used
Laboratory or Facility Primary Identifier
Not Used
Not Used
Not Used
Service Facility Location Address
Laboratory or Facility Address
Laboratory or Facility Address 2
1
Address
N301
N302
R
S
Address Information
Address Information
1
1
55
55
AN
AN
89
N4
R
1
City/State/ZIP
N401
N402
N403
N404
N405
N406
N407
REF
2420D
1
S
R
R
R
S
NU
NU
S
3
S
2
2
3
2
1
1
1
30
2
15
3
2
30
3
AN
ID
ID
ID
ID
AN
id
Lab or Facility City Name
Not Used
Not Used
not send.
Identification
REF01
R
Qualifier
2
3
ID
Valid Values: G2 (Provider Commercial #),
LU (Location #)
REF02
R
1
50
AN
REF03
REF04
NU
S
1
***
80
***
AN
***
Identifier
Not Used
REF041
REF042
REF043
REF044
REF045
REF046
R
2
3
ID
R
1
50
AN
Number)
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
S
NM1
City Name
Postal Code
Country Code
Location Qualifier
Location Identifier
Service Facility Location City/State/ZIP
Description
1
NM101
NM102
R
R
2
1
3
1
ID
ID
90
REF
2420E
1
S
NM103
R
Name
1
60
AN
Supervising Provider Last Name
NM104
NM105
R
S
Name First
Supervising Provider Middle
Name
1
1
35
25
AN
AN
Supervising Provider First Name
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
S
S
S
NU
NU
NU
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
2
2
2
1
10
10
2
80
2
3
60
AN
AN
ID
AN
ID
ID
AN
Not Used
Supervising Provider Name Suffix
Supervising Provider Identifier
Not Used
Not Used
Not Used
Identification
Commercial #)
Supervising Provider Secondary Identifier
Not Used
20
Supervising Provider
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
S
Description
1
1
***
50
80
***
REF041
REF042
REF043
REF044
REF045
REF046
R
2
3
ID
R
1
50
AN
Number)
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
Ordering Provider Name
Valid Value: DK (Ordering Physician)
S
NM1
S
ID
AN
AN
***
1
NM101
NM102
R
R
2
1
3
1
ID
ID
91
N3
S
NM103
R
Name
1
60
AN
Ordering Provider Last Name
NM104
NM105
R
S
Name First
Ordering Provider Middle
Name
1
1
35
25
AN
AN
Ordering Provider First Name
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
S
S
S
NU
NU
NU
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
2
2
2
1
10
10
2
80
2
3
60
AN
AN
ID
AN
ID
ID
AN
Not Used
Ordering Provider Name Suffix
Ordering Provider Identifier
Not Used
Not Used
Not Used
1
1
55
55
AN
AN
Ordering Provider Address
Ordering Provider Address 1
Ordering Provider Address 2
Ordering Provider City/State/ZIP Code
1
N301
N302
N4
REF
S
S
R
S
1
Ordering Provider Address
Address Information
Address Information
Ordering Provider
City/State/ZIP Code
N401
N402
N403
N404
R
S
R
S
City Name
Postal Code
Ordering Provider Country
Code
2
2
3
2
30
2
15
3
AN
ID
ID
ID
Ordering Provider City Name
Ordering Provider State
Ordering Provider Zip Code
N405
N406
N407
NU
NU
S
Location Qualifier
Location Identifier
1
1
1
2
30
3
ID
AN
ID
Not Used
Not Used
not send.
Ordering Provider Secondary Identification
20
Ordering Provider Secondary
Identification
REF01
R
Qualifier
2
3
ID
Commercial #)
REF02
R
1
50
AN
Ordering Provider Secondary Identifier
92
REF03
REF04
NU
S
REF041
REF042
REF043
REF044
REF045
REF046
R
R
Description
1
***
80
***
AN
***
Not Used
2
3
ID
AN
Number)
1
50
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
Ordering Provider Contact Information
c
PER
2420F
2
S
1
Ordering Provider Contact
Information
PER01
PER02
R
R
Ordering Provider Contact
Name
2
1
2
60
ID
AN
PER03
R
Qualifier
2
2
ID
(Facsimile), TE (Telephone)
PER04
PER05
R
S
Qualifier
1
2
256
2
AN
ID
PER06
PER07
S
S
Qualifier
1
2
256
2
AN
ID
PER08
PER09
S
NU
1
1
256
20
AN
AN
S
NM1
S
1
(Telephone Extension), FX (Facsimile), TE
(Telephone)
(Telephone)
Not Used
NM101
R
2
3
ID
Valid Values: DN (Referring Provider), P3
NM102
NM103
R
R
Name
1
1
1
60
ID
AN
93
REF
2420G
S
NM104
NM105
R
S
NM106
NM107
NM108
NM109
NM110
NM111
NM112
NU
S
S
S
NU
NU
NU
20
S
1
1
35
25
AN
AN
Referring Provider Middle Name.
Name Prefix
Name Suffix
Identification Code
Name
1
1
1
2
2
2
1
10
10
2
80
2
3
60
AN
AN
ID
AN
ID
ID
ID
Not Used
Referring Provider Identification Number
Not Used
Not Used
Not Used
Identification
ID
Commercial #)
AN
AN
***
Referring Provider Secondary Identifier
Not Used
Identification
REF01
R
Qualifier
2
3
REF02
REF03
REF04
R
NU
S
Description
1
1
***
50
80
***
REF041
REF042
REF043
REF044
REF045
REF046
R
2
3
ID
R
1
50
AN
Number)
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
NU
2
3
ID
Not Used
NU
1
50
AN
Not Used
1
NM1
Name First
Name Middle
1
NM101
NM102
NM103
R
R
NU
Name
2
1
1
3
1
60
ID
ID
AN
Valid Value: PW (Pick-up Address)
NM104
NU
Name First
1
35
AN
Not Used
NM1
PW
Name Last or Organization Name
Leave blank
94
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
N3
N4
2420H
R
R
NU
NU
NU
NU
NU
NU
NU
NU
1
S
1
1
1
1
2
2
2
1
25
10
10
2
80
2
3
60
AN
AN
AN
ID
AN
ID
ID
ID
Address
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Ambulance Pick-up Location Address
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
N3
N301
R
Address Line 1
1
55
Ambulance Pick-up Location Address Line 1
N302
S
Address Line 2
1
55
Ambulance Pick-up Location Address Line 2
1
City, State, ZIP Code
N401
N402
N403
N404
R
S
S
S
N405
N406
N407
NU
NU
S
1
NM1
Name Middle
Name Prefix
name Suffix
Identification Code
Name
Ambulance Pick-up Location City, State,
ZIP Code
Ambulance Pick-up City
Ambulance Pick-up ZIP Code
Ambulance Pick-up County
Code
2
2
3
2
2
1
15
3
Ambulance Pick-up City
Ambulance Pick-up ZIP Code
Ambulance Pick-up County Code
Location Qualifier
Location identifier
1
1
1
1
30
3
Leave blank
Leave blank
Leave blank
ID
Ambulance Drop-Off Location
1
N4
Not Used
NM101
NM102
NM103
R
R
NU
Name
2
1
1
3
1
60
ID
ID
AN
Valid Value: 45 (Drop-Off Address)
NM104
NM105
NM106
NM107
NM108
NU
NU
NU
NU
NU
Name First
Name Middle
Name Prefix
name Suffix
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Not Used
Not Used
Not Used
Not Used
Not Used
NM1
45
2
Name Last or Organization Name
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
95
NM109
NM110
NM111
NM112
N3
N4
2430
15
R
R
NU
NU
NU
NU
1
S
2
2
2
1
80
2
3
60
AN
ID
ID
ID
Address
Not Used
Not Used
Not Used
Not Used
Ambulance Drop-Off Location Address
Leave blank
Leave blank
Leave blank
Leave blank
N3
N301
R
Address Line 1
R
1
55
Ambulance Drop-Off Location Address Line 1
N302
S
Address Line 2
S
1
55
Ambulance Drop-Off Location Address Line 2
1
City, State, ZIP Code
Ambulance Drop-Off Location City, State,
ZIP Code
N4
N401
N402
N403
N404
Ambulance Drop-Off City
Ambulance Drop-Off State
Ambulance Drop-Off ZIP Code
Ambulance Drop-Off County
Code
2
2
3
2
2
1
15
3
Ambulance Drop-Off City
Ambulance Drop-Off State
Ambulance Drop-Off ZIP Code
Ambulance Drop-Off County Code
N405
N406
N407
S
Location Qualifier
Location identifier
1
1
1
1
30
3
Leave blank
Leave blank
Leave blank
SVD01
R
Line Adjudication Information
SVD02
R
SVD03
ID
Not Used
2
305
80
AN
Monetary Amount
1
18
R
Number should match NM109 in loop
2330B
Service Line Paid Amount. Zero "0" is an
acceptable value for this element.
R
Product or Service ID
Composite
*
*
*
SEE SVD03-___ BELOW
SVD0301
R
2
2
ID
Procedure and Supply Codes), HC (HCPC),
IV (Home Infusion EDI Coalition HIEC), WK
(Advanced Billing Concepts (ABC) Codes)
SVD0302
R
Product/Service ID
1
48
AN
Procedure Code
SVD0303
S
2
2
AN
S
SVD
Identification Code
Name
1
96
CAS
S
SVD0304
S
2
2
AN
SVD0305
S
2
2
AN
SVD0306
S
2
2
AN
SVD0307
S
Procedure Code Description
1
80
AN
Required if SVC01-7 was returned in the
835 transaction.
SVD0308
NU
Product or Service ID
1
80
AN
Required if SVC01-7 was returned in the
835 transaction.
SVD04
SVD05
NU
R
Product/Service ID
Paid Service Unit Count
1
1
48
15
AN
R
Not Used
Crosswalk from SVC05 in 835 or, if not
present in 835, use original billed units
SVD06
S
Bundled or Unbundled line
1
6
N0
Use the LX from this transaction which
points to the bundled line; required if
payer bundled this service line
CAS01
R
Line Adjustment
1
2
ID
Line Adjustment
Valid Values: CO (Contractual Obligations),
CR (Correction and Reversals), OA (Other
adjustments), PI (Payor Initiated
Reductions), PR (Patient Responsibility)
CAS02
R
Code
1
5
ID
Adjustment Reason Code - Line Level
CAS03
CAS04
CAS05
R
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
Adjusted Amount - Line Level
Adjusted Units - Line Level
CAS06
CAS07
CAS08
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
CAS09
CAS10
CAS11
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
CAS12
CAS13
CAS14
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
5
97
DTP
AMT
R
S
CAS15
CAS16
CAS17
S
S
S
Monetary Amount
Quantity
Code
1
1
1
18
15
5
R
R
ID
CAS18
CAS19
S
S
Monetary Amount
Quantity
1
1
18
15
R
R
DTP01
DTP02
R
R
Line Adjudication Date
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Line Adjudication Date
DTP03
R
Date Time Period
1
35
AN
Remaining Patient Responsibility
Valid Value: EAF (Amount Owed)
Not Used
1
1
Remaining Patient
Responsibility
AMT01
AMT02
AMT03
2440
>1
S
LQ
FRM
Trailer
1
R
R
NU
S
R
SE
R
2
18
1
LQ01
R
LQ02
R
Industry Code
1
30
AN
FRM01
FRM02
R
S
Supporting Documentation
Question Number/Letter
Code
1
1
20
1
AN
ID
FRM03
FRM04
FRM05
S
S
S
Date
Percent
1
8
1
50
8
6
AN
DT
R
99
1
1
1
1
Form Identification Code
1
R
Monetary Amount
Trailer
Transaction Set Trailer
1
3
ID
Valid Values: AS (Form Type Code), UT
(HCFA Durable Medical Equipment
Regional Carrier Certificate of Medical
Necessity Forms)
Form Identifier
Supporting Documentation
Valid Values: N (No), W (Not Applicable), Y
(Yes). Question Response.
Format: CCYYMMDD
Used to answer question identified in
FRM01 which utilizes a percent response
format.
Trailer
SE
98
Control
1
SE01
R
Number of Included Segments
1
10
N0
Total number of segments included in a
transaction set including ST and SE
segments
SE02
R
Transaction Set Control
Number
4
9
AN
Must match ST02. Must be unique within
the transaction set functional group,
assigned by originator for a transaction
set.
R
GE
IEA
1
6
N0
Control
Functional Group Trailer
Numeric
Group Control Number
1
9
N0
Numeric
R
Interchange Control Trailer
Number of Included Functional
Groups
1
5
N0
Numeric
R
Interchange Control Number
9
9
N0
R
GE01
R
GE02
R
IEA01
IEA02
R
Control
Number of Transactions Sets
Included
Numeric; Control number assigned by
interchange sender
Total number of segments included in a
transaction set including the ST and the SE
segments.
Must match ST02. Must be unique within the
transaction set fucntional group, assigned by
originator for a transaction set.
GE
Numeric - Total number of transaction sets
included in the functional group or
interchange (transmission) group terminated
by the trailer containing this data element.
Begins eith a 1 and increments +2 for each
subsequent GS within the file. Resets back to
Numeric - A count of the number of functional
groups included in an interchange.
Must match ISA113 (interchange control
number) assigned in the interchange header
segment
99
837 Health Care Claims transaction - Institutional – Version 5010
Payer Specific Data Requirements
Institutional Claims (837I) Data Requirements
************************************************************************************************************************************************
General
The purpose of this section is to clarify the data elements and segments that must be used for (payer specific) institutional claims transactions. This document has been
prepared as Colorado Access specific companion document to that implementation guide and to clarify when conditional data elements and segments must be used for
Colorado Access reporting, and identify those codes and data elements that do not apply to Colorado Access. The following information is designed to help you complete the
837i transaction. If you follow these guidelines, we'll be better able to process your claims accurately and efficiently.
X12 837 Institutional Mapping - 5010
Loop
Rpt Req
Seg
Req
Rpt
Field
ID
Req
Field Name
Min
Max
DT
Comments
Legend:
Loop - Describes the positioning of business data within the data structure/stream.
Seg - Describes the individual data within the loops in the data structure/stream.
Rpt - Indicates the maximum number of times the Loop or Segment can repeat.
Req - Indicates whether a Loop, Segment, or Field ID is required by the X12 standards. R - Required, S - Situational, NU - Not used.
Field ID - Name of the field within the segment structure.
Field Name - Name of the field referred to in the Field ID column.
Min - Mininum length the field can be. (*** - Indicates a null field)
Max - Maximum length the field can be. (*** - Indicates a null field)
DT - Data Type as specified in Implementation Guides (Nn = Numeric, R = Decinal, ID = Identifier, AN = String, DT = Date, TM = Time, B = Binary)
Edits/Comments - Contains information pertaining to the editing of X12 data and how PowerSTEPP may handle the field
Control
R
Control
Control
ISA
R
1
ISA01
R
Auth Information Qualifier
2
2
ID
Valid Values: 00 (No authorization info
present), 03 (Additional data information)
ISA02
ISA03
R
R
Authorization Information
Security Info Qualifier
10
2
10
2
AN
ID
ISA04
ISA05
R
R
Security Information
10
2
10
2
AN
ID
Valid Values: 00 (No security info present), 01
(Password)
Valid Values: 01 (Duns), 14 (Duns plus suffix),
20 (HIN), 27 (HCFA carrier ID), 28 (HCFA - fiscal
intermediary ID), 29 (Medicare provider and
supplier ID), 30 (US Fed Tax ID), 33 (NAIC), ZZ
(Mutually defined)
Valid Values
ISA
00
Spaces
00
Spaces
ZZ
100
GS
R
ISA06
R
Interchange Sender ID
15
15
AN
ISA07
R
2
2
ID
ISA08
ISA09
R
R
Interchange Receiver ID
Interchange Date
15
6
15
6
AN
DT
Format: YYMMDD
ISA10
R
Interchange Time
4
4
TM
Format: HHMM
ISA11
R
Repetition Separator
1
1
ID
Valid Value: ^
ISA12
R
Interchange Control Version No.
5
5
ID
Valid Value: 00401 (Draft Standards for Trial
Use)
ISA13
R
Interchange Control No.
9
9
N0
Numeric. Must match IEA02
ISA14
R
Acknowledgment Requested
1
1
ID
Valid Values: 0 (No acknowledgment
requested), 1 (TA1 Interchange
acknowledgment requested)
ISA15
R
Usage Indicator
1
1
ID
Valid Values: P (Production data), T (Test data)
P = Production. T = Test
ISA16
R
Component Element Separator
1
1
***
Used to separate component data elements
within a composite data structure. This value
must be different than the data element
separator and the segment terminator
Colon (:)
GS01
GS02
R
R
Functional ID Code
Application Sender's Code
2
2
2
15
ID
AN
GS03
GS04
R
R
Application Receiver's Code
Date
2
8
15
8
AN
DT
Format: CCYYMMDD; functional group
creation date
GS05
R
Time
4
8
TM
Formats: HHMM (recommended), HHMMSS,
HHMMSSD, HHMMSSDD
1
Valid Values: 01 (Duns), 14 (Duns plus suffix),
20 (HIN), 27 (HCFA carrier ID), 28 (HCFA - fiscal
intermediary ID), 29 (Medicare provider and
supplier ID), 30 (US Fed Tax ID), 33 (NAIC), ZZ
(Mutually defined)
Valid Value: HC (Health Care Claim (837)
Submitter ID assigned by Colorado
Access
ZZ
COA
Date of Tansmission
YYMMDD
Time of Transmission
HHMM
^
00501
Begins with 000000001 amd
increments +1 for each subsequent file
created each day. Resets each day.
1
GS
HC
Submitter ID assigned by Colorado
Access
COA
Creat Date
CCYYMMDD
Create Time
HHMM
101
Header
1
GS06
R
Group Control No.
1
9
N0
Numeric. Must match GE02
GS07
R
Responsible Agency Code
1
2
ID
Valid Value: X (Accredited Standards
Committee X12)
GS08
R
Version/Release/Industry ID
Code
1
12
AN
Valid Value: 005010X223
R
ST
BHT
R
R
1
ST01
ST02
R
R
ST03
R
1
Header
Transaction Set Identifier Code
Transaction Set Control Number
Implementation Convention
Release
3
4
3
9
ID
AN
1
35
AN
Beginning of Hierarchical
Transaction
Header
Valid Value: 837 (Health Care Claim)
Must match value in SE02 Transaction Set
Control Number. The number must be unique
within the specified functional group (GS-SE)
and interchange(ISA-IEA) but can repeat in
other groups and interchanges
Valid Value: 005010X223
Begins with 1 amd increments +2 for
each subsequent GS within the file.
Resets bavck to 1 for each new file.
X
005010X223A2
ST
837
Begins with 0001 amd omcrements +1
tor each subsequent ST within the GS.
Resets back to 0001 for each new file.
005010X223A2
Beginning of Hierarchical Transaction
BHT
0019
BHT01
R
Hierarchical Structure Code
4
4
ID
Valid Value: 0019 ( Information Source,
Subscriber, Dependent)
BHT02
R
Transaction Set Purpose Code
2
2
ID
Valid Values: 00 (Original - indicates the first
time the transaction is sent), 18 (Reissue)
00
BHT03
R
Originator Application
Transaction Identifier
1
50
AN
To identify the inventory file number of the
tape or transmission assigned by submitter
Begins with 1 and increments +1 for
each subsequent BHT within the ST.
Resets back to 1 with each new file.
BHT04
R
Transaction Set Creation Date
8
8
DT
Format: CCYYMMDD (Identifies the date that
the submitter created the file)
BHT05
R
Transaction Set Creation Time
4
8
TM
Format: HHMMSS, HHMM, HHMMSSD,
HHMMSSDD
BHT06
R
Claim or Encounter Identifier
2
2
ID
Valid Values: 31 (Subrogation Demand), CH
(Chargeable-contains Fee-for-Service claims or
at least one chargeable line), RP (Reportingsending to entity for purposes other than
claim adjudication). If unsure if transaction is
claim or encounter, submit as a claim.
CCYYMMDD
HHMM
CH
102
1000A
1
R
NM1
PER
R
R
1
NM101
NM102
R
R
NM103
R
NM104
NM105
NM106
NM107
NM108
S
S
NU
NU
R
NM109
R
NM110
NM111
NM112
NU
NU
NU
2
Submitter Name
Submitter Name
16
2
1
291
3
1
ID
ID
Submitter Last or Organization
Name
1
60
AN
Submitter First Name
Submitter Middle Name
Name Prefix
Name Suffix
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Submitter Identifier
2
80
AN
Name Last Or Organization
2
2
1
2
3
60
ID
ID
AN
Submitter EDI Contact
Information
13
328
Submitter Name
Submitter Name
Valid Value: 41 (Submitter)
Valid Value: 1 (Person), 2 (Non-Person Entity)
NM1
41
2
Submitter Last or Organization Name
Required if NM102=1
Not Used
Not Used
Identification Number - ETIN)
Not Used
Not Used
Not Used
Submitter EDI Contact Information
Leave blank
Leave blank
Leave blank
Leave blank
46
Submitter Id assigned by Colorado
Access
Leave blank
Leave blank
Leave blank
PER
PER01
PER02
PER03
R
S
R
Qualifier
2
1
2
2
60
2
ID
AN
ID
PER04
R
1
80
AN
Complete communications number including
country or area code when applicable
PER05
S
Qualifier
2
2
ID
(Telephone)
FX
PER06
PER07
S
S
Qualifier
1
2
80
2
AN
ID
See PER04
(Telephone)
Submitter Fax Number
EM
PER08
PER09
S
NU
1
1
80
20
AN
AN
See PER04
Not Used
IC
TE
Submitter Phone Number
Submitter Email Address
Leave blank
103
1000B
1
R
NM1
2000A
>1
R
1
NM101
NM102
NM103
NM104
NM105
NM106
NM107
NM108
R
R
R
NU
NU
NU
NU
R
NM109
NM110
NM111
NM112
R
NU
NU
NU
R
HL
PRV
R
S
1
HL01
R
HL02
HL03
HL04
NU
R
R
1
Receiver Name
Receiver Name
Receiver Name
Name First
Name Middle
Name Prefix
Name Suffix
Information Receiver
Identification Number
Receiver Primary Identifier
Name
15
2
1
1
1
1
1
1
1
231
3
1
60
35
25
10
10
2
ID
ID
AN
AN
AN
AN
AN
ID
2
2
2
1
80
2
3
60
AN
ID
ID
ID
Receiver Name
Receiver Name
Valid Value: 40 (Receiver)
Not Used
Not Used
Not Used
Not Used
Identification Number - ETIN)
Not Used
Not Used
Not Used
Hierarchical Level
Billing/Pay-To Provider Hierarchical Level
Hierarchical Level
Billing/Pay-To Provider Hierarchical Level
NM1
40
2
COA
Leave blank
Leave blank
Leave blank
Leave blank
46
COA
Leave blank
Leave blank
Leave blank
HL
1
12
AN
Must begin with "1" and increment by one for
each HL used. Only Numeric values are
allowed.
Must begin with '1'. Increment for
each servicing provider. Possible to
include this record for each claim.
1
1
1
12
2
1
AN
ID
ID
Not Used
Valid value: 20 (Information Source)
Valid Value: 1 (Additional Subordinate HL data
segment in this hierarchical structure)
Leave blank
20
1
Billing/Pay-To Provider Specialty Information.
Required when adjudication known to be
impacted by provider taxonomy code and
service facility provider is same as billing
and/or pay-to provider.
Colorado Access does not use this
segment.
segment.
segment.
Billing/Pay-To Provider Specialty
Information
PRV01
R
Provider Code
1
3
ID
Valid Values: B (Billing)
PRV02
R
Qualifier
2
3
ID
Taxonomy Code)
PRV03
R
1
50
AN
104
CUR
S
PRV04
NU
PRV05
NU
PRV06
NU
1
segment.
segment.
segment.
2
2
ID
Not Used
***
***
***
Not Used
3
3
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
CUR01
R
2
3
ID
CUR02
R
Currency Code
3
3
ID
Not mapped to a field.
CUR03
NU
Exchange Rate
4
10
R
Not Used
CUR04
NU
2
3
ID
Not Used
CUR05
NU
Currency Code
3
3
ID
Not Used
CUR06
NU
Currency Market/Exchange
Code
3
3
ID
Not Used
CUR07
NU
Date/Time Qualifier
3
3
ID
Not Used
CUR08
NU
Date
8
8
DT
Not Used
CUR09
NU
Time
4
8
TM
Not Used
CUR10
NU
Date/Time Qualifier
3
3
ID
Not Used
CUR11
NU
Date
8
8
DT
Not Used
CUR12
NU
Time
4
8
TM
Not Used
CUR13
NU
Date/Time Qualifier
3
3
ID
Not Used
CUR14
NU
Date
8
8
DT
Not Used
CUR15
NU
Time
4
8
TM
Not Used
CUR16
NU
Date/Time Qualifier
3
3
ID
Not Used
CUR17
NU
Date
8
8
DT
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
105
2010AA
1
CUR18
NU
Time
4
8
TM
Not Used
CUR19
NU
Date/Time Qualifier
3
3
ID
Not Used
CUR20
NU
Date
8
8
DT
Not Used
CUR21
NU
Time
4
8
TM
Not Used
Billing Provider Last or
Organizational Name
15
2
1
1
231
3
1
60
ID
ID
AN
Valid Value: 85 (Billing Provider )
Billing Provider Last or Organizational Name
R
NM1
N3
N4
R
R
R
1
NM101
NM102
NM103
R
R
R
NM104
NM105
NM106
NM107
NM108
NM109
NU
NU
NU
NU
S
S
Name First
Name Middle
Name Prefix
Name Suffix
Billing Provider Identifier
1
1
1
1
1
2
35
25
10
10
2
80
AN
AN
AN
AN
ID
AN
Not Used
Not Used
Not Used
Not Used
If qualifier is "24", Federal Tax Number or EIN.
NM110
NM111
NM112
NU
NU
NU
Name
2
2
1
2
3
60
ID
ID
ID
Not Used
Not Used
Not Used
N301
N302
R
S
Billing Provider Address Line 1
2
1
1
110
55
55
AN
AN
Billing Provider City/State/ZIP
Code
11
82
1
1
Billing Provider City/State/ZIP Code
segment.
segment.
segment.
segment.
NM1
85
2
Billing Provider Last or Organizational
Name
Leave blank
Leave blank
Leave blank
Leave blank
XX
Billing Provider NPI #
Leave blank
Leave blank
Leave blank
N3
N4
N401
N402
R
S
Billing Provider State or
Province Code
2
2
30
2
AN
ID
Billing Provider State or Province Code
N403
S
Billing Provider Postal Zone or
Zip Code
3
15
ID
Billing Provider Postal Zone or Zip
Code
N404
N405
S
NU
Country Code
Location Qualifier
2
1
3
2
ID
ID
Required when outside U.S.
Not Used
Country Code
Leave blank
106
N406
N407
REF
PER
2010AB
1
S
S
NU
S
1
REF01
R
REF02
R
REF03
REF04
NU
NU
2
Location Identifier
1
1
30
3
AN
ID
Identification
Qualifier
4
133
2
3
ID
Valid Values: EI (Employer's Identification #)
Billing Provider Additional
Identifier
1
50
AN
Dependent upon Qualifier, map to Medicare
Provider Number, Medicaid Provider Number,
CHAMPUS Identification Number, Blue Shield
Provider Number, Other Provider Number
Description
1
***
80
***
AN
***
Not Used
Not Used
Billing Provider Contact
Information
13
856
Billing Provider Secondary Identification
PER01
PER02
PER03
R
S
R
Qualifier
2
1
2
2
60
2
ID
AN
ID
PER04
PER05
R
S
Qualifier
1
2
256
2
AN
ID
PER06
PER07
S
S
Qualifier
1
2
256
2
AN
ID
PER08
PER09
S
NU
1
1
256
20
AN
AN
S
NM1
S
1
NM101
R
Not Used
Not Used
15
231
2
3
EI
Billing Provider's TIN
Leave blank
Leave blank
REF
IC
Office Manager for Provider
TE
(Telephone)
(Telephone)
Not Used
ID
REF
Billing Provider Contact Information
Leave blank
Leave blank
Valid Value: 87 (Pay-to Provider )
Office Manager 's Telephone
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
segment.
segment.
segment.
107
N3
N4
R
R
NM102
R
1
1
ID
NM103
NU
Pay-to Provider Last or
Organizational Name
1
60
AN
Not Used
NM104
NU
Name First
1
35
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Pay-to Provider Identifier
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
2
110
1
N301
R
Pay-to Provider Address Line 1
1
55
AN
N302
S
1
55
AN
Pay-To Provider City/State/ZIP
Code
11
82
1
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
Pay-To Provider City/State/ZIP Code
segment.
segment.
segment.
segment.
N401
R
Pay-to Provider City Name
2
30
AN
Pay-to Provider City Name
N402
S
Pay-to Provider State Code
2
2
ID
Pay-to Provider State Code
N403
S
Pay-to Provider Postal Zone or
Zip Code
3
15
ID
Pay-to Provider Postal Zone or Zip Code
N404
S
Pay-to Provider Country Code
2
3
ID
Pay-to Provider Country Code
N405
NU
Location Qualifier
1
2
ID
Not Used
N406
NU
Location Identifier
1
30
AN
Not Used
segment.
segment.
108
N407
2010AC
1
S
S
NM1
N3
S
R
1
1
3
ID
Not Used
Pay-To-Plan Name
Pay-To-Plan Name
Pay-To-Plan Name
Pay-To-Plan Name
NM101
R
2
3
Valid Value: PB (Payee)
NM102
R
1
1
NM103
R
Name
1
60
Pay-to-Plan Organization Name
NM104
NU
Name First
1
35
Not Used
NM105
NU
Name Middle
1
25
Not Used
NM106
NU
Name Prefix
1
10
Not Used
NM107
NU
Name Suffix
1
10
Not Used
NM108
R
1
2
Valid Value: PI (Payor Identification), XV
(Center for Medicate and Medicaid Services
PlanID)
NM109
R
Identification Code
2
80
Not Used
NM110
NU
2
2
Not Used
NM111
NU
2
3
Not Used
NM112
NU
Name
1
60
1
ID
Pay-To-Plan Address
Not Used
Pay-To-Plan Address
N301
R
Pay-To-Plan Address Line 1
1
55
AN
N302
S
1
55
AN
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
109
N4
REF
REF
2000B
>1
R
R
S
R
1
Pay-To-Plan City/State/ZIP Code
Pay-To-Plan City/State/ZIP Code
N401
R
Pay-To-Plan City Name
2
30
AN
N402
S
Pay-To-Plan State Code
2
2
ID
N403
S
Pay-To-Plan Postal Zone or Zip
Code
3
15
ID
N404
S
Pay-To-Plan Country Code
2
3
ID
N405
NU
Location Qualifier
1
2
ID
Not Used
N406
NU
Location Identifier
1
30
AN
Not Used
N407
S
1
3
ID
Not Used
1
Pay-To-Plan Secondary
Identification
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
Pay-To-Plan Secondary Identification
segment.
REF01
R
Qualifier
2
3
ID
Commissioners (NAIC) Code
segment.
REF02
R
1
50
AN
Pay-To-Plan Secondary Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
Pay-To-Plan Tax Identification
Number
Pay-To-Plan Tax Identification Number
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: EI (Employer's Identification
Number)
segment.
REF02
R
1
50
AN
Pay-To-Plan Tax Identifier Number
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
110
HL
SBR
R
R
1
HL01
R
1
12
AN
HL02
HL03
HL04
R
R
R
1
1
1
12
2
1
AN
ID
ID
SBR01
R
Number Code
1
1
ID
SBR02
SBR03
S
S
2
1
2
50
ID
AN
Valid Value: 18 (Self)
18
Leave blank
SBR04
S
Insured Group Name
1
60
AN
Use only when no group number reported in
SBR03
Leave blank
SBR05
SBR06
SBR07
NU
NU
NU
Insurance Type Code
Yes/No or Condition Response
Code
1
1
1
3
1
1
ID
ID
ID
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
SBR08
NU
2
2
ID
Not Used
Leave blank
1
Unique Number Assigned by sender
Valid Value: 22 (Subscriber)
Valid Values: 0 (No subordinate HL segment in
this hierarchical structure), 1 (Additional
subordinate HL data segment in this
hierarchical structure
Valid Values: A (Payer Responsibility Four), B
(Payer Responsibility Five), C (Payer
Seven), E (Payer Responsibility Eight), F (Payer
Responsibility Nine),G (Payer Responsibility
Ten), H (Payer Responsibility Eleven), P
(Primary), S (Secondary), T (Tertiary-payer of
last resort), U (Unknown)
HL
Increments =1 from previous HL
segment
Must = HL01 from previous Liip 2000A
22
0
SBR
P
111
SBR09
2010BA
1
S
NM101
NM102
R
R
Subscriber Name
Subscriber Name
2
1
3
1
ID
ID
NM103
NM104
NM105
NM106
NM107
NM108
R
S
S
NU
S
R
Subscriber First Name
Subscriber Middle Name
Name Prefix
Name Suffix
1
1
1
1
1
1
60
35
25
10
10
2
AN
AN
AN
AN
AN
ID
NM109
R
Subscriber Primary Identifier
2
80
AN
R
NM1
R
1
1
2
ID
Health Risk Organization (HMO) Medicare
Risk), AM (Automobile Medical), BL (Blue
(Commercial Insurance), DS (Disability), HM
(Health Maintenance Organization), LM
(Liability Medical), MA (Medicare Part A), MB
Federal Program), TV (Title V), VA (Veteran
Defined). Use "ZZ" if HIPAA Individual
Identifier is mandated otherwise the MI
Qualifier is used.
Subscriber Name
Subscriber Name
Required when NM102 =1
Not Used
Identifier for each Individual in the States, MI
Leave blank
NM1
IL
1
Member's Last Name
Member's First Name
Member's Middle Name
Leave blank
Leave blank
MI
Memver id assigned by Colorado
Access
or
Medicard State ID = 7 character CO
Medicaid Client ID (1 aplha followede
by 6 numveric)
or
112
Chile Health Plan Plus = SSN
NM110
NM111
NM112
N3
S
1
DMG
R
S
Name
2
2
1
2
3
60
ID
ID
ID
Subscriber Address
N301
N302
N4
NU
NU
NU
R
S
1
Subscriber Address Line 1
Subscriber Address. Required when patient is
same as the subscriber
1
1
55
55
AN
AN
Subscriber City/State/ZIP Code
N401
N402
N403
R
S
R
N404
N405
N406
N407
S
NU
NU
S
1
Not Used
Not Used
Not Used
Subscriber City/State/ZIP Code. Required
when patient is same as the subscriber.
Subscriber Postal Zone or Zip
Code
2
2
3
30
2
15
AN
ID
ID
Subscriber Postal Zone or Zip Code
Country Code
Location Qualifier
Location Identifier
2
1
1
1
3
2
30
3
ID
ID
AN
ID
Country Code
Not Used
Not Used
Not Used
Subscriber Demographic
Information
Subscriber Demographic Information
DMG01
R
Qualifier
2
3
ID
DMG02
DMG03
R
R
Subscriber Birth Date
Subscriber Gender Code
1
1
35
1
AN
ID
DMG04
DMG05
DMG06
DMG07
NU
NU
NU
NU
Marital Status Code
Country Code
1
1
1
2
1
1
2
3
ID
ID
ID
ID
Valid Values: M (Male), F (Female), U
(Unknown).
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
N3
N4
Subscriber Postal Zone or Zip Code
Country Code
Leave blank
Leave blank
Leave blank
DMG
D8
Member's DOB
M, F, or U
Leave blank
Leave blank
Leave blank
Leave blank
113
DMG08
DMG09
REF
REF
2010BB
1
S
S
NU
NU
1
R
1
1
2
15
ID
R
Subscriber Secondary
Identification
Not Used
Not Used
Colorado Access does not used this
segment.
Valid Values: SY (Social Security Number - SSN
may NOT be used for Medicare)
segment.
R
Qualifier
2
3
ID
REF02
R
Subscriber Supplemental
Identifier
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
1
Number
Leave blank
Leave blank
Subscriber Secondary Identification
REF01
segment.
segment.
segment.
Property and Casualty Claim Number
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
Number
1
30
AN
segment.
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
NM101
NM102
NM103
NM104
NM105
NM106
NM107
NM108
R
R
R
NU
NU
NU
NU
R
Payer Name
Payer Name
Payer Name
Name First
Name Middle
Name Prefix
Name Suffix
2
1
1
1
1
1
1
1
3
1
60
35
25
10
10
2
ID
ID
AN
AN
AN
AN
AN
ID
NM109
NM110
R
NU
Payer Identifier
2
2
80
2
AN
ID
R
NM1
Quantity
1
Payer Name
Payer Name
Not Used
Not Used
Not Used
Not Used
(Healthcare Financing Administration National
PlanID)
Payer Identifier
Not Used
NM1
PR
2
Colorado Access
Leave blank
Leave blank
Leave blank
Leave blank
PI
COA
Leave blank
114
N3
N4
REF
S
S
S
NM111
NM112
NU
NU
N301
R
N302
S
1
1
Name
2
1
3
60
ID
ID
Not Used
Not Used
Payer Address
Payer Address Line 1
1
55
AN
Payer Address
1
55
AN
N401
R
Payer City Name
2
30
AN
N402
S
Payer State Code
2
2
ID
N403
S
Payer Postal Zone or Zip Code
3
15
ID
N404
S
Payer Country Code
2
3
ID
N405
NU
Location Qualifier
1
2
ID
Not Used
N406
NU
Location Identifier
1
30
AN
Not Used
N407
S
1
3
ID
Required when the address is not in the US,
including its territories, or Canada, and the
country in N404 has administrative
provinces, cantons, etc. If not required, do not
send.
3
REF01
R
Qualifier
2
3
ID
REF02
R
Payer Additional Identifier
1
50
AN
REF03
NU
Description
1
80
AN
Commissioners Code)
Not Used
Leave blank
Leave blank
N3
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
115
REF04
REF
2000C
>1
S
NU
1
PAT
S
R
***
***
***
Information
Not Used
segment.
Billing Provider Secondary Information
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
Payer Additional Identifier
1
50
AN
Billing Provider Secondary Information
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
S
HL
1
HL01
R
1
12
AN
structure
HL02
R
1
12
AN
Next higher Hierarchical data segment
HL03
R
1
2
ID
Valid Value: 23 (Dependent)
HL04
R
1
1
ID
Valid Value: 0 (No subordinate HL segment in
this hierarchical structure)
1
Patient Information
PAT01
R
PAT02
Patient Information
Patient's Relationship to Insured
2
2
ID
Valid Values: 01 (Spouse), 19 (Child), 20
(Employee), 21 (Unknown), 39 (Organ Donor),
40 (Cadaver Donor), 53 (Life Partner), G8
(Other Relationship)
NU
1
1
ID
Not Used
PAT03
NU
2
2
ID
Not Used
PAT04
NU
Student Status Code
1
1
ID
Not Used
PAT05
NU
Qualifier
2
3
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
116
2010CA
1
PAT06
NU
Date Time Period
1
35
AN
Not Used
PAT07
NU
Code
2
2
ID
Not Used
PAT08
NU
Patient Weight
1
10
R
Not Used
PAT09
NU
Pregnancy Indicator
1
1
ID
Not Used
S
NM1
N3
N4
R
R
R
1
NM101
NM102
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
R
R
R
S
S
NU
S
NU
NU
NU
NU
NU
N301
N302
R
S
N401
N402
N403
N404
N405
N406
N407
R
S
S
S
NU
NU
S
1
1
Patient Name
Patient Name
Patient Last Name
Patient First Name
Patient Middle Name
Name Prefix
Patient Name Suffix
Patient Primary Identifier
Name
2
1
1
1
1
1
1
1
2
2
2
1
3
1
60
35
25
10
10
2
80
2
3
60
ID
ID
AN
AN
AN
AN
AN
ID
AN
ID
ID
ID
Patient Address
Patient Address Line 1
1
1
55
55
AN
AN
Patient City Name
Patient State Code
Patient Postal Zone or Zip Code
Country Code
Location Qualifier
Location Identifier
2
2
3
2
1
1
1
30
2
15
3
2
30
3
AN
ID
ID
ID
ID
AN
ID
Patient Name
Patient Name
Valid Value: QC (Patient)
segment.
segment.
segment.
segment.
segment.
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
NM1
QC
1
Patient Last Name
Patient First Name
Patient Middle Name
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Patient Address
N3
Required when outside the U.S.
Not Used
Not Used
Not Used
N4
Patient City Name
Patient State Code
Patient Postal Zone or Zip Code
Country Code
Leave blank
Leave blank
Leave blank
117
DMG
REF
2300
100
R
S
1
Patient Demographic
Information
Patient Demographic Information
DMG01
R
Qualifier
2
3
ID
DMG02
DMG03
R
R
Patient Birth Date
Patient Gender Code
1
1
35
1
AN
ID
Format: CCYYMMDD
(Unknown)
DMG04
DMG05
DMG06
DMG07
DMG08
DMG09
DMG10
DMG11
NU
NU
NU
NU
NU
NU
NU
NU
Marital Status Code
Country Code
Quantity
Industry Code
1
1
1
2
1
1
1
1
1
1
2
3
2
15
3
30
ID
ID
ID
ID
ID
R
ID
AN
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
1
Number
CLM
R
segment.
2
3
ID
REF02
R
Number
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
CLM01
R
CLM02
CLM03
CLM04
R
NU
NU
Claim Information
Patient Account Number
Total Claim Charge Amount
Non-Institutional Claim Type
Code
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Qualifier
1
Patient Birth Date
F, M, U
segment.
R
Claim Information
D8
REF01
R
DMG
segment.
Claim Information
1
38
AN
Claim Information
Maximum field size is 38 however only 20
bytes required to store/placed on outgoing
transaction.
1
1
1
18
2
2
R
ID
ID
Zero may be a valid amount
Not Used
Not Used
segment.
segment.
Each occurrence of this loop will
represent one claim.
CLM
Patient's Account Number assigned by
the Provider
Total Claim Amount
Leave blank
Leave blank
118
CLM05
R
Health Care Service Location
Information Composite
*
*
*
SEE CLM05-_ below
CLM0501
R
Facility Type Code
1
2
AN
First 2 positions of UB type of bill (Reference 4)
or Place of Service Code from NSF format.
Appendix A
CLM0502
R
Facility Code Qualifier
1
2
ID
Valid Value: A (Uniform Billing Claim Form Bill
Type).
A
CLM0503
R
Claim Frequency Code
1
1
ID
This is the third position of the Uniform Claim
Bill Type.
Appendix A
CLM06
NU
Provider or Supplier Signature
Indicator
1
1
ID
Not Used
Leave blank
CLM07
R
Medicare Assignment Code
1
1
ID
Valid Values: A (Assigned), b (Assignment
Accepted on Clinical Lab Services Only), C (Not
Assigned)
Leave blank
CLM08
R
Benefits Assignment
Certification Indicator
1
1
ID
Valid Values: N (No, benefits are not assigned),
W (Not Applicable), Y (Yes, benefits are
assigned),
Y
CLM09
R
1
1
ID
Valid Values: N (No), W (No applicable), Y (Yes,
Provider has a Signed Statement for Release of
Info)
N (No), W (No applicable), Y (Yes,
Provider has a Signed Statement for
Release of Info)
CLM10
CLM11
CLM12
CLM13
NU
NU
NU
NU
Related Causes Information
Special Program Indicator
Code
1
*
2
1
1
*
3
1
ID
*
ID
ID
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
CLM14
CLM15
NU
NU
Level of Service Code
Code
1
1
3
1
ID
ID
Not Used
Not Used
Leave blank
Leave blank
CLM16
CLM17
CLM18
NU
NU
NU
Claim Status Code
Explanation of Benefits Indicator
1
1
1
1
2
1
ID
ID
ID
Not Used
Not Used
Valid Values: Y (Paper EOB is requested), N (No
paper EOB is requested)
Leave blank
Leave blank
Leave blank
CLM19
NU
2
2
ID
Not Used
Leave blank
119
CLM20
DTP
DTP
DTP
DTP
S
R
S
S
S
1
Delay Reason Code
1
2
ID
Discharge Hour
Valid Values: 1 (Proof of Eligibility Unknown), 2
(Litigation), 3 (Authorization Delays), 4 (Delay
in Certifying Provider), 5 (Delay in Supplying
Billing Forms), 6 (Delay in Delivery of Custommade Appliances), 7 (Third Party Processing
Delay), 8 (Delay in Eligibility Determination), 9
(Original Claim Rejected or Denied/Unrelated
to Billing Limitation Rules), 10 (Administration
Delay in Prior Approval Process), 11 (Other), 15
(Natural Disaster). Required if claim
submitted late and any of these codes apply.
Discharge Hour. Required on all final
inpatient claims/encounters
DTP
096
TM
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 096 (Discharge)
Valid Value: TM (Time Expressed in Format:
HHMM)
DTP03
R
Date Time Period
1
35
AN
Discharge Hour
DTP01
DTP02
R
R
Statement Dates
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Statement Dates
Valid Value: 434 (Statement)
Valid Values: RD8 (CCYYMMDDCCYYMMDD)
DTP03
R
Date Time Period
1
35
AN
Statement From or To Date
1
1
Admission Date/Hour
DTP
434
RD8
Statement From or To Date
DTP
435
DTP
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 435 (Admission)
Valid Value: DT (Date/Time Expressed in
Format: CCYYMMDDHHMM)
DTP03
R
Date Time Period
1
35
AN
Admission Date and Hour
Repricer Received Date
Patient Discharge Hour
Admission Date/Hour. Required on all
Inpatient Claims
DTP01
DTP02
1
Leave blank
Repricer Received Date. Required when a
repricer is passing the claim onto the payer
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 050 (Received)
Valid Values: D8 (CCYYMMDD)
DTP03
R
Date Time Period
1
35
AN
DTP
120
CL1
PWK
R
S
1
10
Institutional Claim Code
Institutional Claim Code. This segment
required on all hospital based admission and
Medicare outpatient registrations on
claims/encounters
CL101
S
Admission Type Code
1
1
ID
Required when patient being admitted to
hospital for inpatient services
CL102
S
Admission Source Code
1
1
ID
Required for all inpatient admissions.
Required on Medicare outpatient registrations
for diagnostic testing services.
CL103
R
Patient Status Code
1
2
ID
Required for inpatient claims/encounters
CL104
NU
Nursing Home Residential Status
Code
1
1
ID
Not Used
Claim Supplemental Information
Claim Supplemental Information
CL1
Appendix B
Admission Type Codes
Appendix B
Addmission Source Codes
Appendix B
Patient Status Code
Leave blank
segment.
121
PWK01
R
2
2
ID
Valid Values: 03 (Report Justifying Treatment
Beyond Utilization Guidelines), 04 (Drugs
Analysis), 13 (Certified Test Report), 15
(Justification for Admission), 21 (Recovery
Plan), A3 (Allergies/Sensitivities Document),
A4 (Autopsy Report), AM (Ambulance
Certification), AS (Admission Summary), B2
(Prescription), B3 (Physician Order), B4
(Consent Form), CT (Certification), D2 (Drug
Profile Document), DA (Dental Models), DB
(Durable Medical Equipment Prescription), DG
(Diagnostic Report), DS (Discharge Summary),
EB (Explanation of Benefits), HC (Health
Certificate), HR (Health Clinic Records), I5
(Immunization Record), IR (State School
Immunization Records), LA (Laboratory
Results), M1 (Medical Records Attachment),
MT (Models), NN (Nursing Notes), OB
(Operative Note),
segment.
122
CN1
S
1
PWK02
R
PWK03
OC (Oxygen Content Averaging Report), OD
(Order and Treatments Document), OE
(Objective Physical Examination (including vital
signs) Document), OX (Oxygen Therapy
Certification), OZ (Support Data for Claim), P4
(Pathology Report), P5 (patient medical
History Document), PE (Parenteral or Enteral
(Prosthetic or Orthotic Certification), PQ
(Paramedical Results), PY (Physician’s Report),
PZ (Physical Therapy Certification), RB
(Radiology Films), RR (Radiology Reports), RT
(Report of Tests and Analysis Report), RX
(Renewable Oxygen Content Averaging
Report), SG (Symptoms Document), V5 (Death
Notification), XP (Photographs)
Valid Values: AA (Available Upon Request), BM
(By Mail), EL (Electronically Only), EM (Email),
FT (File Transfer), FX (By Fax)
segment.
segment.
Attachment Transmission Code
1
2
ID
NU
1
2
N0
Not Used
PWK04
NU
2
3
ID
Not Used
PWK05
S
1
2
ID
Valid Value: AC (Attachment Control Number).
Required when PWK02 is not "AA".
segment.
segment.
segment.
PWK06
S
Attachment Control Number
2
80
AN
Required if PWK02 = "BM", "EL", "EM", "FT" or
"FX"
segment.
PWK07
NU
Description
1
80
AN
PWK08
NU
Actions Indicated
***
***
***
Not Used
PWK09
NU
1
2
ID
Not Used
segment.
segment.
segment.
segment.
123
AMT
REF
S
S
CN101
R
Contract Type Code
2
2
ID
Valid Values: 01 (Diagnosis Related GroupDRG), 02 (Per Diem), 03 (Variable Per Diem),
04 (Flat), 05 (Capitated), 06 (Percent), 09
(Other)
segment.
CN102
S
Contract Amount
1
18
R
Required if provider is contractually obligated
to include info on the claim
segment.
CN103
S
Contract Percentage
1
6
R
segment.
CN104
S
Contract Code
1
50
AN
segment.
CN105
S
1
6
R
segment.
CN106
S
Contract Version Identifier
1
30
AN
segment.
Patient Estimated Amount Due. Required
when Patient Responsibility Amount applies to
claim.
segment.
1
Patient Estimated Amount Due
AMT01
R
1
3
ID
Valid Value: F3 (Patient Responsibility Estimated)
segment.
AMT02
R
Monetary Amount
1
18
R
Patient Responsibility Amount
AMT03
NU
1
1
ID
Not Used
segment.
segment.
1
Service Authorization Exception
Code
Service Authorization Exception Code
segment.
REF01
R
Qualifier
2
3
ID
Valid Value: 4N (Special Payment Reference
Number)
segment.
REF02
R
Service Authorization Exception
Code
1
50
AN
Valid Values: 1 (Immediate/Urgent Care), 2
(Services Rendered in a Retroactive Period), 3
(Emergency Care), 4 (Client as Temporary
Medicaid), 5 (Request from Country for
Second Opinion to Recipient Can Work), 6
(Request for Override Pending), 7 (Special
Handling)
segment.
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
124
REF
REF
REF
REF
S
S
S
S
1
Referral Number
REF01
R
Qualifier
2
3
ID
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
AN
AN
***
1
Prior Authorization
REF01
R
Qualifier
2
3
ID
REF02
REF03
REF04
R
NU
NU
Description
1
1
***
50
80
***
AN
AN
***
1
Referral Number. Required where services on
claim where a referral is involved.
REF
9F
Referral Number
Not Used
Not Used
Prior Authorization. Required where services
on claim where pre-authorized is involved.
REF
Valid Values: G1 (Prior Authorization Number)
G1
Not Used
Not Used
REF01
R
Qualifier
2
3
ID
Valid Values: 9A (Repriced Claim Reference
Number)
REF02
R
1
50
AN
Repriced Claim Reference Number
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
1
Adjusted Repriced Claim
Number
Referral Number
Leave blank
Leave blank
Leave blank
Leave blank
segment.
segment.
segment.
segment.
segment.
Adjusted Repriced Claim Number
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: 9C (Adjusted Repriced Claim
Reference Number)
segment.
REF02
R
1
50
AN
Adjusted Repriced Claim Reference Number
REF03
NU
Description
1
80
AN
Not Used
segment.
segment.
125
REF04
REF
REF
REF
REF
S
S
S
S
NU
5
***
***
***
Investigational Device
Exemption Number
Not Used
segment.
Investigational Device Exemption Number
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: LX (Qualified Products List)
segment.
REF02
R
1
50
AN
Investigational Device Exemption Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
Claims Identifier For
Transmission Intermediaries
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: S9 (Claim Number)
segment.
REF02
R
1
50
AN
Value Added Network Trace Number
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
Auto Accident State
Auto Accident State
REF01
R
Qualifier
2
3
ID
Valid Values: LU (Location Number)
REF02
R
1
50
AN
Auto Accident State or Province Code
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
REF01
R
Qualifier
2
3
ID
Valid Value: EA (Medical Record Identification
Number)
REF02
REF03
R
NU
Description
1
1
50
80
AN
AN
Not Used
1
segment.
segment.
segment.
segment.
segment.
REF
EA
Leave blank
126
REF04
REF
REF
K3
NTE
S
S
S
S
NU
1
***
***
***
Not Used
Leave blank
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
Peer Review Organization (PRO)
Approval Number
Peer Review Organization (PRO) Approval
Number. Required when external Peer
Review Organization assigns an Approval
Number to services deemed medically
necessary by that organization.
segment.
REF01
R
Qualifier
2
3
ID
Valid Value: G4 (Peer Review Organization
Review Number)
segment.
REF02
R
1
50
AN
Peer Review Authorization Number
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
10
10
File Information
K301
R
K302
K303
File Information
1
80
AN
NU
Record Format Code
1
2
ID
Not Used
NU
***
***
***
Not Used
Claim Note
Claim Note. Required when provider deems
necessary. (Free form comments discouraged)
segment.
segment.
segment.
segment.
segment.
127
NTE
CRC
S
S
NTE01
R
Note Reference Code
3
3
ID
NTE02
R
Claim Note Text
1
80
AN
1
Billing Note
R
Note Reference Code
3
3
ID
NTE02
R
Billing Note Text
1
80
AN
EPSDT Referral
segment.
segment.
Billing Note
NTE01
1
Valid Values: ALG (Allergies), DCP (Goals,
Rehab Potential or Discharge Plans), DGN
(Diagnosis Description), DME (Durable Medical
Equipment and Supplies), MED (Medications),
NTR (Nutritional Requirements), ODT (Orders
for Disciplines and Treatments), RHB
(Functional Limitations, Reason Homebound or
Both), RLH (Reasons Patient Leaves Homes),
RNH (Times and Reasons Patient Not at
Home), SET (Unusual Home, Social
Environment or Both), SFM (Safety Measures),
SPT (Supplementary Plan of Treatment), UPI
(Updated Information)
Valid Value: ADD (Additional Information)
EPSDT Referral
segment.
segment.
segment.
segment.
segment.
segment.
CRC01
R
Code Category
2
2
ID
Valid Value: ZZ (Mutually Defined)
CRC02
R
Certification Condition Code
Applies Indicator
1
1
ID
Valid Values: N (If No, then choose NU in
CRC03indicating no referral given), Y (Yes)
CRC03
R
Mental Status Code
2
2
ID
Valid Values: AV (Available - Not Used), NU
(Not Used), S2 (Under Treatment), ST (New
Services Requested)
segment.
CRC04
S
Mental Status Code
2
2
ID
See CRC03 values
CRC05
S
Mental Status Code
2
2
ID
See CRC03 values
CRC06
NU
Mental Status Code
2
2
ID
Not Used
CRC07
NU
Mental Status Code
2
2
ID
Not Used
segment.
segment.
segment.
segment.
128
HI
R
1
Principal Diagnosis Information
Principal Diagnosis Information
Required when claim involves an inpatient
admission.
HI
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Value: ABK (International Classification
of Diseases Clinical Modification (ICD-10-CM)
Principal Diagnosis), BK (International
Classification of Diseases Clinical Modification
(ICD-9-CM) Principal Diagnosis)
HI0102
HI0103
R
Industry Code
1
30
AN
Principal Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
Valid Values: N (No), U (Unknown), W (Not
Applicable), Y (Yes)
HI02
HI03
HI04
HI05
HI06
HI07
HI08
HI09
HI10
HI11
HI12
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
BK
Principal Diagnosis Code
Required for inpatient claims
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
129
HI
S
1
Admitting Diagnosis Information
Admitting Diagnosis Information.
Required when claim involves a inpatient
admission.
HI
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Value: ABJ (International Classification of
Diseases Clinical Modification (ICD-10-CM)
Principal Diagnosis), BJ (International
HI0102
HI0103
R
Industry Code
1
30
AN
Admitting Diagnosis Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI03
HI04
HI05
HI06
HI07
HI08
HI09
HI10
HI11
HI12
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
130
HI
S
1
Patient's Reason for Visit
Information
Patient's Reason for Visit Information.
Required when claim involves outpatient visits.
HI
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Value: APR (International Classification
Principal Diagnosis), PR (International
HI0102
HI0103
R
Industry Code
1
30
AN
Patient Reason for Visit
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI0201
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
HI0202
HI0203
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
HI0204
HI0205
131
HI0206
HI0207
HI0208
HI0209
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI03
HI0301
NU
S
*
1
*
3
*
ID
SEE HI03-__ BELOW
Leave blank
HI0302
HI0303
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI05
HI06
HI07
HI08
HI09
HI10
HI11
HI12
NU
NU
NU
NU
NU
NU
NU
NU
NU
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
132
HI
S
1
External Cause of Injury
Information
External Cause of Injury Information
Required when an external Cause of Injury is
needed to describe an injury, poisoning or
adverse affect.
HI
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Value: ABN (International Classification
Principal Diagnosis), BN (International
HI0102
HI0103
R
Industry Code
1
30
AN
External Cause of Injury Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI02
HI0201
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
HI0202
HI0203
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
HI0204
HI0205
133
HI0206
HI0207
HI0208
HI0209
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI03
HI0301
S
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
HI0302
HI0303
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI04
HI0401
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
HI0402
HI0403
R
Industry Code
1
30
AN
Qualifier
2
3
ID
Not Used
NU
Leave blank
134
HI0404
HI0405
HI0406
HI0407
HI0408
HI0409
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI05
HI0501
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
HI0502
HI0503
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI06
HI0601
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
135
HI0602
HI0603
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI07
HI0701
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
HI0702
HI0703
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI08
S
*
*
*
SEE HI08-__ BELOW
136
HI0801
R
1
3
ID
HI0802
HI0803
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0804
HI0805
HI0806
HI0807
HI0808
HI0809
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI09
HI0901
S
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
HI0902
HI0903
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
HI0904
HI0905
HI0906
HI0907
HI09-
137
08
HI0909
S
Code
1
1
ID
HI10
HI1001
S
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
HI1002
HI1003
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1004
HI1005
HI1006
HI1007
HI1008
HI1009
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI11
HI1101
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
HI1102
HI1103
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
HI1104
HI1105
138
HI1106
HI1107
HI1108
HI1109
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI12
HI1201
S
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
HI1202
HI1203
R
Industry Code
1
30
AN
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
Code
1
1
ID
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
HI
S
S
1
Diagnosis Related Group (DRG)
Information
HI01
HI0101
HI0102
Diagnosis Related Group (DRG) Information.
DRG information is required when an inpatient
hospital is under DRG contract with a payer
and contract requires provider to identify DRG
to the payer.
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Value: DR (DRG code)
R
Industry Code
1
30
AN
Diagnosis Related Group (DRG) Information
HI
DR
DRG CODE
139
HI
S
HI0103
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI03
HI04
HI05
HI06
HI07
HI08
HI09
HI10
HI11
HI12
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
2
Other Diagnosis Information
Other Diagnosis Information. Required when
other condition(s) co-exists with principal
diagnosis, co-exists at time of admission, or
develops during patient's treatment
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Value: ABF (International Classification of
Principal Diagnosis), BF (International
HI0102
R
Industry Code
1
30
AN
Other Diagnosis
HI
BF
Other Diagnosis
140
HI0103
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI02
HI0201
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
HI0202
HI0203
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0204
HI0205
HI0206
HI0207
HI0208
HI0209
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI03
S
*
*
*
SEE HI03-__ BELOW
141
HI0301
R
1
3
ID
HI0302
HI0303
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI04
HI0401
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
HI0402
HI0403
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
HI0404
HI0405
HI0406
HI0407
HI04-
Other Diagnosis
Other Diagnosis
142
08
HI0409
S
Code
1
1
ID
HI05
HI0501
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
HI0502
HI0503
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI06
HI0601
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
HI0602
HI0603
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
HI0604
HI0605
Other Diagnosis
Other Diagnosis
143
HI0606
HI0607
HI0608
HI0609
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI07
HI0701
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
HI0702
HI0703
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI08
HI0801
S
R
*
1
*
3
*
ID
SEE HI08-__ BELOW
HI0802
HI0803
R
Industry Code
1
30
AN
Other Diagnosis
Qualifier
2
3
ID
Not Used
NU
Other Diagnosis
Other Diagnosis
Leave blank
144
HI0804
HI0805
HI0806
HI0807
HI0808
HI0809
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI09
HI0901
S
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
HI0902
HI0903
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0904
HI0905
HI0906
HI0907
HI0908
HI0909
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI10
HI1001
S
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
Other Diagnosis
145
HI1002
HI1003
R
Industry Code
1
30
AN
Other Diagnosis
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1004
HI1005
HI1006
HI1007
HI1008
HI1009
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI11
HI1101
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
HI1102
HI1103
R
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1104
HI1105
HI1106
HI1107
HI1108
HI1109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
S
Code
1
1
ID
HI12
S
*
*
*
SEE HI12-__ BELOW
Other Diagnosis
146
HI1201
R
1
3
ID
HI1202
HI1203
S
Industry Code
1
30
AN
Other Diagnosis
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
Code
1
1
ID
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
HI
S
S
1
Principal Procedure Information
Principal Procedure Information. Required on
inpatient claims when a procedure was
performed.
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Values: BBR (international Classification
of Disease clinical Modification (ICD-10-PCS)
principal Procedure Codes), BR (International
Principal Procedure).
HI0102
HI0103
R
Industry Code
1
30
AN
Principal Procedure Code
R
Qualifier
2
3
ID
HI0104
HI0105
R
Date Time Period
1
35
AN
Principal Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Other Diagnosis
HI
Principal Procedure Code
D8
Principal Procedure Date
Leave blank
147
HI
S
HI0106
HI0107
HI0108
HI0109
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI03
HI04
HI05
HI06
HI07
HI08
HI09
HI10
HI11
HI12
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
2
Other Procedure Information
Other Procedure Information. Required on
inpatient claims when additional procedures
must be reported.
HI
HI01
HI0101
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
Valid Values: BBQ (international Classification
principal Procedure Codes), BQ (International
HI0102
HI0103
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
Valid Value: D8 (CCYYMMDD).
HI0104
HI0105
HI0106
HI01-
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
Procedure Code 2
D8
Procedure Date
148
07
HI0108
HI0109
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI0201
R
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
HI0202
HI0203
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0204
HI0205
HI0206
HI0207
HI0208
HI0209
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI03
HI0301
R
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
HI0302
HI0303
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0304
R
Date Time Period
1
35
AN
Procedure Date
Procedure Code 3
D8
Procedure Date
Procedure Code 4
D8
Procedure Date
149
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI0401
R
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
HI0402
HI0403
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0404
HI0405
HI0406
HI0407
HI0408
HI0409
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI05
HI0501
R
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
HI0502
R
Industry Code
1
30
AN
Procedure Code
Procedure Code 5
D8
Procedure Date
Procedure Code 6
150
HI0503
R
Qualifier
2
3
ID
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI06
HI0601
R
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
HI0602
HI0603
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
R
*
*
*
SEE HI07-__ BELOW
HI07
D8
Procedure Date
Procedure Code 7
D8
Procedure Date
151
HI0701
R
1
3
ID
HI0702
HI0703
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI08
HI0801
R
R
*
1
*
3
*
ID
SEE HI08-__ BELOW
HI0802
HI0803
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0804
HI0805
HI0806
HI0807
HI08-
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
Procedure Code 8
D8
Procedure Date
Procedure Code 9
D8
Procedure Date
152
08
HI0809
NU
Code
1
1
ID
Not Used
HI09
HI0901
R
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
HI0902
HI0903
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI0904
HI0905
HI0906
HI0907
HI0908
HI0909
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI10
HI1001
R
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
HI1002
HI1003
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI1004
HI1005
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
Procedure Code 10
D8
Procedure Date
Procedure Code 11
D8
Procedure Date
Leave blank
153
HI1006
HI1007
HI1008
HI1009
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI11
HI1101
R
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
HI1102
HI1103
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
HI1104
HI1105
HI1106
HI1107
HI1108
HI1109
R
Date Time Period
1
35
AN
Procedure Date
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI12
HI1201
R
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
HI1202
HI1203
R
Industry Code
1
30
AN
Procedure Code
R
Qualifier
2
3
ID
Procedure Code 12
D8
Procedure Date
Procedure Code 13
D8
154
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
HI
S
R
Date Time Period
1
35
AN
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
2
Procedure Date
Procedure Date
HI01
HI0101
HI0102
HI0103
R
R
Occurrence Span Information
*
1
*
3
*
ID
Occurrence Span Information
SEE HI01-__ BELOW
Valid Value: BI (Occurrence Span)
HI
R
Industry Code
1
30
AN
Occurrence Span Code
R
Qualifier
2
3
ID
Valid Value: RD8 (CCYYMMDD-CCYYMMDD)
HI0104
R
Date Time Period
1
35
AN
Occurrence or Occurrence Span Code
Associated Date
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI0201
HI0202
HI0203
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0204
R
Date Time Period
1
35
AN
Associated Date
BI
Occurrence Span Code 1
RD8
Associated Date
BI
RD8
Associated Date
155
HI0205
HI0206
HI0207
HI0208
HI0209
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI03
HI0301
HI0302
HI0303
S
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0304
R
Date Time Period
1
35
AN
Associated Date
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI0401
HI0402
HI0403
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0404
R
Date Time Period
1
35
AN
Associated Date
HI0405
HI0406
HI04-
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
BI
RD8
Associated Date
BI
RD8
Associated Date
156
07
HI0408
HI0409
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI05
HI0501
HI0502
HI0503
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0504
R
Date Time Period
1
35
AN
Associated Date
HI0505
HI0506
HI0507
HI0508
HI0509
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI06
HI0601
HI0602
HI0603
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0604
R
Date Time Period
1
35
AN
Associated Date
HI0605
HI0606
HI0607
HI0608
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
BI
RD8
Associated Date
BI
RD8
Associated Date
157
HI0609
NU
Code
1
1
ID
Not Used
Leave blank
HI07
HI0701
HI0702
HI0703
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0704
R
Date Time Period
1
35
AN
Associated Date
HI0705
HI0706
HI0707
HI0708
HI0709
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI08
HI0801
HI0802
HI0803
S
R
*
1
*
3
*
ID
SEE HI08-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0804
R
Date Time Period
1
35
AN
Associated Date
HI0805
HI0806
HI0807
HI0808
HI0809
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI09
HI09-
S
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
BI
RD8
Associated Date
BI
RD8
Associated Date
BI
158
01
HI0902
HI0903
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI0904
R
Date Time Period
1
35
AN
Associated Date
HI0905
HI0906
HI0907
HI0908
HI0909
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI10
HI1001
HI1002
HI1003
S
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI1004
R
Date Time Period
1
35
AN
Associated Date
HI1005
HI1006
HI1007
HI1008
HI1009
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI11
HI1101
HI1102
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
R
Industry Code
1
30
AN
RD8
Associated Date
BI
RD8
Associated Date
BI
159
HI
S
HI1103
R
Qualifier
2
3
ID
HI1104
R
Date Time Period
1
35
AN
Associated Date
HI1105
HI1106
HI1107
HI1108
HI1109
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI12
HI1201
HI1202
HI1203
S
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
R
Industry Code
1
30
AN
R
Qualifier
2
3
ID
HI1204
R
Date Time Period
1
35
AN
Associated Date
HI1205
HI1206
HI1207
HI1208
HI1209
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI01
HI0101
HI0102
HI0103
R
R
Occurrence Information
*
1
*
3
*
ID
Occurrence Information
SEE HI01-__ BELOW
Valid value: BH (Occurrence)
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
2
RD8
Associated Date
BI
RD8
Associated Date
HI
BH
Occurrence Code 1
D8
160
HI0104
R
Date Time Period
1
35
AN
Associated Date
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI0201
HI0202
HI0203
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0204
R
Date Time Period
1
35
AN
Associated Date
HI0205
HI0206
HI0207
HI0208
HI0209
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI03
HI0301
HI0302
HI0303
S
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0304
R
Date Time Period
1
35
AN
Associated Date
HI0305
NU
Monetary Amount
1
18
R
Not Used
Associated Date
BH
Occurrence Code 2
D8
Associated Date
BH
Occurrence Code 3
D8
Associated Date
Leave blank
161
HI0306
HI0307
HI0308
HI0309
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI0401
HI0402
HI0403
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0404
R
Date Time Period
1
35
AN
Associated Date
HI0405
HI0406
HI0407
HI0408
HI0409
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI05
HI0501
HI0502
HI0503
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0504
R
Date Time Period
1
35
AN
Associated Date
HI0505
HI0506
HI0507
HI05-
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
BH
Occurrence Code 4
D8
Associated Date
BH
Occurrence Code 5
D8
Associated Date
162
08
HI0509
NU
Code
1
1
ID
Not Used
Leave blank
HI06
HI0601
HI0602
HI0603
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0604
R
Date Time Period
1
35
AN
Associated Date
HI0605
HI0606
HI0607
HI0608
HI0609
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI07
HI0701
HI0702
HI0703
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0704
R
Date Time Period
1
35
AN
Associated Date
HI0705
HI0706
HI0707
HI0708
HI0709
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI08
S
*
*
*
SEE HI08-__ BELOW
BH
Occurrence Code 6
D8
Associated Date
BH
Occurrence Code 7
D8
Associated Date
163
HI0801
HI0802
HI0803
R
1
3
ID
BH
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0804
R
Date Time Period
1
35
AN
Associated Date
HI0805
HI0806
HI0807
HI0808
HI0809
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI09
HI0901
HI0902
HI0903
S
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI0904
R
Date Time Period
1
35
AN
Associated Date
HI0905
HI0906
HI0907
HI0908
HI0909
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI10
HI1001
HI1002
S
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
Occurrence Code 8
D8
Associated Date
BH
Occurrence Code 9
D8
Associated Date
BH
Occurrence Code 10
164
HI1003
R
Qualifier
2
3
ID
D8
HI1004
R
Date Time Period
1
35
AN
Associated Date
HI1005
HI1006
HI1007
HI1008
HI1009
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI11
HI1101
HI1102
HI1103
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI1104
R
Date Time Period
1
35
AN
Associated Date
HI1105
HI1106
HI1107
HI1108
HI1109
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI12
HI1201
HI1202
HI1203
S
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
R
Industry Code
1
30
AN
Occurrence Code
R
Qualifier
2
3
ID
HI1204
R
Date Time Period
1
35
AN
Associated Date
Associated Date
BH
Occurrence Code 11
D8
Associated Date
BH
Occurrence Code 12
D8
Associated Date
165
HI
S
HI1205
HI1206
HI1207
HI1208
HI1209
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI01
HI0101
HI0102
HI0103
R
R
Value Information
*
1
*
3
*
ID
Value Information
SEE HI01-__ BELOW
Valid Value: BE (Value)
R
Industry Code
1
30
AN
Value Code
Value Code 1
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI0201
HI0202
HI0203
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 2
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
Quantity
1
15
R
Not Used
2
HI0204
HI0205
HI02-
NU
HI
BE
BE
Leave blank
166
06
HI0207
HI0208
HI0209
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 3
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI0401
HI0402
HI0403
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 4
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
HI03
HI0301
HI0302
HI0303
HI0404
HI0405
HI0406
HI0407
HI0408
BE
BE
167
HI0409
NU
Code
1
1
ID
Not Used
Leave blank
HI05
HI0501
HI0502
HI0503
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 5
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI06
HI0601
HI0602
HI0603
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 6
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI07
HI0701
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
BE
BE
BE
168
HI0702
HI0703
Industry Code
1
30
AN
Value Code
Value Code 7
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI08
HI0801
HI0802
HI0803
S
R
*
1
*
3
*
ID
SEE HI08-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 8
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0804
HI0805
HI0806
HI0807
HI0808
HI0809
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI09
HI0901
HI0902
HI0903
S
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
R
Industry Code
1
30
AN
Value Code
Value Code 9
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
HI09-
R
BE
BE
169
04
HI0905
HI0906
HI0907
HI0908
HI0909
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
R
Industry Code
1
30
AN
Value Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1004
HI1005
HI1006
HI1007
HI1008
HI1009
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI11
HI1101
HI1102
HI1103
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
R
Industry Code
1
30
AN
Value Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
Quantity
1
15
R
Not Used
HI10
HI1001
HI1002
HI1003
HI1104
HI1105
HI1106
R
NU
BE
Value Code 10
BE
Value Code 11
Leave blank
170
HI
S
HI1107
HI1108
HI1109
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI12
HI1201
HI1202
HI1203
S
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
R
Industry Code
1
30
AN
Value Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
NU
Date Time Period
1
35
AN
Not Used
Leave blank
R
Monetary Amount
1
18
R
Value Code Amount
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI01
HI0101
HI0102
HI0103
R
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
2
HI0104
HI0105
HI0106
HI0107
HI01-
BE
Value Code 12
HI
BG
Condition Code 1
171
08
HI0109
NU
Code
1
1
ID
Not Used
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0204
HI0205
HI0206
HI0207
HI0208
HI0209
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI03
HI0301
HI0302
HI0303
S
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI04-
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
HI02
HI0201
HI0202
HI0203
Leave blank
BG
Condition Code 2
BG
Condition Code 3
BG
172
01
HI0402
HI0403
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0404
HI0405
HI0406
HI0407
HI0408
HI0409
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI05
HI0501
HI0502
HI0503
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0504
HI0505
HI0506
HI0507
HI0508
HI0509
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI06
HI0601
HI0602
HI0603
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
R
Industry Code
1
30
AN
Condition Code
Qualifier
2
3
ID
Not Used
NU
Condition Code 4
BG
Condition Code 5
BG
Condition Code 6
Leave blank
173
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI07
HI0701
HI0702
HI0703
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0704
HI0705
HI0706
HI0707
HI0708
HI0709
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI08
HI0801
HI0802
HI0803
S
R
*
1
*
3
*
ID
SEE HI08-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
HI0804
HI0805
HI08-
BG
Condition Code 7
BG
Condition Code 8
174
06
HI0807
HI0808
HI0809
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
SEE HI09-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0904
HI0905
HI0906
HI0907
HI0908
HI0909
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI10
HI1001
HI1002
HI1003
S
R
*
1
*
3
*
ID
SEE HI10-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
HI09
HI0901
HI0902
HI0903
HI1004
HI1005
HI1006
HI1007
HI1008
BG
Condition Code 9
BG
Condition Code 10
175
HI
S
HI1009
NU
Code
1
1
ID
Not Used
HI11
HI1101
HI1102
HI1103
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1104
HI1105
HI1106
HI1107
HI1108
HI1109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI12
HI1201
HI1202
HI1203
S
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
R
Industry Code
1
30
AN
Condition Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI01
R
*
*
*
Treatment Code Information
SEE HI01-__ BELOW
2
Treatment Code Information
Leave blank
BG
Condition Code 11
BG
Condition Code 12
HI
176
HI0101
HI0102
HI0103
R
1
3
ID
Valid Value: TC (Treatment Code)
TC
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0104
HI0105
HI0106
HI0107
HI0108
HI0109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI02
HI0201
HI0202
HI0203
S
R
*
1
*
3
*
ID
SEE HI02-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0204
HI0205
HI0206
HI0207
HI0208
HI0209
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI03
HI0301
HI0302
S
R
*
1
*
3
*
ID
SEE HI03-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
Treatment Code 1
TC
Treatment Code 2
TC
Treatment Code 3
177
HI0303
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0304
HI0305
HI0306
HI0307
HI0308
HI0309
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI04
HI0401
HI0402
HI0403
S
R
*
1
*
3
*
ID
SEE HI04-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0404
HI0405
HI0406
HI0407
HI0408
HI0409
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI05
HI0501
HI0502
HI0503
S
R
*
1
*
3
*
ID
SEE HI05-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
HI0504
HI05-
TC
Treatment Code 4
TC
Treatment Code 5
178
05
HI0506
HI0507
HI0508
HI0509
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
S
R
*
1
*
3
*
ID
SEE HI06-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0604
HI0605
HI0606
HI0607
HI0608
HI0609
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI07
HI0701
HI0702
HI0703
S
R
*
1
*
3
*
ID
SEE HI07-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
HI06
HI0601
HI0602
HI0603
HI0704
HI0705
HI0706
HI0707
TC
Treatment Code 6
TC
Treatment Code 8
179
HI0708
HI0709
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI08
HI0801
HI0802
HI0803
S
R
*
1
*
3
*
ID
SEE HI08-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0804
HI0805
HI0806
HI0807
HI0808
HI0809
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI09
HI0901
HI0902
HI0903
S
R
*
1
*
3
*
ID
SEE HI01-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI0904
HI0905
HI0906
HI0907
HI0908
HI0909
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI10
S
*
*
*
SEE HI10-__ BELOW
TC
Treatment Code 9
TC
Treatment Code 10
180
HI1001
HI1002
HI1003
R
1
3
ID
TC
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1004
HI1005
HI1006
HI1007
HI1008
HI1009
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI11
HI1101
HI1102
HI1103
S
R
*
1
*
3
*
ID
SEE HI11-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1104
HI1105
HI1106
HI1107
HI1108
HI1109
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
HI12
HI1201
HI1202
S
R
*
1
*
3
*
ID
SEE HI12-__ BELOW
R
Industry Code
1
30
AN
Treatment Code
Treatment Code 11
TC
Treatment Code
TC
Treatment Code 12
181
HCP
S
HI1203
NU
Qualifier
2
3
ID
Not Used
Leave blank
HI1204
HI1205
HI1206
HI1207
HI1208
HI1209
NU
Date Time Period
1
35
AN
Not Used
Leave blank
NU
Monetary Amount
1
18
R
Not Used
Leave blank
NU
Quantity
1
15
R
Not Used
Leave blank
NU
Version Identifier
1
30
AN
Not Used
Leave blank
NU
Industry Code
1
30
AN
Not Used
Leave blank
NU
Code
1
1
ID
Not Used
Leave blank
1
Claim Pricing/Repricing
Information
Claim Pricing/Repricing Information
segment.
HCP01
R
Pricing Methodology
2
2
ID
Valid Values: 00 (Zero Pricing-Not Covered
Under Contract), 01 (Priced as Billed at 100%),
02 (Priced at the Standard Fee Schedule), 03
(Priced at a Contractual Percentage), 04
(Bundled Pricing), 05 (Peer Review Pricing), 06
(Per Diem Pricing), 07 (Flat Rate Pricing), 08
(Combination Pricing), 09 (Maternity Pricing),
10 (Other Pricing), 11 (Lower of Cost), 12
(Ratio of Cost), 13 (Cost Reimbursed), 14
(Adjustment Pricing)
segment.
HCP02
R
Monetary Amount
1
18
R
HCP03
S
Monetary Amount
1
18
R
HCP04
S
1
50
AN
HCP05
S
Rate
1
9
R
segment.
segment.
segment.
segment.
HCP06
S
1
50
AN
Repricing Organization Identifier
(Repricing rate)
Repriced Approved DRG code-hospital.
Required when necessary to report Approved
DRG code on claims priced or repriced
segment.
182
2310A
1
HCP07
S
Monetary Amount
1
18
R
Approved DRG amount. Required when
necessary to report Approved DRG Amount on
claim priced/repriced.
segment.
HCP08
S
Product/Service ID
1
48
AN
Repriced Approved Revenue Code
2
ID
Not Used
1
48
AN
Not Used
Code (Repriced unit count)
2
2
ID
Valid Values: DA (Days), UN (Units). Required
when HCP12 exists
segment.
segment.
segment.
segment.
HCP09
NU
2
HCP10
NU
Product/Service ID
HCP11
S
HCP12
S
Quantity
1
15
R
Repriced Approved Service Unit Count.
Required when necessary to report Approved
Service Unit Count on claims priced/repriced
segment.
HCP13
S
Reject Reason Code
2
2
ID
Valid Values: T1 (Cannot Identify Provider as
TPO Participant), T2 (Cannot Identify Payer as
TPO Participant), T3 (Cannot Identify Insured
as TPO Participant), T4 (Payer Name or
Identifier Missing), T5 (Certification
Information Missing), T6 (Claim does not
contain enough information for repricing)
segment.
HCP14
S
1
2
ID
Valid Values: 1 (Procedure FollowedCompliance), 2 (Not Followed-Call not Made),
3 (Not Medically Necessary), 4 (Not FollowedOther), 5 (Emergency Admit to Non-Network
Hospital)
segment.
HCP15
S
Exception Reason Code
1
2
ID
Valid Values: 1 (Non-network Professional
Provider in Network Hospital), 2 (Emergency
Care), 3 (Services or Specialist Not in Network),
4 (Out-of-Service Area), 5 (State Mandates), 6
(Other)
segment.
S
NM1
S
Attending Physician Name
1
NM101
R
Attending Physician Name. Required on all
inpatient claims or encounters. Required to
indicate the primary physician responsible on a
home health agency plan of treatment.
2
3
ID
Valid Value: 71 (Attending Physician)
NM1
71
183
PRV
REF
S
S
NM102
R
1
1
ID
NM103
R
Name
1
60
AN
Attending Physician Last Name
Attending Physician Last Name
NM104
S
Name First
1
35
AN
Attending Physician First Name. Required if
NM102=1
Attending Physician First Name
NM105
S
Middle Name
1
25
AN
Attending Physician Middle Name. Required if
known and NM102=1
Leave blank
NM106
NM107
NU
S
Name Prefix
Attending Physician Name Suffix
1
1
10
10
AN
AN
Not Used
Required if known.
Leave blank
Leave blank
NM108
NM109
NM110
NM111
NM112
S
S
NU
NU
NU
Identification Code
Name
1
2
2
2
1
2
80
2
3
60
ID
AN
ID
ID
ID
Attending Physician Primary Identifier
Not Used
Not Used
Not Used
XX
Attending Physican's NPI
Leave blank
Leave blank
Leave blank
Attending Physician Specialty Information
segment.
1
Attending Physician Specialty
Information
1
PRV01
R
Provider Code
1
3
ID
Valid Values: AT (Attending), SU (Supervising)
segment.
PRV02
R
Qualifier
2
3
ID
Taxonomy Code)
segment.
PRV03
R
1
50
AN
PRV04
NU
2
2
ID
Not Used
PRV05
NU
***
***
***
Not Used
segment.
segment.
segment.
PRV06
NU
3
3
ID
Not Used
segment.
Attending Physician Secondary Identification
segment.
4
Attending Physician Secondary
Identification
REF01
R
Qualifier
2
3
ID
Valid Values: 0B (State License #), 1G (Provider
UPIN Number), G2 (Provider Commercial #),
LU (Location #)
segment.
REF02
R
1
30
AN
Attending Physician Secondary Identifier
segment.
184
2310B
1
REF
1
NU
Description
REF04
NU
S
NM1
2310C
REF03
S
S
S
1
80
AN
Not Used
***
***
***
Not Used
Operating Physician Name
1
Operating Physician Name. Required when
any surgical procedure code is listed on the
claim
segment.
segment.
NM1
NM101
NM102
NM103
R
R
R
Name
2
1
1
3
1
60
ID
ID
AN
Valid Value: 72 (Operating Physician)
Operating Physician Last Name
72
1
NM104
NM105
S
S
Name First
Name Middle
1
1
35
25
AN
AN
Operating Physician First Name
Operating Physician Middle Name. Required
when known and NM102=1
Leave blank
NM106
NM107
NU
S
Name Prefix
Name Suffix
1
1
10
10
AN
AN
Not Used
Operating Physician Name Suffix. Required if
known
Leave blank
NM108
NM109
NM110
NM111
NM112
S
S
NU
NU
NU
Identification Code
Name
1
2
2
2
1
2
80
2
3
60
ID
AN
ID
ID
ID
Operating Physician Primary Identifier
Not Used
Not Used
Not Used
4
Operating Physician Secondary
Identification
XX
Operating Physician's NPI
Leave blank
Leave blank
Leave blank
Operating Physician Secondary Identification
segment.
REF01
R
Qualifier
2
3
ID
LU (Location #)
segment.
REF02
R
1
50
AN
Operating Physician Secondary Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
Other Operating Provider Name
185
NM1
REF
2310D
2
S
S
1
S
1
Other Operating Physician Name
segment.
segment.
segment.
NM101
R
2
3
ID
Valid Value: 73 (Other Physician)
NM102
R
1
1
ID
NM103
R
Name
1
60
AN
Other Operating Physician Name
segment.
NM104
S
Name First
1
35
AN
Other Physician First Name. Required if
NM102=1
segment.
NM105
S
Name Middle
1
25
AN
Other Physician Middle Name. Required if
known and NM102=1
segment.
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
S
Name Suffix
1
10
AN
Other Physician Name Suffix. Required if
known.
segment.
segment.
NM108
S
1
2
ID
NM109
S
Identification Code
2
80
AN
Other Physician Identifier
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
4
S
NM1
Other Operating Physician
Name
Other Provider Secondary
Identification
segment.
segment.
segment.
segment.
segment.
Other Provider Secondary Identification
segment.
REF01
R
Qualifier
2
3
ID
LU (Location #)
segment.
REF02
R
1
50
AN
Other Physician Secondary Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
NM1
186
REF
2310E
1
S
NM101
NM102
NM103
R
R
R
Entity type qualifier
Name
2
1
1
3
1
60
ID
ID
AN
Valid Values: 82 (Rendering Provider)
NM104
S
Name First
1
35
AN
Rendering Provider First Name. Required if
NM102=1
NM105
S
Name Middle
1
25
AN
Referring Provider Middle Name. Required if
known and NM102=1
Leave blank
NM106
NM107
NU
S
Name Prefix
Name Suffix
1
1
10
10
AN
AN
Not Used
Referring Provider Name Suffix. Required if
known
Leave blank
Leave blank
NM108
NM109
NM110
NM111
NM112
S
S
NU
NU
NU
Identification Code
Name
1
2
2
2
1
2
80
2
3
60
ID
AN
ID
ID
ID
Referring Provider Identifier
Not Used
Not Used
Not Used
4
Identification
NM1
S
Valid Values: OB (State License #), 1G (Provider
LU (Location #)
segment.
Reference identification
qualifier
2
3
ID
REF02
R
Referring Physician Secondary
Identifier
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
R
R
R
NU
NU
NU
NU
Service Facility Name
Name First
Name Middle
Name Prefix
Name Suffix
ID
ID
AN
AN
AN
AN
AN
Valid Value: 77 (Service Location)
Not Used
Not Used
Not Used
Not Used
NM101
NM102
NM103
NM104
NM105
NM106
NM107
2
1
1
1
1
1
1
3
1
60
35
25
10
10
XX
Leave blank
Leave blank
Leave blank
segment.
R
1
Rendering Provider Secondary Identification
REF01
S
82
1
segment.
segment.
segment.
N1
77
2
Leave blank
Leave blank
Leave blank
Leave blank
187
N3
N4
REF
R
R
S
NM108
NM109
S
S
NM110
NM111
NM112
NU
NU
NU
N301
R
N302
S
1
1
Laboratory or Facility Primary
Identifier
1
2
2
80
ID
AN
XX
Facility's NPI
Name
2
2
1
2
3
60
ID
ID
ID
Not Used
Not Used
Not Used
Leave blank
Leave blank
Leave blank
1
55
AN
Service Facility Address
N3
1
55
AN
Service Facility City/State/ZIP Code
N4
Service Facility Address
Line 1
Line 2
Service Facility City/State/ZIP
Code
N401
R
Laboratory or Facility City Name
2
30
AN
N402
S
Laboratory or Facility State or
Province Code
2
2
ID
Laboratory or Facility State or Province Code
Laboratory or Facility State or Province
Code
N403
S
Laboratory or Facility Postal
Zone or Zip Code
3
15
ID
Laboratory or Facility Postal Zone or Zip Code
Laboratory or Facility Postal Zone or
Zip Code
N404
N405
N406
N407
S
NU
NU
S
Country Code
Location Qualifier
Location Identifier
2
1
1
1
3
2
30
3
ID
ID
AN
ID
Country Code
Not Used
Not Used
Not Used
Service Facility Secondary
Identification
4
133
3
Country Code
Leave blank
Leave blank
Leave blank
Service Facility Secondary Identification
segment.
Valid Values: 0B (State License #), G2 (Provider
Commercial #), G5 (Provider Site #), LU
(Location #)
segment.
REF01
R
qualifier
2
3
ID
REF02
R
Laboratory or Facility secondary
identifier
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
188
2310F
2
S
NM1
REF
2320
10
S
S
S
1
segment.
segment.
segment.
segment.
segment.
NM101
R
2
3
ID
Valid Values: DN (Referring Provider)
NM102
R
Entity type qualifier
1
1
ID
NM103
R
Name
1
35
AN
NM104
S
Name First
1
25
AN
Referring Provider First Name. Required if
NM102=1
segment.
NM105
S
Name Middle
1
25
AN
Referring Provider Middle Name. Required if
known and NM102=1
segment.
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
S
Name Suffix
1
10
AN
Referring Provider Name Suffix. Required if
known
segment.
segment.
NM108
S
1
2
ID
NM109
S
Identification Code
2
80
AN
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
3
Identification
Referring Provider Secondary Identification
segment.
Valid Values: OB (State License #), 1G (Provider
UPIN Number),G2 (Provider Commercial #)
segment.
REF01
R
qualifier
2
3
ID
REF02
R
Referring Physician Secondary
Identifier
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
189
SBR
S
1
SBR01
R
Other Subscriber Information. Required if
other payers are known to potentially be
involved in paying on this claim.
Number Code
1
1
ID
SBR02
R
2
2
ID
SBR03
S
1
30
AN
SBR04
SBR05
SBR06
SBR07
S
NU
NU
NU
Insurance Type Code
Code
1
1
1
1
60
3
1
1
AN
ID
ID
ID
SBR08
SBR09
NU
S
2
1
2
2
ID
ID
Valid Values: A (Payer Responsibility Four), B
(Payer Responsibility Five),C (Payer
Seven), E (Payer Responsibility Eight), F (Payer
Responsibility Nine), G (Payer Responsibility
Ten), H (Payer Responsibility Eleven), P
(Primary), S (Secondary), T (Tertiary), U
(Unknown)
Valid Values: 01 (Spouse), 18 (Self), 19 (Child),
20 (Employee), 21 (Unknown), 39 (Organ
Donor), 40 (Cadaver Donor), 53 (Life Partner),
G8 (Other Relationship).
SBR
A (Payer Responsibility Four), B (Payer
Responsibility Five),C (Payer
Responsibility Six), D (Payer
Responsibility Seven), E (Payer
Responsibility Eight), F (Payer
Responsibility Nine), G (Payer
Responsibility Ten), H (Payer
Responsibility Eleven), P (Primary), S
(Secondary), T (Tertiary), U (Unknown)
01 (Spouse), 18 (Self), 19 (Child), 20
(Employee), 21 (Unknown), 39 (Organ
Donor), 40 (Cadaver Donor), 53 (Life
Partner), G8 (Other Relationship)
Not Used
Not Used
Not Used
Not Used
(Dental maintenance Organization), AM
(Commercial Insurance), DS (Disability), FI
(Federal Employees Program), HM (Health
Maintenance Organization), LM (Liability
Medical), MA (Medicare Part A), MB
Federal Program), TV (Title V), VA (Veteran
Defined)
Leave blank
Leave blank
Leave blank
Leave blank
Leave blank
190
CAS
S
5
Claim Level Adjustment
Claim Level Adjustment
CAS01
R
1
2
ID
Valid Values: CO (Contractual Obligations), CR
(Corrections and Reversals), OA (Other
Adjustments), PI (Payor Initiated Reductions),
PR (Patient Responsibility)
CAS02
R
Claim Adjustment Reason Code
1
5
ID
CAS03
R
Monetary Amount
1
18
R
Adjustment Amount
CAS04
S
Quantity
1
15
R
Adjustment Quantity
CAS05
S
1
5
ID
CAS06
S
Monetary Amount
1
18
R
Adjustment Amount
CAS07
S
Quantity
1
15
R
Adjustment Quantity
CAS08
S
1
5
ID
CAS09
S
Monetary Amount
1
18
R
Adjustment Amount
CAS10
S
Quantity
1
15
R
Adjustment Quantity
CAS11
S
1
5
ID
CAS12
S
Monetary Amount
1
18
R
Adjustment Amount
CAS13
S
Quantity
1
15
R
Adjustment Quantity
CAS14
S
1
5
ID
CAS15
S
Monetary Amount
1
18
R
Adjustment Amount
CAS16
S
Quantity
1
15
R
Adjustment Quantity
CAS17
S
1
5
ID
CAS18
S
Monetary Amount
1
18
R
Adjustment Amount
CAS19
S
Quantity
1
15
R
Adjustment Quantity
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
191
AMT
AMT
AMT
OI
S
S
S
R
1
Payor Amount Paid
Coordination of Benefits (COB) Payor Amount
Paid
segment.
segment.
segment.
segment.
AMT01
R
1
3
ID
Valid Value: D (Payor Amount Paid)
AMT02
R
Monetary Amount
1
18
R
Other Payer Patient Paid Amount
AMT03
NU
1
1
ID
Not Used
1
AMT01
R
1
3
ID
AMT02
R
Monetary Amount
1
18
R
Allowed Amount
AMT03
NU
1
1
ID
Not Used
1
Total Non-covered Amount
Coordination of Benefits (COB) Total Noncovered Amount
segment.
segment.
segment.
segment.
segment.
segment.
AMT01
R
1
3
ID
Valid Value: A8 (Non-covered Charges - Actual)
segment.
AMT02
R
Monetary Amount
1
18
R
Non-Covered Charge Amount
AMT03
NU
1
1
ID
Not Used
segment.
segment.
segment.
segment.
1
Other Insurance Coverage
Information
Other Insurance Coverage Information
OI01
NU
1
2
ID
Not Used
OI02
NU
2
2
ID
Not Used
OI03
R
Benefits Assignment
Certification Indicator
1
1
ID
Valid Values: N (No), W (Not Applicable), Y
(Yes)
OI04
NU
1
1
ID
Not Used
OI05
NU
1
1
ID
Not Used
segment.
segment.
segment.
segment.
segment.
192
OI06
MIA
S
R
1
1
1
ID
Medicare Inpatient Adjudication
Information
Valid Values: I (Informed Consent to Release
Info), Y (Yes, Provider has a Signed Statement
for Release of Info)
segment.
Medicare Inpatient Adjudication Information
segment.
Covered Days or Visits Count
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
MIA01
R
Quantity
1
15
R
MIA02
S
Monetary Amount
1
18
R
MIA03
S
Quantity
1
15
R
Lifetime Psychiatric Days Count
MIA04
S
Monetary Amount
1
18
R
Claim DRG Amount
MIA05
S
1
50
AN
MIA06
S
Monetary Amount
1
18
R
Claim Disproportionate Share Amount
MIA07
S
Monetary Amount
1
18
R
Claim MSP Pass-Thru Amount
MIA08
S
Monetary Amount
1
18
R
Claim PPS Capital Amount
MIA09
S
Monetary Amount
1
18
R
PPS-Capital FSP DRG Amount
MIA10
S
Monetary Amount
1
18
R
PPS-Capital HSP DRG Amount
MIA11
S
Monetary Amount
1
18
R
PPS-Capital DSH DRG Amount
MIA12
S
Monetary Amount
1
18
R
Old Capital Amount
MIA13
S
Monetary Amount
1
18
R
PPS-Capital IME Amount
MIA14
S
Monetary Amount
1
18
R
PPS-Operating Hospital Specific DRG Amount
MIA15
S
Quantity
1
15
R
Cost Report Day Count
MIA16
S
Monetary Amount
1
18
R
PPS-Operating Federal Specific DRG Amount
MIA17
S
Monetary Amount
1
18
R
Claim PPS Capital Outlier Amount
MIA18
S
Monetary Amount
1
18
R
Claim Indirect Teaching Amount
Claim Payment Remark Code
segment.
segment.
segment.
segment.
193
MOA
S
MIA19
S
Monetary Amount
1
18
R
MIA20
S
1
50
MIA21
S
1
MIA22
S
MIA23
S
MIA24
S
1
Nonpayable Professional Component Amount
segment.
AN
Remark Code
50
AN
Remark Code
1
50
AN
Remark Code
1
50
AN
Remark Code
Monetary Amount
1
18
R
segment.
segment.
segment.
segment.
segment.
Medicare Outpatient
Adjudication Information
PPS-Capital Exception Amount
Medicare Outpatient Adjudication Information
segment.
MOA01
S
Percent
1
10
R
Reimbursement Rate. Required if returned on
Electronic Remittance Advice (835).
segment.
MOA02
S
Monetary Amount
1
18
R
Claim HCPCS Payable Amount. Required if
returned on the Electronic Remittance Advice
(835)
segment.
MOA03
S
1
50
AN
Remark Code. Required if returned on the
Electronic Remittance Advice (835)
segment.
MOA04
S
1
50
AN
segment.
MOA05
S
1
50
AN
segment.
MOA06
S
1
50
AN
segment.
MOA07
S
1
50
AN
segment.
MOA08
S
Monetary Amount
1
18
R
Claim ESRD Payment Amount. Required if
returned on the Electronic Remittance Advice
(835)
segment.
MOA09
S
Monetary Amount
1
18
R
Nonpayable Professional Component Amount.
Required if returned on the Electronic
Remittance Advice (835)
segment.
194
2330A
1
S
NM1
N3
N4
R
S
R
1
Other Subscriber Name. The 2330A loop is
required when Loop ID 2320 Other Subscriber
Information is used; otherwise this loop is not
used.
2
1
3
1
ID
ID
R
S
S
NU
S
R
Other Insured Middle Name
Name Prefix
Name Suffix
1
1
1
1
1
1
60
35
25
10
10
2
AN
AN
AN
AN
AN
ID
R
NU
NU
NU
Other Insured Identifier
Name
2
2
2
1
80
2
3
60
AN
ID
ID
ID
NM101
NM102
R
R
NM103
NM104
NM105
NM106
NM107
NM108
NM109
NM110
NM111
NM112
1
N301
R
Other Insured Address Line
1
55
AN
N302
S
Other Insured Address Line 2
1
55
AN
1
Other Subscriber City/State/ZIP
Code
N401
R
Other Insured City Name
2
30
AN
N402
S
Other Insured State Code
2
2
ID
N403
S
Other Insured Postal Zone or Zip
Code
3
15
ID
N404
S
2
3
ID
N405
NU
Location Qualifier
1
2
ID
Required if NM102=1
Not Used
Required if known
Identifier for each Individual in the US), MI
Other Insured Identifier
Not Used
Not Used
Not Used
NM1
IL
1
Leave blank
Leave blank
Leave blank
M(I
Other Insured's Member ID
Leave blank
Leave blank
Leave blank
segment.
segment.
segment.
Other Subscriber City/State/ZIP Code
segment.
segment.
segment.
segment.
Not Used
segment.
segment.
195
REF
2330B
1
S
N406
NU
N407
S
2
R
1
30
AN
Not Used
1
3
ID
send.
Other Subscriber Secondary
Information
4
133
segment.
segment.
R
Qualifier
2
3
ID
REF02
R
Other Insured Additional
Identifier
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
1
NM101
NM102
NM103
R
R
R
NM104
NM105
NM106
NM107
NM108
NU
NU
NU
NU
R
NM109
NM110
NM111
NM112
R
NU
NU
NU
Other Payer Name
Other Payer Name
Other Payer Last or
Organization Name
2
1
1
3
1
60
ID
ID
AN
Name First
Name Middle
Name Prefix
Name Suffix
1
1
1
1
1
35
25
10
10
2
AN
AN
AN
AN
ID
Name
2
2
2
1
80
2
3
60
AN
ID
ID
ID
segment.
segment.
Other Subscriber Secondary Information
REF01
R
NM1
Location Identifier
segment.
Other Payer Name
Other Payer Name
Not Used
Not Used
Not Used
Not Used
(Healthcare Financing Administration National
Plan ID)
Not Used
Not Used
Not Used
segment.
segment.
NM1
PR
2
Other Payer Last or Organization
Name
Leave blank
Leave blank
Leave blank
Leave blank
PI
0
Leave blank
Leave blank
Leave blank
196
N3
N4
DTP
REF
S
R
S
S
1
Other Payer Address
N301
R
Other Payer Address Line
1
55
AN
N302
S
1
55
AN
1
Other Payer City/State/ZIP Code
segment.
segment.
segment.
Other Payer City/State/ZIP Code
segment.
N401
R
2
30
AN
N402
S
Other Payer State Code
2
2
ID
N403
S
Other Payer Postal Zone or Zip
Code
3
15
ID
N404
S
Country Code
2
3
ID
N405
NU
Location Qualifier
1
2
ID
Not Used
N406
NU
Location Identifier
1
30
AN
Not Used
N407
S
1
3
ID
send.
1
2
Other Payer Address
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
DTP01
R
Date/Time Qualifier
3
3
ID
DTP02
R
Qualifier
2
3
ID
DTP03
R
Date Time Period
1
35
AN
segment.
Other Payer Secondary Identification and
Reference Number
segment.
Identification and Reference
Number
197
REF
REF
REF
S
S
S
REF01
R
Qualifier
2
3
ID
REF02
R
Identifier
1
30
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
1
Other Payer Prior Authorization
Commissioners (NAIC) Code)
segment.
segment.
segment.
segment.
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: G1 (Prior Authorization Number)
segment.
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
REF01
R
Qualifier
2
3
ID
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
1
Other Payer Claim Adjustment
Number
segment.
segment.
segment.
segment.
segment.
Other Payer Claim Adjustment Number
segment.
REF01
R
Qualifier
2
3
ID
Valid Values:T4 (Signal Code)
segment.
REF02
R
1
50
AN
Valid Value: Y
REF03
NU
Description
1
80
AN
Not Used
segment.
198
REF04
REF
2330C
1
S
NU
1
S
***
***
***
Other Payer Claim Control
Number
Not Used
segment.
segment.
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: F8 Claim Control Number)
segment.
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
S
NM1
Other Payer Attending Provider
1
segment.
segment.
segment.
NM101
R
2
3
ID
Valid Value: 71 (Attending Physician)
NM102
R
1
1
ID
NM103
NU
Name
1
60
AN
Not Used
segment.
NM104
NU
Name First
1
35
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
199
REF
2330D
1
R
4
Other Payer Attending
Secondary Provider Secondary
Identification
S
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: 0B (State License Number), 1G
(Provider UPIN), G2 (Provider Commercial
segment.
REF02
R
1
50
AN
Other Payer Attending Provider Secondary
Identifier
segment.
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
S
NM1
Other Payer Attending Secondary Provider
Other Payer Operating Provider
1
NM101
R
2
3
ID
NM102
R
1
1
ID
NM103
NU
Name
1
60
AN
Not Used
NM104
NU
Name First
1
35
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
200
REF
2330E
1
R
4
Other Payer Operating
Secondary Provider
Identification
S
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
1
50
AN
Other Payer Operating Provider Secondary
Identifier
segment.
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
S
NM1
Other Payer Operating Secondary Provider
Identification
1
Other Payer Other Operating
Provider
Other Payer Other Operating Provider
Other Payer Other Provider
segment.
segment.
segment.
NM101
R
2
3
ID
Valid Value: 73 (Other Physician)
NM102
R
1
1
ID
NM103
NU
Name
1
35
AN
Not Used
segment.
NM104
NU
Name First
1
25
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
201
REF
2330F
1
R
4
Identification
S
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
1
50
AN
Other Payer Other Provider Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
S
NM1
Other Payer Other Provider Identification
1
Location
Location
segment.
segment.
segment.
segment.
NM101
R
2
3
ID
Valid Value: 77 (Service Location)
NM102
R
1
1
ID
NM103
NU
Name
1
60
AN
Not Used
NM104
NU
Name First
1
35
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
202
REF
2330G
1
R
3
Location Secondary
Identification
S
segment.
REF01
R
Qualifier
2
3
ID
Valid Values: 0B (State License Number), G2
(Provider Commercial Number), LU (Location
Number)
segment.
REF02
R
1
50
AN
Other Payer Other Provider Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
S
NM1
1
NM101
R
2
3
ID
Valid Value: 82 (Rendering Physician)
NM102
R
1
1
ID
NM103
NU
Name
1
60
AN
Not Used
NM104
NU
Name First
1
35
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
203
REF
2330H
1
R
4
Identification
REF
S
R
R
Qualifier
2
3
ID
segment.
REF02
R
1
50
AN
Other Payer Attending Provider Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
3
segment.
REF01
S
NM1
Other Payer Attending Provider Identification
NM101
R
2
3
ID
Valid Values: DN (Referring Provider)
NM102
R
1
1
ID
NM103
NU
Name
1
60
AN
Not Used
NM104
NU
Name First
1
34
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
Identification
Other Payer Referring Provider Identification
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
204
23301
1
REF01
R
qualifier
2
3
ID
Number)
segment.
REF02
R
1
50
AN
Other Payer Referring Provider Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
S
NM1
REF
S
R
1
NM101
R
2
3
ID
Valid Values: 85 (Billing Provider)
NM102
R
1
1
ID
NM103
NU
Name
1
60
AN
Not Used
NM104
NU
Name First
1
34
AN
Not Used
NM105
NU
Name Middle
1
25
AN
Not Used
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
NU
Name Suffix
1
10
AN
Not Used
NM108
NU
1
2
ID
Not Used
NM109
NU
Identification Code
2
80
AN
Not Used
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
2
Identification
REF01
R
qualifier
2
3
ID
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
Other Payer Billing Provider Identification
segment.
segment.
205
2400
999
REF02
R
1
50
AN
Other Payer Billing Provider Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
R
LX
SV2
R
R
1
1
SV201
R
SV202
S
SV20201
Service Line Number
Service Line Number
Institutional Service Line
Service Line Revenue Code
Service Line Number
Service Line Number
Institutional Service Line
See Code Source 132: National Uniform Billing
Committee (NUBC) Codes
segment.
segment.
segment.
LX
SV2
Revenue Code
1
48
AN
COMPOSITE Medical Procedure
Identifier
*
*
*
SEE SV202-___ BELOW Required for
Outpatient when appropriate HCPCs exist for
the service line item
R
2
2
ID
Procedure and Supply Codes, HC (HCPCS), HP
(Health Insurance Prospective Payment System
(HIPPS) Skilled Nursing Facility Rate Code), IV
(Home Infusion EDI Coalition-NIECProduct/Service Code - not currently allowed),
WK (Advanced Billing Concepts (ABC) Codes)
SV20202
R
Procedure Code
1
48
AN
Procedure Code
SV20203
S
HCPCS Modifier 1
2
2
AN
HCPCS Modifier 1
SV20204
S
HCPCS Modifier 2
2
2
AN
HCPCS Modifier 2
SV20205
S
HCPCS Modifier 3
2
2
AN
HCPCS Modifier 3
SV20206
S
HCPCS Modifier 4
2
2
AN
HCPCS Modifier 4
SV20207
S
Description
1
80
AN
Leave blank
SV20208
NU
Product/Service ID
1
48
AN
Not Used
SV203
SV204
R
R
Code
1
2
18
2
R
ID
Use for submitted charge amount
Valid Values : DA (Days), UN (Units)
HC
Leave blank
Line Item Charge
DA (Days), UN (Units)
206
PWK
S
SV205
SV206
SV207
R
NU
S
Service Unit Count
Service Line Rate
Line Item Denied Charge or
Non-Covered Charge Amount
1
1
1
15
10
18
R
R
R
Not Used
Unit Count
Leave blank
Leave blank
SV208
NU
Code
1
1
ID
Not Used
Leave blank
SV209
NU
Nursing Home Residential Status
Code
1
1
ID
Not Used
Leave blank
SV210
NU
Level of Care Code
1
1
ID
Not Used
Leave blank
10
PWK01
R
2
2
ID
Valid Values: 03 (Report Justifying Treatment
Beyond Utilization Guidelines), 04 (Drugs
Analysis), 13 (Certified Test Report), 15
(Justification for Admission), 21 (Recovery
Plan), A3 (Allergies/Sensitivities Document),
A4 (Autopsy Report), AM (Ambulance
Certification), AS (Admission Summary), B2
(Prescription), B3 (Physician Order), B4
(Consent Form(s)), CT (Certification), D2 (Drug
Profile Document), DA (Dental Models), DB
(Durable Medical Equipment Prescription), DG
(Diagnosis Report), DJ (Discharge Monitoring
Report), DS (Discharge Summary),
segment.
segment.
207
EB (Explanation of Benefits, Coordination of
Benefits or Medicate Secondary Payer), HC
(Health Certificate), HR (Health Clinic Records),
I5 (Immunization Record), IR (State School
Immunization Records), LA (Laboratory
Results), M1 (Medical Record Attachment), MT
(Models), NN (Nursing Notes), OB (Operative
Notes), OC (Oxygen Content Averaging
Report), OD (Orders and Treatments
Document), OE (Objective Physical
Examination (including vital signs) Document),
OX (Oxygen Therapy Certification), OZ
(Support Data for Claim), P4 (Pathology
Report), P5 (Patient Medical History
Document), PE (Parenteral or Enteral
(Prosthetics or Orthotics Certification), PQ
(paramedical Results), PY (Physician’s Report),
PZ (Physical Therapy Certification), RB
(Radiology Films), RR (Radiology Reports), RT
(Report of Tests and Analysis Report), RX
(Renewable Oxygen Content Averaging
Report), SG (Symptoms Document), V5 (Death
Notification), XP (Photographs)
PWK02
R
Attachment Transmission Code
1
2
ID
Valid Values: AA (Available Upon Request), BM
(By Mail), EL (Electronically Only), EM (Email),
FY (File transfer), FX (By Fax)
segment.
PWK03
NU
1
2
N0
Not Used
PWK04
NU
2
3
ID
Not Used
PWK05
S
1
2
ID
Valid Value: AC (Attachment Control Number).
Required when PWK02 is BM, EL, EM, FT or FX.
segment.
segment.
segment.
PWK06
S
Attachment Control Number
2
80
AN
Required when PWK02 is BM, EL, EM, FT or
FX.
segment.
PWK07
NU
Description
1
80
AN
Not Used
segment.
208
DTP
REF
REF
REF
S
S
S
S
PWK08
NU
Actions Indicated
PWK09
NU
1
***
***
Not Used
segment.
1
2
ID
Not Used
segment.
Service Line Date
Service Line Date Required on outpatient
claims when revenue, procedure, HIEC or drug
codes are reported in SV2 segment.
Assessment Date DTP not used when this
segment is present
DTP
472
D8
DTP01
DTP02
R
R
Date/Time Qualifier
Qualifier
3
2
3
3
ID
ID
Valid Value: 472 (Service)
Valid Values: D8 (Format: CCYYMMDD), RD8
(Range of Dates Format: CCYYMMDD CCYYMMDD)
DTP03
R
Date Time Period
1
35
AN
Service Date
1
REF01
R
Qualifier
2
3
ID
Valid Values: 6R (Provider Control Number)
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
1
1
***
REF01
R
Qualifier
2
3
ID
Valid Values: 9B (Repriced Line Item
Reference)
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
Adjusted Repriced Line Item
Reference
Service Date
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
209
AMT
AMT
NTE
HCP
S
S
S
S
REF01
R
Qualifier
2
3
ID
Valid Values: 9D (Adjusted Repriced Line Item
Reference)
segment.
REF02
R
1
50
AN
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
1
Service Tax Amount
AMT01
R
1
3
ID
Valid Value: GT (Goods and Services Tax)
AMT02
R
Monetary Amount
1
18
R
Service Tax Amount
AMT03
NU
1
1
ID
Not Used
1
Facility Tax Amount
Facility Tax Amount
AMT01
R
1
3
ID
Valid Value: N8 (Miscellaneous Taxes)
AMT02
R
Monetary Amount
1
18
R
Facility Tax Amount
AMT03
NU
1
1
ID
Not Used
1
1
Service Tax Amount
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
NTE01
R
Note Reference Code
3
3
ID
Valid Value: TPO (Third Party Organization
Notes)
NTE02
R
Description
1
80
AN
Line Note Text
segment.
Line Pricing/Repricing Information
segment.
Line Pricing/Repricing
Information
210
HCP01
R
Pricing Methodology
2
2
ID
Under Contract), 01 (Priced as Billed at 100%),
02 (Priced at the Standard Fee Schedule), 03
(Priced at a Contractual Percentage), 04
(Bundled Pricing), 05 (Peer Review Pricing), 06
(Per Diem Pricing), 07 (Flat Rate Pricing), 08
(Combination Pricing), 09 (Maternity Pricing),
10 (Other Pricing), 11 (Lower of Cost), 12
(Ratio of Cost), 13 (Cost Reimbursed), 14
(Adjustment Pricing)
segment.
HCP02
R
Monetary Amount
1
18
R
HCP03
S
Monetary Amount
1
18
R
HCP04
S
1
50
AN
HCP05
S
Rate
1
9
R
HCP06
S
1
50
AN
Repriced Approved Ambulatory Patient Group
Code
segment.
segment.
segment.
segment.
segment.
HCP07
S
Monetary Amount
1
18
R
Repriced Approved Ambulatory Patient Group
Amount
segment.
HCP08
S
Product/Service ID
1
48
AN
Repriced Approved Revenue Code
HCP09
S
2
2
ID
Procedure and Supply Codes, HC (HCPCS), HP
(Home Infusion EDI Coalition (HIEC)
Product/Service Code), WK (Advanced Billing
Concepts (ABC) Codes)
segment.
segment.
HCP10
S
Product/Service ID
1
48
AN
Repriced Approved HCPCS Code
HCP11
S
Code
2
2
ID
Valid Values: DA (Days), UN (Units)
HCP12
S
Quantity
1
15
R
Repricing Approved Service Unit Count
Repriced Organizational Identifier
segment.
segment.
segment.
211
2410
25
HCP13
S
Reject Reason Code
2
2
ID
Valid Values: T1 (Cannot Identify Provider as
TPO Participant), T2 (Cannot Identify Payer as
TPO Participant), T3 (Cannot Identify Insured
as TPO Participant), T4 (Payer Name or
Identifier Missing), T5 (Certification
Information Missing), T6 (Claim does not
contain enough information for repricing)
segment.
HCP14
S
1
2
ID
Valid Values: 1 (Procedure FollowedCompliance), 2 (Not Followed - Call Not Made Non-Compliance Call Not Made), 3 (Not
Medically Necessary - Non-Compliance NonMedically Necessary), 4 (Not Followed Other Non-Compliance Other), 5 (Emergency Admit
to Non-Network Hospital)
segment.
HCP15
S
Exception Code
1
2
ID
Provider in Network Hospital), 2 (Emergency
Care), 3 (Services or Specialist not in Network),
4 (Out-of-Service Area), 5 (State Mandates), 6
(Other)
segment.
S
LIN
S
Drug Identification
Drug Identification
1
LIN01
NU
LIN02
Drug Identification
Drug Identification 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. NDC reported in LIN
Assigned Identification
1
20
AN
Not Used
R
2
2
ID
Valid Value: N4 (National Drug Code 5-4-2
Format)
LIN03
R
Product/Service ID
1
48
AN
National Drug Code
LIN04
NU
2
2
ID
Not Used
LIN05
NU
Product/Service ID
1
48
AN
Not Used
LIN06
NU
2
2
ID
Not Used
LIN07
NU
Product/Service ID
1
48
AN
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
212
LIN08
NU
2
2
ID
Not Used
LIN09
NU
Product/Service ID
1
48
AN
Not Used
LIN10
NU
2
2
ID
Not Used
LIN11
NU
Product/Service ID
1
48
AN
Not Used
LIN12
NU
2
2
ID
Not Used
LIN13
NU
Product/Service ID
1
48
AN
Not Used
LIN14
NU
2
2
ID
Not Used
LIN15
NU
Product/Service ID
1
48
AN
Not Used
LIN16
NU
2
2
ID
Not Used
LIN17
NU
Product/Service ID
1
48
AN
Not Used
LIN18
NU
2
2
ID
Not Used
LIN19
NU
Product/Service ID
1
48
AN
Not Used
LIN20
NU
2
2
ID
Not Used
LIN21
NU
Product/Service ID
1
48
AN
Not Used
LIN22
NU
2
2
ID
Not Used
LIN23
NU
Product/Service ID
1
48
AN
Not Used
LIN24
NU
2
2
ID
Not Used
LIN25
NU
Product/Service ID
1
48
AN
Not Used
LIN26
NU
2
2
ID
Not Used
LIN27
NU
Product/Service ID
1
48
AN
Not Used
LIN28
NU
2
2
ID
Not Used
LIN29
NU
Product/Service ID
1
48
AN
Not Used
LIN30
NU
2
2
ID
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
213
LIN31
CTP
R
NU
1
Product/Service ID
1
48
AN
Drug Quantity
Not Used
Drug Quantity
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
CTP01
NU
Class of Trade Code
2
2
ID
Not Used
CTP02
NU
Price Identifier Code
3
3
ID
Not Used
CTP03
NU
Unit Price
1
17
R
Not Used
CTP04
R
Quantity
1
15
R
National Drug Unit Count
CTP05
R
COMPOSITE Unit of Measure
*
*
*
SEE CTP05-___ BELOW
CTP0501
R
Code
2
2
ID
Valid Values: F2 (International Unit), GR
(Gram), ML (Milliliter), UN (Unit)
CTP0502
NU
Exponent
1
15
R
Not Used
segment.
CTP0503
NU
Multiplier
1
10
R
Not Used
segment.
CTP0504
NU
Code
2
2
ID
Not Used
segment.
CTP0505
NU
Exponent
1
15
R
Not Used
segment.
CTP0506
NU
Multiplier
1
10
R
Not Used
segment.
CTP0507
NU
Code
2
2
ID
Not Used
segment.
CTP0508
NU
Exponent
1
15
R
Not Used
segment.
CTP0509
NU
Multiplier
1
10
R
Not Used
segment.
CTP0510
NU
Code
2
2
ID
Not Used
segment.
CTP0511
NU
Exponent
1
15
R
Not Used
segment.
CTP0512
NU
Multiplier
1
10
R
Not Used
segment.
214
REF
2420A
1
S
CTP0513
NU
Code
2
2
ID
Not Used
segment.
CTP0514
NU
Exponent
1
15
R
Not Used
segment.
CTP0515
NU
Multiplier
1
10
R
Not Used
segment.
CTP06
NU
Price Multiplier Qualifier
3
3
ID
Not Used
CTP07
NU
Multiplier
1
10
R
Not Used
CTP08
NU
Monetary Amount
1
18
R
Not Used
CTP09
NU
Basis of Unit Price Code
2
2
ID
Not Used
CTP10
NU
Condition Value
1
10
AN
Not Used
CTP11
NU
Multiple Price Quantity
1
2
N0
Not Used
segment.
segment.
segment.
segment.
segment.
segment.
1
Prescription Number
REF01
R
Qualifier
2
3
ID
Valid Value: VY (Link Sequence Number, XZ
(Pharmacy Prescription Number)
REF02
R
1
50
AN
Prescription Number
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
S
NM1
S
Prescription Number
1
NM101
R
2
3
ID
NM102
R
1
1
ID
NM103
R
1
60
AN
NM104
S
1
35
AN
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
215
REF
2420B
1
S
NM105
S
Operating Physician Middle
Name
1
25
AN
Required when known
segment.
NM106
NU
Name Prefix
1
10
AN
Not Used
S
Operating Physician Name Suffix
1
10
AN
Required if known
segment.
segment.
NM107
NM108
S
1
2
ID
NM109
S
2
80
AN
Operating Physician Primary Identifier
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
20
Operating Physician Secondary
Identification
S
Operating Physician Secondary Identification
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
1
50
AN
Operating Physician Second Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
S
NM1
segment.
segment.
segment.
segment.
segment.
1
segment.
NM101
R
2
3
ID
Valid Value: ZZ (Mutually Defined) ZZ is used
to indicate Other Operating
segment.
NM102
R
1
1
ID
NM103
R
Other Physician Last Name
1
60
AN
NM104
S
Other Physician First Name
1
35
AN
Required if NM102=1
NM105
S
Other Physician Middle Name
1
25
AN
segment.
segment.
segment.
segment.
216
REF
2420C
1
S
S
NU
Name Prefix
1
10
AN
Not Used
NM107
S
Other Physician Name Suffix
1
10
AN
Required if known
NM108
S
1
2
ID
NM109
S
Identification Code
2
80
AN
Other Physician Primary Identifier
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
20
S
NM1
NM106
1
Other Operating Physician
segment.
segment.
segment.
segment.
segment.
segment.
segment.
Other Operating Physician Secondary
Identification
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
1
30
AN
Other Operating Physician Secondary
Identification
segment.
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
REF0401
R
2
3
ID
Valid Values: 2U (Payer Identification Number)
REF0402
R
1
50
ID
REF0403
NU
2
3
ID
Not Used
segment.
REF0404
NU
1
50
ID
Not Used
segment.
REF0405
NU
2
3
ID
Not Used
segment.
REF0406
NU
1
50
ID
Not Used
segment.
segment.
segment.
217
REF
S
NM101
R
2
3
ID
NM102
R
1
1
ID
NM103
R
1
60
AN
NM104
S
1
35
AN
Required if NM102=1
NM105
S
Name
1
25
AN
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
S
Rendering Provider Name Suffix
1
10
AN
Required if known
NM108
S
1
2
ID
NM109
S
Rendering Provider Primary
Identifier
2
80
AN
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
20
Identification
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
Rendering Provider Secondary Identification
segment.
REF01
R
Qualifier
2
3
ID
segment.
REF02
R
1
50
AN
Rendering Provider Second Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
segment.
segment.
segment.
REF0401
R
2
3
ID
REF0402
R
1
50
ID
segment.
segment.
218
2420D
1
REF0403
NU
2
3
ID
Not Used
segment.
REF0404
NU
1
50
ID
Not Used
segment.
REF0405
NU
2
3
ID
Not Used
segment.
REF0406
NU
1
50
ID
Not Used
segment.
S
NM1
REF
S
S
1
NM101
R
2
3
ID
Valid Value: DN (Referring Provider)
NM102
R
1
1
ID
NM103
R
1
60
AN
NM104
S
1
35
AN
Required if NM102=1
NM105
S
Referring Provider Middle Name
1
25
AN
NM106
NU
Name Prefix
1
10
AN
Not Used
NM107
S
1
10
AN
Required if known
NM108
S
1
2
ID
NM109
S
Referring Provider Primary
Identifier
2
80
AN
NM110
NU
2
2
ID
Not Used
NM111
NU
2
3
ID
Not Used
NM112
NU
Name
1
60
ID
Not Used
20
Identification
REF01
R
Qualifier
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
segment.
Referring Provider Secondary Identification
2
3
ID
Number)
219
2430
15
REF02
R
1
50
AN
Referring Provider Secondary Identifier
REF03
NU
Description
1
80
AN
Not Used
REF04
NU
***
***
***
Not Used
REF0401
R
2
3
ID
REF0402
R
1
50
ID
REF0403
NU
2
3
ID
Not Used
segment.
REF0404
NU
1
50
ID
Not Used
segment.
REF0405
NU
2
3
ID
Not Used
segment.
REF0406
NU
1
50
ID
Not Used
segment.
S
SVD
S
1
segment.
segment.
segment.
segment.
segment.
Service Line Adjudication
Information
Service Line Adjudication Information
Service Line Adjudication
Information
Service Line Adjudication Information
segment.
Must match one of the corresponding loops2330B-Other Payer Name
segment.
segment.
segment.
SVD01
R
Payer Identifier
2
80
AN
SVD02
R
Monetary Amount
1
18
R
Service Line Paid Amount
SVD03
R
COMPOSITE Medical Procedure
Identifier
*
*
*
SEE SVD03-___ BELOW
SVD0301
R
2
2
ID
Procedure and Supply Codes), HC (HCPCS), HO
(Home Infusion EDI Coalition-NIECProduct/Service Code - not currently allowed),
WK (Advanced Billing Concepts (ABC) Codes)
SVD0302
R
Procedure Code
1
48
AN
segment.
segment.
220
CAS
S
SVD0303
S
Procedure Modifier-1
2
2
AN
segment.
SVD0304
S
2
2
AN
segment.
SVD0305
S
2
2
AN
segment.
SVD0306
S
2
2
AN
segment.
SVD0307
S
Procedure Code Description
1
80
AN
Required if SVC01-7 returned in 835
segment.
SVD0308
NU
Products/Service ID
1
48
AN
Not Used
segment.
SVD04
NU
Products/Service ID
1
48
AN
Not Used
SVD05
R
Adjustment Quantity
1
15
R
SVD06
S
Bundled or Unbundled Line
Number
1
6
N0
segment.
segment.
segment.
Service Line Adjustment
segment.
segment.
5
Service Line Adjustment
CAS01
R
1
2
ID
Valid Values: CO (Contractual Obligations), CR
(Corrections and Reversals), OA (Other
Adjustments), PI (Payor Initiated Reductions),
PR (Patient Responsibility)
CAS02
R
1
5
ID
CAS03
R
Monetary Amount
1
18
R
Adjustment Amount
CAS04
S
Quantity
1
15
R
Adjustment Quantity
CAS05
S
1
5
ID
CAS06
S
Monetary Amount
1
18
R
Adjustment Amount
CAS07
S
Quantity
1
15
R
Adjustment Quantity
CAS08
S
1
5
ID
CAS09
S
Monetary Amount
1
18
R
segment.
Adjustment Amount
segment.
segment.
segment.
segment.
segment.
segment.
segment.
221
DTP
AMT
Trailer
1
R
S
CAS10
S
Quantity
1
15
R
Adjustment Quantity
segment.
segment.
CAS11
S
1
5
ID
CAS12
S
Monetary Amount
1
18
R
Adjustment Amount
15
R
Adjustment Quantity
1
5
ID
segment.
segment.
segment.
CAS13
S
Quantity
1
CAS14
S
CAS15
S
Monetary Amount
1
18
R
Adjustment Amount
CAS16
S
Quantity
1
15
R
Adjustment Quantity
CAS17
S
1
5
ID
CAS18
S
Monetary Amount
1
18
R
Adjustment Amount
CAS19
S
Quantity
1
15
R
Adjustment Quantity
1
Service Adjudication Date
R
segment.
segment.
segment.
segment.
segment.
DTP01
R
Date/Time Qualifier
3
3
ID
DTP02
R
Qualifier
2
3
ID
DTP03
R
Date Time Period
1
35
AN
Service Adjudication or Payment Date
segment.
segment.
segment.
segment.
segment.
1
AMT01
R
1
3
ID
AMT02
R
Monetary Amount
1
18
R
AMT03
NU
1
1
ID
R
SE
Service Adjudication Date
segment.
segment.
segment.
1
SE01
R
Trailer
Transaction Segment Count
Trailer
1
10
N0
SE
Total numbrt of segments included in
a transaction set including ST and SE
222
segments.
SE02
Control
1
R
R
GE
IEA
R
R
Transaction Set Control Number
9
AN
Must match ST02
1
6
N0
Control
Numeric
Group Control Number
1
9
N0
Numeric. Must match GS06.
R
Number of Included Functional
Groups
1
5
N0
Numeric
R
Interchange Control Number
9
9
N0
1
GE01
R
GE02
R
IEA01
IEA02
1
Control
Number of Transactions Sets
Included
4
Numeric; Control number assigned by
interchange sender
Begins with 0001 and increments _1
for each subsequent ST with in the GE.
Resets back to 0001 with each new
file.
GE
Numeric.
Total number of transation sets
included in the functional group or
interchange (transmission) group
terminated by the rrailer containg this
data element.
Begine with 1 and increments +2 for
each subsequent GS within the file.
Resets back to 1 with each new file.
IEA
Numeric.
A count of the number of functional
groups included in an interchange.
Must match ISA13 (interchange
control number assigned in the
interchange header segment).
223
837 Health Care Claims transaction - Professional and Institutional – Version 5010
Appendix A
Relationship Codes:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
Place of Service Codes:
00-09
Patient is insured
Spouse
Natural Child/Insured has Financial Responsibility
Natural Child/Insured does not have Financial Responsibility
Step Child
Foster Child
Ward of the Court
Employee
Unknown - Patient's Relationship to the insured is other than
that indicated
Handicapped Dependent
Organ Donor
Cadaver Donor
Grandchild
Niece/Nephew
Injured Plaintiff
Sponsored Dependent
Minor Dependent of a Minor Dependent
Parent
Grandparent
Unassigned
11
12
Office
Home
10,13-19
Unassigned
21
22
23
24
25
26
Inpatient Hospital
Outpatient Hospital
Emergency Room - Hospital
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
20,27-29
Unassigned
31
Skilled Nursing Facility
224
837 Health Care Claims transaction - Professional and Institutional – Version 5010
32
33
34
Nursing Facility
Custodial Care Facility
Hospice
30,35-39
Unassigned
41
42
Ambulance - Land
Ambulance - Air or Water
40,43-49
Unassigned
51
52
53
54
55
56
50
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospitalization
Community Mental Health Center
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Center
Federally Qualified Health Center
57-59
Unassigned
61
62
65
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End Stage Renal Disease Treatment Facility
60,63,64,66-69
Unassigned
71
72
State or Local Public Health Clinic
Rural Health Clinic
70,73-79
Unassigned
81
Independent Laboratory
80,82-89
Unassigned
99
Other Unlisted Facility
90-98
Unassigned
225

X12 837 Institutional Mapping

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