ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

National Electronic Data Interchange Transaction Set Implementation Guide

Health Care Claim: Professional 837

ASC X12N 837 (004010X098)

May 2000
MAY 2000

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

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Table of Contents
1 Purpose and Overview .......................................................... 13
1.1 Document Purpose......................................................................... 13
1.1.1 Trading Partner Agreements................................................. 13 1.1.2 The HIPAA Role in Implementation Guides ......................... 14

1.2 Version and Release ..................................................................... 14 1.3 Business Use and Definition ...................................................... 14
1.3.1 Terminology............................................................................ 15 1.3.2 Batch and Real Time Definitions .......................................... 16

1.4 Information Flows ........................................................................... 16

1.4.1 National Standard Format (NSF) .......................................... 17 1.4.2 Coordination of Benefits ....................................................... 17 1.4.2.1 Coordination of Benefits Data Models Detail ..... 17 1.4.2.2 Coordination of Benefits Correction Detail ......... 20 1.4.3 Service Line Procedure Code Bundling and Unbundling ............................................................................. 23 1.4.4 Payer-to-Payer COB .............................................................. 30 1.4.5 Crosswalking COB Data Elements ...................................... 31

1.5 Property and Casualty .................................................................. 33

2 Data Overview ............................................................................. 33

2.1 Overall Data Architecture ............................................................ 33 2.2 Loop Labeling and Use................................................................. 34
2.2.1 Required and Situational Loops ........................................... 35

2.3 Data Use by Business Use .......................................................... 36

2.3.1 Table 1 Transaction Control Information......................... 36 2.3.1.1 837 Table 1 Header Level .................................. 36 2.3.1.2 Hierarchical Level Data Structure ........................... 37 2.3.2 Table 2 Detail Information................................................. 37 2.3.2.1 HL Segment............................................................ 37

2.4 Loop ID-1000 ..................................................................................... 40 2.5 The Claim............................................................................................ 42 2.6 Interactions with Other Transactions ..................................... 43
2.6.1 Functional Acknowledgment (997)....................................... 43 2.6.2 Unsolicited Claim Status (277) ............................................. 43 2.6.3 Remittance Advice (835)........................................................ 43

2.7 National Uniform Claim Committee ......................................... 43 2.8 Limitations to the Size of a Claim/Encounter (837) Transaction ............................................................................. 44 2.9 Use of Data Segment and Elements Marked Situational ...................................................................................... 44

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3 Transaction Set ........................................................................... 45

3.1 Presentation Examples................................................................. 45 Transaction Set Listing................................................................. 51
Segments ST Transaction Set Header.......................................... 62 BHT Beginning of Hierarchical Transaction .................... 63 REF Transmission Type Identification............................. 66 NM1 Submitter Name...................................................... 67 N2 Additional Submitter Name Information .................. 70 PER Submitter EDI Contact Information......................... 71 NM1 Receiver Name....................................................... 74 N2 Receiver Additional Name Information ................... 76 HL Billing/Pay-to Provider Hierarchical Level............... 77 PRV Billing/Pay-to Provider Specialty Information.......... 79 CUR Foreign Currency Information ................................. 81 NM1 Billing Provider Name ............................................. 84 N2 Additional Billing Provider Name Information ......... 87 N3 Billing Provider Address.......................................... 88 N4 Billing Provider City/State/ZIP Code ....................... 89 REF Billing Provider Secondary Identification ................ 91 REF Credit/Debit Card Billing Information ...................... 94 PER Billing Provider Contact Information ....................... 96 NM1 Pay-to Provider Name ............................................ 99 N2 Additional Pay-to Provider Name Information ...... 102 N3 Pay-to Provider Address ....................................... 103 N4 Pay-to Provider City/State/ZIP Code .................... 104 REF Pay-to-Provider Secondary Identification ............. 106 HL Subscriber Hierarchical Level ............................... 108 SBR Subscriber Information ......................................... 110 PAT Patient Information ............................................... 114 NM1 Subscriber Name.................................................. 117 N2 Additional Subscriber Name Information .............. 120 N3 Subscriber Address .............................................. 121 N4 Subscriber City/State/ZIP Code............................ 122 DMG Subscriber Demographic Information ................... 124 REF Subscriber Secondary Identification ..................... 126 REF Property and Casualty Claim Number .................. 128 NM1 Payer Name.......................................................... 130 N2 Additional Payer Name Information ...................... 133 N3 Payer Address ...................................................... 134 N4 Payer City/State/ZIP Code ................................... 135 REF Payer Secondary Identification ............................. 137 NM1 Responsible Party Name...................................... 139 N2 Additional Responsible Party Name Information .. 142 N3 Responsible Party Address .................................. 143 N4 Responsible Party City/State/ZIP Code................ 144 NM1 Credit/Debit Card Holder Name............................ 146 N2 Additional Credit/Debit Card Holder Name Information............................................................ 149 REF Credit/Debit Card Information ............................... 150 HL Patient Hierarchical Level ..................................... 152

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PAT NM1 N2 N3 N4 DMG REF REF CLM DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP PWK CN1 AMT AMT AMT REF REF REF REF REF REF REF REF REF REF REF REF REF K3 NTE CR1 CR2

Patient Information ............................................... 154 Patient Name........................................................ 157 Additional Patient Name Information .................... 160 Patient Address .................................................... 161 Patient City/State/ZIP Code.................................. 162 Patient Demographic Information ......................... 164 Patient Secondary Identification ........................... 166 Property and Casualty Claim Number .................. 168 Claim Information ................................................. 170 Date - Order Date ................................................. 180 Date - Initial Treatment ......................................... 182 Date - Referral Date ............................................. 184 Date - Date Last Seen .......................................... 186 Date - Onset of Current Illness/Symptom............. 188 Date - Acute Manifestation ................................... 190 Date - Similar Illness/Symptom Onset .................. 192 Date - Accident ..................................................... 194 Date - Last Menstrual Period ................................ 196 Date - Last X-ray .................................................. 197 Date - Estimated Date of Birth.............................. 199 Date - Hearing and Vision Prescription Date ........ 200 Date - Disability Begin .......................................... 201 Date - Disability End ............................................. 203 Date - Last Worked............................................... 205 Date - Authorized Return to Work......................... 206 Date - Admission .................................................. 208 Date - Discharge................................................... 210 Date - Assumed and Relinquished Care Dates .... 212 Claim Supplemental Information........................... 214 Contract Information ............................................. 217 Credit/Debit Card Maximum Amount .................... 219 Patient Amount Paid ............................................. 220 Total Purchased Service Amount.......................... 221 Service Authorization Exception Code ................. 222 Mandatory Medicare (Section 4081) Crossover Indicator ................................................................ 224 Mammography Certification Number .................... 226 Prior Authorization or Referral Number................. 227 Original Reference Number (ICN/DCN) ............... 229 Clinical Laboratory Improvement Amendment (CLIA) Number ..................................................... 231 Repriced Claim Number ....................................... 233 Adjusted Repriced Claim Number ........................ 235 Investigational Device Exemption Number ........... 236 Claim Identification Number for Clearing Houses and Other Transmission Intermediaries... 238 Ambulatory Patient Group (APG) ......................... 240 Medical Record Number ....................................... 241 Demonstration Project Identifier ........................... 242 File Information ..................................................... 244 Claim Note ............................................................ 246 Ambulance Transport Information ........................ 248 Spinal Manipulation Service Information .............. 251

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CRC CRC CRC HI HCP CR7 HSD NM1 PRV N2 REF NM1 PRV N2 REF NM1 REF NM1 N2 N3 N4 REF NM1 N2 REF SBR CAS AMT AMT AMT AMT AMT AMT AMT AMT AMT AMT DMG OI

Ambulance Certification........................................ 257 Patient Condition Information: Vision.................... 260 Homebound Indicator ........................................... 263 Health Care Diagnosis Code ................................ 265 Claim Pricing/Repricing Information ..................... 271 Home Health Care Plan Information..................... 276 Health Care Services Delivery.............................. 278 Referring Provider Name ...................................... 282 Referring Provider Specialty Information .............. 285 Additional Referring Provider Name Information .. 287 Referring Provider Secondary Identification ......... 288 Rendering Provider Name .................................... 290 Rendering Provider Specialty Information ............ 293 Additional Rendering Provider Name Information............................................................ 295 Rendering Provider Secondary Identification ....... 296 Purchased Service Provider Name ...................... 298 Purchased Service Provider Secondary Identification ......................................................... 301 Service Facility Location ....................................... 303 Additional Service Facility Location Name Information............................................................ 306 Service Facility Location Address ......................... 307 Service Facility Location City/State/ZIP................ 308 Service Facility Location Secondary Identification ......................................................... 310 Supervising Provider Name .................................. 312 Additional Supervising Provider Name Information............................................................ 315 Supervising Provider Secondary Identification ..... 316 Other Subscriber Information ............................... 318 Claim Level Adjustments ...................................... 323 Coordination of Benefits (COB) Payer Paid Amount ................................................................. 332 Coordination of Benefits (COB) Approved Amount ................................................................. 333 Coordination of Benefits (COB) Allowed Amount ................................................................. 334 Coordination of Benefits (COB) Patient Responsibility Amount .......................................... 335 Coordination of Benefits (COB) Covered Amount ................................................................. 336 Coordination of Benefits (COB) Discount Amount ................................................................. 337 Coordination of Benefits (COB) Per Day Limit Amount ................................................................. 338 Coordination of Benefits (COB) Patient Paid Amount ................................................................. 339 Coordination of Benefits (COB) Tax Amount ........ 340 Coordination of Benefits (COB) Total Claim Before Taxes Amount............................................ 341 Subscriber Demographic Information ................... 342 Other Insurance Coverage Information ................ 344

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MOA NM1 N2 N3 N4 REF NM1 N2 PER DTP REF REF REF NM1 REF NM1 REF NM1 REF NM1 REF NM1 REF NM1 REF LX SV1 SV4 PWK CR1 CR2 CR3 CR5 CRC CRC CRC DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP

Medicare Outpatient Adjudication Information ...... 347 Other Subscriber Name........................................ 350 Additional Other Subscriber Name Information .... 353 Other Subscriber Address .................................... 354 Other Subscriber City/State/ZIP Code.................. 355 Other Subscriber Secondary Identification ........... 357 Other Payer Name................................................ 359 Additional Other Payer Name Information ............ 362 Other Payer Contact Information.......................... 363 Claim Adjudication Date........................................ 366 Other Payer Secondary Identifier ......................... 368 Other Payer Prior Authorization or Referral Number ................................................................. 370 Other Payer Claim Adjustment Indicator .............. 372 Other Payer Patient Information ........................... 374 Other Payer Patient Identification ......................... 376 Other Payer Referring Provider ............................ 378 Other Payer Referring Provider Identification ....... 380 Other Payer Rendering Provider .......................... 382 Other Payer Rendering Provider Secondary Identification ......................................................... 384 Other Payer Purchased Service Provider............. 386 Other Payer Purchased Service Provider Identification ......................................................... 388 Other Payer Service Facility Location .................. 390 Other Payer Service Facility Location Identification ......................................................... 392 Other Payer Supervising Provider ........................ 394 Other Payer Supervising Provider Identification ... 396 Service Line .......................................................... 398 Professional Service ............................................. 400 Prescription Number ............................................. 408 DMERC CMN Indicator ........................................ 410 Ambulance Transport Information ........................ 412 Spinal Manipulation Service Information .............. 415 Durable Medical Equipment Certification.............. 421 Home Oxygen Therapy Information...................... 423 Ambulance Certification........................................ 427 Hospice Employee Indicator ................................. 430 DMERC Condition Indicator ................................. 432 Date - Service Date .............................................. 435 Date - Certification Revision Date ........................ 437 Date - Referral Date ............................................. 439 Date - Begin Therapy Date ................................... 440 Date - Last Certification Date ............................... 442 Date - Order Date ................................................. 444 Date - Date Last Seen .......................................... 445 Date - Test ............................................................ 447 Date - Oxygen Saturation/Arterial Blood Gas Test ....................................................................... 449 Date - Shipped...................................................... 451 Date - Onset of Current Symptom/Illness ............. 452 Date - Last X-ray .................................................. 454

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DTP DTP DTP QTY MEA CN1 REF REF REF REF REF REF REF REF REF REF REF AMT AMT AMT K3 NTE PS1 HSD HCP NM1 PRV N2 REF NM1 REF NM1 N2 N3 N4 REF NM1 N2 REF NM1 N2 N3 N4 REF PER

Date - Acute Manifestation ................................... 456 Date - Initial Treatment ......................................... 458 Date - Similar Illness/Symptom Onset .................. 460 Anesthesia Modifying Units .................................. 462 Test Result ............................................................ 464 Contract Information ............................................. 466 Repriced Line Item Reference Number ................ 468 Adjusted Repriced Line Item Reference Number ................................................................. 469 Prior Authorization or Referral Number................. 470 Line Item Control Number .................................... 472 Mammography Certification Number .................... 474 Clinical Laboratory Improvement Amendment (CLIA) Identification .............................................. 475 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification.............. 477 Immunization Batch Number ................................ 478 Ambulatory Patient Group (APG) ......................... 479 Oxygen Flow Rate ................................................ 480 Universal Product Number (UPN) ........................ 482 Sales Tax Amount ................................................. 484 Approved Amount ................................................. 485 Postage Claimed Amount ..................................... 486 File Information ..................................................... 487 Line Note .............................................................. 488 Purchased Service Information ............................ 489 Health Care Services Delivery.............................. 491 Line Pricing/Repricing Information........................ 495 Rendering Provider Name .................................... 501 Rendering Provider Specialty Information ............ 504 Additional Rendering Provider Name Information............................................................ 506 Rendering Provider Secondary Identification ....... 507 Purchased Service Provider Name ...................... 509 Purchased Service Provider Secondary Identification ......................................................... 512 Service Facility Location ....................................... 514 Additional Service Facility Location Name Information............................................................ 517 Service Facility Location Address ......................... 518 Service Facility Location City/State/ZIP................ 519 Service Facility Location Secondary Identification ......................................................... 521 Supervising Provider Name .................................. 523 Additional Supervising Provider Name Information............................................................ 526 Supervising Provider Secondary Identification ..... 527 Ordering Provider Name....................................... 529 Additional Ordering Provider Name Information ... 532 Ordering Provider Address ................................... 533 Ordering Provider City/State/ZIP Code................. 534 Ordering Provider Secondary Identification .......... 536 Ordering Provider Contact Information ................. 538

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NM1 PRV N2 REF NM1 REF SVD CAS DTP LQ FRM SE

Referring Provider Name ...................................... 541 Referring Provider Specialty Information .............. 544 Additional Referring Provider Name Information .. 546 Referring Provider Secondary Identification ......... 547 Other Payer Prior Authorization or Referral Number ................................................................. 549 Other Payer Prior Authorization or Referral Number ................................................................. 552 Line Adjudication Information................................ 554 Line Adjustment .................................................... 558 Line Adjudication Date .......................................... 566 Form Identification Code ...................................... 567 Supporting Documentation ................................... 569 Transaction Set Trailer.......................................... 572

4 EDI Transmission Examples for Different Business Uses .......................................................................... 573

4.1 Professional .................................................................................... 573
4.1.1 4.1.2 4.1.3 4.1.4 Example 1 ............................................................................. 573 Example 2 ............................................................................. 577 Example 3 ............................................................................. 582 Example 4 ............................................................................. 602

4.2 Property and Casualty ................................................................ 606

4.2.1 Example 1 ............................................................................. 606 4.2.2 Example 2 ............................................................................. 611 4.2.3 Example 3 ............................................................................. 616

A ASC X12 Nomenclature .......................................................A.1

A.1 Interchange and Application Control Structures ..............A.1
A.1.1 Interchange Control Structure .............................................A.1 A.1.2 Application Control Structure Definitions and Concepts................................................................................A.2 A.1.2.1 Basic Structure ......................................................A.2 A.1.2.2 Basic Character Set...............................................A.2 A.1.2.3 Extended Character Set ........................................A.2 A.1.2.4 Control Characters ................................................A.3 A.1.2.5 Base Control Set ...................................................A.3 A.1.2.6 Extended Control Set ............................................A.3 A.1.2.7 Delimiters...............................................................A.4 A.1.3 Business Transaction Structure Definitions and Concepts................................................................................A.4 A.1.3.1 Data Element.........................................................A.4 A.1.3.2 Composite Data Structure .....................................A.6 A.1.3.3 Data Segment........................................................A.7 A.1.3.4 Syntax Notes .........................................................A.7 A.1.3.5 Semantic Notes .....................................................A.7 A.1.3.6 Comments .............................................................A.7 A.1.3.7 Reference Designator............................................A.7 A.1.3.8 Condition Designator .............................................A.8 A.1.3.9 Absence of Data ....................................................A.9 A.1.3.10 Control Segments ..................................................A.9
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A.1.3.11 Transaction Set....................................................A.10 A.1.3.12 Functional Group .................................................A.12 A.1.4 Envelopes and Control Structures ....................................A.12 A.1.4.1 Interchange Control Structures............................A.12 A.1.4.2 Functional Groups ...............................................A.13 A.1.4.3 HL Structures.......................................................A.13 A.1.5 Acknowledgments ..............................................................A.14 A.1.5.1 Interchange Acknowledgment, TA1 .....................A.14 A.1.5.2 Functional Acknowledgment, 997 ........................A.14

B EDI Control Directory ............................................................B.1

B.1 Control Segments ..........................................................................B.3
ISA IEA GS GE TA1 ST AK1 AK2 AK3 AK4 AK5 AK9 SE Interchange Control Header.................................................B.3 Interchange Control Trailer ..................................................B.7 Functional Group Header .....................................................B.8 Functional Group Trailer ....................................................B.10 Interchange Acknowledgment ........................................... B.11 Transaction Set Header ......................................................B.16 Functional Group Response Header.................................B.18 Transaction Set Response Header ....................................B.19 Data Segment Note .............................................................B.20 Data Element Note ..............................................................B.22 Transaction Set Response Trailer .....................................B.24 Functional Group Response Trailer ..................................B.27 Transaction Set Trailer........................................................B.30

B.2 Functional Acknowledgment Transaction Set, 997 .......B.15

C External Code Sources ........................................................C.1

5 22 41 51 77 121 130 131 139 235 237 240 245 411 513 522 540 Countries, Currencies and Funds .......................................C.1 States and Outlying Areas of the U.S..................................C.1 Universal Product Code .......................................................C.2 ZIP Code ................................................................................C.2 X12 Directories......................................................................C.3 Health Industry Identification Number................................C.3 Health Care Financing Administration Common Procedural Coding System ..................................................C.4 International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure...........................................................C.4 Claim Adjustment Reason Code..........................................C.5 Claim Frequency Type Code ................................................C.5 Place of Service from Health Care Financing Administration Claim Form..................................................C.5 National Drug Code by Format ............................................C.6 National Association of Insurance Commissioners (NAIC) Code...........................................................................C.6 Remittance Remark Codes ..................................................C.6 Home Infusion EDI Coalition (HIEC) Product/Service Code List................................................................................C.7 Health Industry Labeler Identification Code.......................C.7 Health Care Financing Administration National PlanID ....C.7

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D Change Summary ....................................................................D.1 E Data Element Name Index..................................................E.1 F NSF Mapping ............................................................................... F.1
F.1 X12N-NSF Map ................................................................................ F.1 F.2 Complete NSF to ASC X12N 837 Map .................................. F.17

G Credit/Debit Card Use .......................................................... G.1

G.1 Credit/Debit Card Scenario 837 Transaction Set ............. G.1

H Medicare Primary, Secondary and Supplemental Payers ............................................................H.1

H.1 How to Indicate Whether Medicare is Primary or Secondary....................................................................................H.1 H.2 How to Indicate Other Payers Supplementary to Medicare .......................................................................................H.1

I National Uniform Claim Committee Recommendations ................................................................... I.1

I.1 National Uniform Claim Committee (NUCC) ........................ I.1

J X12N 837 Professional Implementation Guide Alias Index. .................................................................... J.1 K Loop 2440 Example ................................................................K.1

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1 Purpose and Overview

1.1 Document Purpose
For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical. This is the implementation guide for the ANSI ASC X12N 837 Health Care Claims (837) transaction for professional claims and/or encounters. This implementation guide provides standardized data requirements and content for all users of the 837. The purpose of this implementation guide is to expedite the goal of achieving a totally electronic data interchange health encounter/claims processing and payment environment. This implementation guide provides a definitive statement of what data translators must be able to handle in this version of the 837. The implementation guide also specifies limits and guidance to what a provider (submitter) can place in an 837. This implementation guide is intended to be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated rules.

1.1.1

Trading Partner Agreements

It is appropriate and prudent for payers to have trading partner agreements that go with the standard Implementation Guides. This is because there are 2 levels of scrutiny that all electronic transactions must go through. First is standards compliance. These requirements MUST be completely described in the Implementation Guides for the standards, and NOT modified by specific trading partners. Second is the specific processing, or adjudication, of the transactions in each trading partners individual system. Since this will vary from site to site (e.g., payer to payer), additional documentation which gives information regarding the processing, or adjudication, will prove helpful to each sites trading partners (e.g., providers), and will simplify implementation. For example, while a certain code may be valid in an IG, a specific trading partner may not process transactions which utilize that specific code. This would be important to communicate in a trading partner agreement. It is important that these trading partner agreements NOT: Modify the definition, condition, or use of a data element or segment in the standard Implementation Guide Add any additional data elements or segments to the standard Utilize any code or data values which are not valid (because they are either marked not used in the IG or they are not in the standard X12 transaction at all) in the standard Implementation Guide Change the meaning or intent of the standard Implementation Guide These types of companion documents should exist solely for the purpose of clarification, and should not be required for acceptance of a transaction as valid.

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1.1.2

The HIPAA Role in Implementation Guides

The Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191 known as HIPAA) includes provisions for Administrative Simplification, which require the Secretary of Department of Health and Human Services to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard. Detailed Implementation Guides for each standard must be available at the time of the adoption of HIPAA standards so that health plans, providers, clearinghouses, and software vendors can ready their information systems and application software for compliance with the standards. Consistent usage of the standards, including loops, segments, data elements, etc., across all guides is mandatory to support the Secretarys commitment to standardization. This Implementation Guide has been developed for use as a HIPAA Implementation Guide for Health claims or equivalent encounter information. Should the Secretary adopt the X12N 837 Health Care Professional Claim transaction as an industry standard, this Implementation Guide describes the consistent industry usage called for by HIPAA. When adopted under HIPAA, the X12 837 Health Care Professional Claim transaction cannot be implemented except as described in this Implementation Guide.

1.2

Version and Release

This implementation guide is based on the October 1997 ASC X12 standards, referred to as Version 4, Release 1, Sub-release 0 (004010).

1.3

Business Use and Definition

The ASC X12 standards are formulated to minimize the need for users to reprogram their data processing systems for multiple formats by allowing data interchange through the use of a common interchange structure. These standards do not define the method in which interchange partners should establish the required electronic media communication link, nor the hardware and translation software requirements to exchange EDI data. Each trading partner must provide these specific requirements separately. This implementation guide is intended to provide assistance in developing and executing the electronic transfer of health encounter and health claim data. With a few exceptions, this implementation guide does not contain payer-specific instructions. Trading partners agreements are not allowed to set data specifications that conflict with the HIPAA implementations. Payers are required by law to have the capability to send/receive all HIPAA transactions. For example, a payer who does not pay claims with certain home health information must still be able to electronically accept on their front end an 837 with all the home health data. The payer cannot up-front reject such a claim. However, that does not mean that the payer is required to bring that data into their adjudication system. The payer, acting in accordance with policy and contractual agreements, can ignore data within the 837 data set. In light of this, it is permissible for trading partners to specify a subset of an implementation guide as data they are able to *process* or act upon

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most efficiently. A provider who sends the payer in the example above home health data has just wasted their resources and the resources of the payer. Thus, it behooves trading partners to be clear about the specific data within the 837 (i.e., a subset of the HIPAA implementation guide data) they require or would prefer to have in order to efficiently adjudicate a claim. The subset implementation guide must not contain any loops, segments, elements or codes that are not included in the HIPAA implementation guide. In addition, the order of data must not be changed. Trading partners cannot up-front, reject a claim based on the standard HIPAA transaction.

1.3.1

Terminology
Certain terms have been defined to have a specific meaning within this guide. The following terms are particularly key to understanding and using this guide. Dependent In the hierarchical loop coding, the dependent code indicates the use of the patient hierarchical loop (Loop 2000C). Destination Payer The destination payer is the payer who is specified in the Subscriber/Payer loop (Loop ID-2010BB). Patient The term patient is intended to convey the case where the Patient loop (Loop ID-2000C) is used. In that case, the patient is not the same person as the subscriber, and the patient is a person (e.g., spouse, children, others) who is covered by the subscribers insurance plan. However, it also happens that the patient is sometimes the same person as the subscriber. In that case, all information about the patient/subscriber is carried in the Subscriber loop (Loop ID2000B). See Section 2.3.2.1 for further details. Every effort has been made to ensure that the meaning of the word patient is clear in its specific context. Provider In a generic sense, the provider is the entity that originally submitted the claim/encounter. A provider may also have provided or participated in some aspect of the health care service described in the transaction. Specific types of providers are identified in this implementation guide (e.g., billing provider, referring provider). Secondary Payer The term secondary payer indicates any payer who is not the primary payer. The secondary payer may be the secondary, tertiary, or even quaternary payer. Subscriber The subscriber is the person whose name is listed in the health insurance policy. Other synonymous terms include member and/or insured. In some cases the subscriber is the same person as the patient. See the definition of patient, and see Section 2.3.2.1 for further details. Transmission Intermediary A transmission intermediary is any entity that handles the transaction between the provider (originator of the claim/encounter transmission) and the destination payer. The term intermediary is not used to convey a specific Medicare contractor type.

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1.3.2

Batch and Real Time Definitions

Within telecommunications, there are multiple methods used for sending and receiving business transactions. Frequently, different methods involve different timings. Two methods applicable for EDI transactions are batch and real time. This guide is intended for use in a Batch only environment. Batch - When transactions are used in batch mode, they are typically grouped together in large quantities and processed en-masse. In a batch mode, the sender sends multiple transactions to the receiver, either directly or through a switch (clearinghouse), and does not remain connected while the receiver processes the transactions. If there is an associated business response transaction (such as a 271 response to a 270 for eligibility), the receiver creates the response transaction for the sender off-line. The original sender typically reconnects at a later time (the amount of time is determined by the original receiver or switch) and picks up the response transaction. Typically, the results of a transaction that is processed in a batch mode would be completed for the next business day if it has been received by a predetermined cut off time. Important: When in batch mode, the 997 Functional Acknowledgment transaction must be returned as quickly as possible to acknowledge that the receiver has or has not successfully received the batch transaction. In addition, the TA1 segment must be supported for interchange level errors (see section A.1.5.1 for details). Real Time - Transactions that are used in a real time mode typically are those that require an immediate response. In a real time mode, the sender sends a request transaction to the receiver, either directly or through a switch (clearinghouse), and remains connected while the receiver processes the transaction and returns a response transaction to the original sender. Typically, response times range from a few seconds to around thirty seconds, and should not exceed one minute. Important: When in real time mode, the receiver must send a response of either the response transaction, a 997 Functional Acknowledgment, or a TA1 segment (for details on the TA1 segment, see section A.1.5.1). Generally speaking, the 837 functions in a batch mode with the possible exception of preadjudication or predetermination of benefits situations (determined by trading partner agreements).

1.4

Information Flows
The Health Care Claim Transaction for Professional Claims/Encounters (837) is intended to originate with the health care provider or the health care providers designated agent. It may also originate with payers in an encounter reporting situation. The 837 provides all necessary information to allow the destination payer to at least begin to adjudicate the claim. The 837 coordinates with a variety of other transactions including, but not limited to, the following: Claim Status (277), Remittance Advice (835), and Functional Acknowledgment (997). See Section 2.6, Interactions with Other Transactions, for a summary description of these interactions.

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1.4.1

National Standard Format (NSF)

As an aid to the initial implementation for National Standard Format (NSF) users, Appendix F, NSF Mapping, maps the NSF data elements to the elements locations on the 837. Version 003.01 of the HCFA NSF is the basis of this map. However, due to factors such as the differences between variable and fixed-length records, the map can not provide one-to-one correspondence.

1.4.2

Coordination of Benefits
One primary goal of this specific version and release of the 837 is to further develop the capability of handling coordination of benefits (COB) in a totally EDI environment. Electronic data interchange COB is predicated upon using two transactions the 837 and the 835 (Health Care Claim Payment/Advice). See Sections 1.4.2.1and 1.4.2.2 for details about the two methods of using the 837 in conjunction with the 835 to achieve electronic COB. See Section 4, EDI Transmission Examples for Different Business Uses, for several detailed examples. Trading partners must understand that EDI COB can not be achieved efficiently without using both the 837 and the 835 transactions. Furthermore, EDI COB creates a new interdependence in the health care industry. Previously, if Payer A chose not to develop the capability to send electronic remittance advices (835s), the effect was largely limited to its provider trading partners. However, if Payer A chooses not to implement electronic remittance advices, this now affects all other payers who are involved in COB over a claim with Payer A. In other words, if Payer A as a secondary payer wishes to achieve EDI COB, Payer A must rely on all other payers who are primary to it on any claim to also implement the 835.

1.4.2.1

Coordination of Benefits Data Models Detail

The 837 transaction handles two models of coordinating benefits. Both models are discussed in section 1.4.2.2, Coordination of Benefits - Correction Detail. See section 4, EDI Transmission Examples for Different Business Uses, for examples of these models. The implementation guide contains notes on each COB-related

835 RA from Payer A First 837 Claim Provider Second 837 Claim

Payer A Primary

Payer B Secondary 835 RA from Payer B

Figure 1. Provider-to-Payer-to-Provider COB Model

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data element specifying when it is used. See the final HIPAA rules for more information on COB. Model 1 Provider-to-Payer-to-Provider Step 1. In model 1, the provider originates the transaction and sends the claim information to Payer A, the primary payer. See figure 1, Provider-to-Payer-toProvider COB Model. The Subscriber loop (Loop ID-2000B) contains information about the person who holds the policy with Payer A. Loop ID-2320 contains information about Payer B and the subscriber who holds the policy with Payer B. In this model, the primary payer adjudicates the claim and sends an electronic remittance advice (RA) transaction (835) back to the provider. The 835 contains the claim adjustment reason codes that applies to that specific claim. The claim adjustment reason codes detail what was adjusted and why. Step 2. Upon receipt of the 835, the provider sends a second health care claim transaction (837) to Payer B, the secondary payer. The Subscriber loop (Loop ID2000B) now contains information about the subscriber who holds the policy from Payer B. The information about the subscriber for Payer A is now placed in Loop ID-2320. Any total amounts paid at the claim level go in the AMT segments in Loop ID-2300. Any claim level adjustments codes are retrieved from the 835 from Payer A and put in the CAS (Claims Adjustment) segment in Loop ID-2320. Claim level amounts are placed in the AMT segment at the Loop ID 2320 level. Line Level adjustment reason codes are retrieved similarly from the 835 and go in the CAS segment in the 2430 loop. Payer B adjudicates the claim and sends the provider an electronic remittance advice. Step 3. If there are additional payers (not shown in figure 1, Provider-to-Payer-toProvider COB Model), step 2 is repeated with the Subscriber loop (Loop ID2000B) having information about the subscriber who holds the policy from Payer C, the tertiary payer. COB information specific to Payer B is included by running the Loop ID-2320 again and specifying the payer as secondary, and, if necessary, by running Loop ID-2430 again for any line level adjudications. Model 2 Provider-to-Payer-to-Payer Step 1. In model 2, the provider originates the transaction and sends claim information to Payer A, the primary payer. See figure 2, Provider-to-Payer-to-Payer COB Model. The Subscriber loop (Loop-ID 2000B) contains information about the person who holds the policy with Payer A. All other subscriber/payer informa-

835 RA from Payer A

Payer A Primary

First 837 Claim Provider Includes all information on other insurers involved in this claim. Second 837 Claim Claim has been reformatted to place Payer B information in Destination Payer position and Payer A information in COB loops.

835 RA from Payer B

Payer B Secondary

Figure 2. Provider-to-Payer-to-Payer COB Model

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tion is included in Loop-ID 2320. In this model, the primary payer adjudicates the claim and sends an 835 back to the provider. Step 2. Payer A reformats the 837 and sends it to the secondary payer. In reformatting the claim, Payer A takes the information about their subscriber and places it in Loop ID-2320. Payer A also takes the information about Payer B, the secondary payer/subscriber, and places it in the appropriate fields in the Subscriber Loop ID-2000B. Then Payer A sends the claim to Payer B. All COB information from Payer A is placed in the appropriate Loop ID-2320 and/or Loop ID2430. Step 3. Payer B receives the claim from Payer A and adjudicates the claim. Payer B sends an 835 to the provider. If there is a tertiary payer, Payer B performs step 2 (not shown in figure 2, Provider-to-Payer-to-Payer COB Model).

1.4.2.1.1

Coordination of Benefits Claim Level

The destination payers information is located in Loop ID-2010BB. In addition, any destination payer specific claim information (e.g., referral number), is located in the 2300 loop. All provider identifiers in the 2310 and 2420 loops are specific to the destination payer. Loop ID-2320 occurs once for each payer responsible for the claim, except for the payer receiving the 837 transaction set (destination payer). Loop ID-2320 contains the following: claim level adjustments other subscriber demographics various amounts other payer information assignment of benefits indicator patient signature indicator Inside Loop ID-2320, Loop ID-2330 contains the information for the payer and the subscriber. As the claim moves from payer to payer, the destination payers information in Loop ID-2000B and Loop ID-2010BB must be exchanged with the next payers information from Loop ID-2320/2330. The table below shows claim level loop ID and payer information. Sending the Claim to the First Destination Payer: 2000B/2010BB First (usually the primary) payer 2320/2330 Second payer 2320/2330 Third payer (repeat 2320/2330 loops as needed for additional payers). Sending the Claim to the Second Destination Payer: 2000B/2010BB Second (usually the secondary) payer 2320/2330 Primary payer 2320/2330 Third payer 2320/2330 Any other payer (repeat 2320/2330 loops as needed for additional payers).

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Sending the Claim to the Third Destination Payer: 2000B/2010BB Third (usually the tertiary) payer 2320/2330 Primary payer 2320/2330 Secondary payer (repeat 2320/2330 loops as needed for additional payers.)

1.4.2.1.2

Coordination of Benefits Service Line Level

Loop ID-2430 is an optional loop that can occur one or more times for each service line. As each payer adjudicates the service lines, occurrences may be added to this loop to explain how the payer adjudicated the service line. Loop ID-2430 contains the following: ID of the payer who adjudicated the service line amount paid for the service line procedure code upon which adjudication of the service line was based. This code may be different than the submitted procedure code. (This procedure code also can be used for unbundling or bundling service lines.) paid units of service service line level adjustments adjudication date To enable accurate matching of billed service lines with paid service lines, it is required that the payer return the original billed procedure code(s) and/or modifiers in the 835 if they are different from those used to pay the line. In addition, if a provider includes line item control numbers at the 2400 level (REF01 = 6R) then payers are required to return this in the corresponding 835.

1.4.2.2

Coordination of Benefits Correction Detail

In electronic coordination of benefits, it occasionally happens that a claim is paid in error by the primary payer, and the error is discovered and corrected only after the claim was sent (with the payment information from the primary payer incorporated) to the secondary payer. When a claim is paid in error, the incorrect payment (835) is reversed out and the claim is re-paid. If a provider has a claim that involves coordination of benefits between several payers and the primary (or other) payer made a correction on a claim by reversing and resending the data, the implementation guide developers recommend that the entity sending the secondary claim send the corrected payment information to the secondary payer. Only segments specific to COB are included in the following examples. Example (This example is included in the Health Care Claim Payment/Advice (835004010) Implementation Guide also.) Original Claim/Remittance Advice: In the original Preferred Provider Organization (PPO) payment, the reported charges are as follows: Submitted charges: Adjustments Disallowed amount Co-insurance $100.00 $ 20.00 $ 16.00
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Deductible Payment amount

$ 24.00 $ 40.00

Original 835: In the original payment (835), the information is as follows:

CLP*1234567890*1*100*40*40*12~
1234567890 = Providers claim identification number 1 = Paid as primary 100 = Amount billed 40 = Amount paid 40 = Patient responsibility 12 = PPO

CAS*PR*1*24**2*16~
PR = Patient Responsibility adjustment reason group code 1 = Claim adjustment reason code Deductible 24 = Amount of deductible 2 = Claim adjustment reason code Coinsurance 16 = Amount of co-insurance

CAS*CO*45*20~
CO = Contractual Obligation adjustment reason group code 45 = Claim adjustment reason code Charges exceed your contracted/legislated fee arrangement 20 = Amount of adjustment Original secondary 837: The 837is sent to the secondary as follows: CLM05-3 uses code 1 - ORIGINAL, because this is the first time the secondary payer received this claim.

CAS*PR*1*24**2*16~
PR = Patient Responsibility adjustment reason group code 1 = Claim adjustment reason code Deductible 24 = Amount of deductible 2 = Claim adjustment reason code Coinsurance 16 = Amount of co-insurance

CAS*CO*45*20~
CO = Contractual Obligation adjustment reason group code 45 = Claim adjustment reason code Charges exceed your contracted/legislated fee arrangement 20 = Amount of adjustment

AMT*D*40~
D = Payer Amount Paid code 40 = Amount

AMT*F2*40~
F2 = Patient Responsibility code 40 = Amount

1.4.2.2.1

Reversal and Correction Method of COB

Corrected Remittance Advice and Claim: The primary payer finds an error in the original claim adjudication that requires a

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correction. In this case, the disallowed amount should have been $40.00 instead of the original $20.00. The co-insurance amount should have been $12.00 instead of $16.00, and the deductible amount remained the same. The reversal and correction method reverses the original payment, restoring the patient accounting system to the pre-posting balance for this patient. The payer sends an 835 showing the reversal of the original claim (reversal 835) and then sends the corrected claim payment (corrected 835) to the provider to post to the account. It is anticipated that the provider has the ability to post these reversals electronically, without any human intervention. The secondary payer also should be able to handle corrections electronically. The provider does not need to send the information from the reversal 835 to the secondary payer. The provider must send the information from the corrected 835 to the secondary payer. The secondary payer handles the information from the corrected 835 in the manner that best suits the secondary payers specific accounting system. In the 835, reversing the original claim payment is accomplished with code 22, Reversal of Previous Payment, in CLP02; code CR, Corrections and Reversals, in CAS01; and appropriate adjustments. All original charge, payment, and adjustment amounts are negated. Reversal 835:

CLP*1234567890*22*-100*-40**12~
1234567890 = Providers claim identification number 22 = Reversal of Previous Payment code -100 = Reversal of original billed amount -40 = Reversal of original paid amount 12 = PPO provider code

CAS*CR*1*-24**2*-16**45*-20~
CR = Correction and Reversals adjustment reason group code 1 = Claim adjustment reason code Deductible -24 = Amount of deductible 2 = Claim adjustment reason code Coinsurance -16 = Amount of co-insurance 45 = Claim adjustment reason code Charges exceed your contracted/legislated fee arrangement -20 = Amount of adjustment Corrected 835: The corrected payment information is then sent in a subsequent 835.

CLP*1234567890*1*100*24*36*12~
1234567890 = Providers claim identification number 1 = Paid as primary 100 = Amount billed 24 = Amount paid 36 = Patient responsibility 12 = PPO

CAS*PR*1*24**2*12~
PR = Patient Responsibility adjustment reason group code 1 = Claim adjustment reason code Deductible 24 = Amount of deductible

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2 = Claim adjustment reason code Coinsurance 12 = Amount of co-insurance

CAS*CO*45*40~
CO = Contractual Obligation adjustment reason group code 45 = Claim adjustment reason code Charges exceed your contracted/legislated fee arrangement 40 = Amount of adjustment Corrected secondary 837: The reversal information is sent to the secondary payer in an 837. The corrected 837 COB payment information is sent as follows: CLM05-3 uses code 7 - RESUBMISSION, to indicate that this claim is not a duplicate.

CAS*PR*1*24**2*12~
PR = Patient Responsibility adjustment reason group code 1 = Claim adjustment reason code Deductible 24 = Amount of deductible 2 = Claim adjustment reason code Coinsurance 12 = Amount of co-insurance

CAS*CO*45*40~
CO = Contractual Obligation adjustment reason group code 45 = Claim adjustment reason code Charges exceed your contracted/legislated fee arrangement 40 = Amount of adjustment

AMT*D*24~
D = Payer Amount Paid code 24 = Amount

AMT*F2*36~
F2 = Patient Responsibility code 36 = Amount

1.4.3

Service Line Procedure Code Bundling and Unbundling

This explanation of bundling and unbundling is not applicable to the building of initial claims to primary payers. However, it is applicable to secondary claims that must contain the results of the primary payers processing. Procedure code bundling or unbundling occurs when a payer believes that the actual services performed and reported for payment in a claim can be represented by a different group of procedure codes. Bundling occurs when two or more reported procedure codes are paid under only one procedure code. Unbundling occurs when one submitted procedure code is paid and reported back as two or more procedure codes. In the interest of standardization, payers should perform bundling or unbundling in a consistent manner when including their explanation of benefits on a claim. See the 004010 835 implementation guide for an explanation on how bundling and unbundling are handled in that transaction.

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Bundling: In a COB situation, it may be necessary to show payment on bundled lines. When showing bundled service lines, the health care claim must report all of the originally submitted service lines. The first bundled procedure should include the new bundled procedure code in the SVD (Service Line Adjudication) segment (SVD03). The other procedure or procedures that are bundled into the same line should be reported as originally submitted with the following: an SVD segment with zero payment (SVD02), a pointer to the new bundled procedure code (SVD06, data element 554 (Assigned Number) is the bundled service line number that refers to either the line item control number (REF01 = 6R) submitted by the provider in the 837 (one/line) or the LX assigned number of the service line into which this service line was bundled if no line item control number is assigned), a CAS segment with a claim adjustment reason code of 97 (payment is included in the allowance for the basic service), and an adjustment amount equal to the submitted charge. The Adjustment Group in the CAS01 should be either CO (Contractual Obligation) or PI (Payer Initiated), depending upon the provider/payer relationship. Bundling Example Dr. Smith submits procedure code A and B for $100.00 each to his PPO as primary coverage. Each procedure was performed on the same date of service. The PPOs adjudication system screens the submitted procedures and notes that procedure C covers the services rendered by Dr. Smith on that single date of service. The PPOs maximum allowed amount for procedure C is $120.00. The patients co-insurance amount for procedure C is $20.00. The patient has not met the $50.00 deductible. The following example includes only segments specific to bundling. Claim Level (Loop ID-2320)

CAS*PR*1*50~
PR = Patients Responsibility 1 = Adjustment reason - Deductible amount 50 = Amount of adjustment Service Line Level (Loop ID-2430)

LX*1~
1 = Service line 1

SV1*HC:A:100*UN*1*****N~
HC = HCPCS qualifier A = HCPCS procedure code 100 = Submitted charge UN = Units 1 = Number of units N = Not an emergency

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SVD* PAYER ID*70*HC:C**1~

PAYER ID = ID of the payer who adjudicated this service line 70 = Payer amount paid HC = HCPCS qualifier C = HCPCS procedure code 1 = Paid units of service

CAS*PR*2*20~
PR = Patient Responsibility 2 = Adjustment reason - Coinsurance amount 20 = Amount of adjustment

LX*2~
2 = Service line 2

SV1*HC:B*100*UN*1*****N~
HC = HCPCS qualifier B = HCPCS procedure code 100 = Submitted charge UN = Units 1 = Number of units N = Not an emergency

SVD* PAYER ID*0*HC:C**1*1~

PAYER ID = ID of the payer who adjudicated this service line 0 = Payer amount paid HC = HCPCS qualifier C = HCPCS procedure code 1 = Paid units of service 1 = Service line this line was bundled into

CAS*CO*97*100~
CO = Contractual Obligation 97 = Adjustment reason - Payment is included in the allowance for the basic service/procedure. 100 = Amount of adjustment Bundling with COB Example Heres an example of how to combine bundling with COB: Dr. Smith submits procedure code A and B for $100.00 each to his PPO as primary coverage. Each procedure was performed on the same date of service. The original 837 submitted by Dr. Smith contains this information. Only segments specific to bundling are included in the example. Original 837

LX*1~ (Loop 2400)

1 = Service line 1

SV1*HC:A*100*UN*1**N~
HC = HCPCS qualifier A = HCPCS code 100 = Submitted charge UN = Units code 1 = Units billed N = Not an emergency code
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REF*6R*2J01K~
6R = Line item control number code 2J01K = Control number for this line

LX*2~ (Loop 2400)

2 = Service line 2

SV1*HC:B*100*UN*1**N~
HC = HCPCS qualifier B = HCPCS code 100 = Submitted charge UN = Units code 1 = Units billed N = Not an emergency code

REF*6R*2J02K~
6R = Line item control number 2J02K = Control number for this line The PPOs adjudication system screens the submitted procedures and notes that procedure C covers the services rendered by Dr. Smith on that single date of service. The PPOs maximum allowed amount for procedure C is $120.00. The patients co-insurance amount for procedure C is $20.00. The patient has not met the $50.00 deductible. The following example includes only segments specific to bundling. The key number to automate tracking of bundled lines is the line item control number assigned to each service line by the provider. Claim Level (Loop ID-2320)

CAS*PR*1*50~
PR = Patients Responsibility 1 = Adjustment reason - Deductible amount 50 = Amount of adjustment Service Line Level (Loop ID-2400)

SV1*HC:A*100*UN*1**N~
HC = HCPCS qualifier A = HCPCS code 100 = Submitted charge UN = Units code 1 = Units billed N = Not an emergency code

REF*6R*2J01K~
6R = Line item control number 2J01K = Control number for this line

SVD*PAYER ID*70*HC:C**1~ (Loop 2430)

Payer ID = ID of the payer who adjudicated this service line 70 = Payer amount paid HC = HCPCS qualifier C = HCPCS code for bundled procedure 1 = Paid units of service 2J01K = Line item control number

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CAS*PR*2*20~
PR = Patient Responsibility 2 = Adjustment reason Co-insurance amount 20 = Amount of adjustment

LX*2~ (Loop 2400)

2 = Service line 2

SV1*HC:B*100*UN*1**N~
HC = HCPCS qualifier B = HCPCS code 100 = Submitted charge UN = Units code 1 = Units billed N = Not an emergency code

REF*6R*2J02K~
6R = Line item control number code 2J02K = Control number for this line

SVD*PAYER ID*0*HC:C*1*2J01K~ (Loop 2430)

Payer ID = ID of the payer who adjudicated this service line 0 = Payer amount paid HC = HCPCS qualifier C = HCPCS code for bundled procedure 1 = Units paid 2J01K = Service line into which this service line was bundled

CAS*CO*97*100~
CO = Contractual obligations qualifier 97 = Adjustment reason - Payment is included in the allowance for the basic service/procedure 100 = Amount of adjustment Bundling with more than two payers in a COB situation where there is bundling and more than two payers show all claim level adjustments for each payer in 2320 and 2330 loop as follows: 2330 Loop (for payer A) SBR* identifies the other subscriber for payer A identified in 2330B CAS* identifies all the claim level adjustments for payer A 2330A Loop NM1*identifies other subscriber for payer A 2330B Loop NM1* identifies payer A 2320 Loop (for payer B) SBR* identifies the other subscriber for payer B identified in 2330B loop CAS* identifies all the claim level adjustments for payer B 2330A Loop NM1*identifies other subscriber for payer B 2330B Loop NM1* identifies payer B

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2320 Loop (for payer C) SBR* identifies the other subscriber for payer C identified in 2330B loop CAS* identifies all the claim level adjustments for payer C 2330A Loop NM1*identifies other subscriber for payer C 2330B Loop NM1* identifies payer C Repeat as necessary up to a maximum of 10 times. Any one claim can carry up to a total of 11 payers (10 carried at the COB level and 1 carried up at the top 2010BB loop). Once all the claim level payers and adjustments have been identified, run the 2400 loop once for each original billed service line. Use 2430 loops to show line level adjustment by each payer. 2400 Loop

LX*1~
SV1* original data from provider 2430 Loop (for payer A) SVD*A* their data for this line (the original billed procedure code plus the code A paid on) CAS* payer As data for this line (repeat CAS as necessary) DTP* As adjudication date for this line. 2430 Loop (for payer B) SVD*B* their data for this line (the original billed procedure code plus the code B paid on) CAS* payer Bs data for this line (repeat CAS as necessary) DTP* Bs adjudication date for this line. 2430 Loop (for payer C, only used if 837 is being sent to payer D) SVD*C* their data for this line (the original billed procedure code plus the code C paid on) CAS* payer Cs data for this line (repeat CAS as necessary) DTP* Cs adjudication date for this line. 2400 Loop

LX*2~
SV1* original data from provider for line 2 2430 Loop (for payer A) SVD*A* their data for this line (the original billed procedure code plus the code A paid on) CAS* payer As data for this line (repeat CAS as necessary) DTP* As adjudication date for this line. 2430 Loop (for payer B) SVD*B* their data for this line (the original billed procedure code plus the code B paid on) CAS* payer Bs data for this line (repeat CAS as necessary) DTP* Bs adjudication date for this line.

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2430 Loop (for payer C, only used if 837 is being sent to payer D) SVD*C* their data for this line (the original billed procedure code plus the code C paid on) CAS* payer Cs data for this line (repeat CAS as necessary) DTP* Cs adjudication date for this line. Etc. Unbundling with COB When unbundling, the original service line detail should be followed by occurrences of the SVD loop, once for each unbundled procedure code. Unbundling Example The same PPO provider submits a one service claim. The billed service procedure code is A, with a submitted charge of $200.00. The payer unbundled this into two services - B and C - each with an allowed amount of $60.00. There is no deductible or co-insurance amount. Claim Level (Loop ID-2320) Only segments specific to unbundling are included in the following example.

CAS*OA*93*0~
OA = Other adjustments qualifier 93 = Adjustment reason - No claim level adjustments. 0 = Amount of adjustment Service Line Level (Loop ID-2400):

LX*1~
1 = Service line 1

SV1*HC:A*200*UN*1**N~
HC = HCPCS qualifier A = HCPCS code 200 = Submitted charge UN = Units code 1 = Units billed N = Not an emergency code

REF*6R*JR001426789~
6R = Line item control number code JR001426789 = Control number for this service line Service Line Adjudication Information: (Loop ID-2430)

SVD*PAYER ID*60*HC:B**1~
Payer ID = ID of the payer who adjudicated this service line 60 = Payer amount paid HC = HCPCS qualifier B = Unbundled HCPCS code

CAS*CO*45*35~
CO = Contractual obligations qualifier 45 = Adjustment reason Charges exceed your contracted/legislated fee arrangement 35 = Amount of adjustment

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SVD*PAYER ID*60*HC:C
Payer ID = ID of the payer who adjudicated this service line 60 = Payer amount paid HC = HCPCS qualifier C = Unbundled HCPCS code

CAS*CO*45*45~
CO = Contractual obligations qualifier 45 = Adjustment reason Charges exceed your contracted/legislated fee arrangement 45 = Amount of adjustment

1.4.4

Payer-to-Payer COB
See the final HIPAA rules for specifics on payer to payer COB. With the exception of Medicaid and Medicare crossover claims, most payers (with some notable exceptions) only accept COB claims from providers. According to the information available to X12N, the most extensively documented payer-to-payer COB transactions are Medicare to Medicaid/Medicare Secondary Payers. X12N has made every effort to make this implementation guide compatible with the data requirements set out by Medicare for their payer-to-payer transactions as defined in the Medicare NSF COB implementation guide version 3.01. The list of NSF elements specific and unique to COB is given below (in alphabetical order). NSF elements that HCFA no longer considers necessary for COB are so indicated.
Element Name NSF Field 837 Crosswalk

Approved amount - Claim level Approved amount - Line level Balance bill limiting charge - Claim Balance bill limiting charge - Line Beneficiary adjustment amount Beneficiary liability amount Blood units paid Blood units remaining Claim adjustment indicator Limit charge percent Original approved amount Original paid amount Original payor claim control number Paid amount Performing provider assignment indicator Performing provider phone Performing provider tax ID Performing provider tax type Provider adjustment amount

FA0-51.0 FA0-51.0 FA0-54.0 FA0-54.0 DA3-26.0 FA0-53.0 EA0-51.0 EA0-52.0 DA3-24.0 FA0-55.0 DA3-27.0 DA3-28.0 DA3-29.0 FA0-52.0 FA0-59.0 FA0-56.0 FA0-58.0 FA0-57.0 DA3-25.0

2320 - AMT 2400 - AMT 2320 - CAS 2420 - CAS 2320 - CAS 2320 - CAS No longer used No longer used 2330B - REF Calculated from CAS Obtained from original claim Obtained from original claim 2330B - REF 2320 AMT, 2430 SVD 2300 - CLM07 No longer used NM109/REF02 of provider loops NM108/REF01 of provider loops 2320, 2430 - CAS

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Type of units indicator

FA0-50.0

2400 - SV103, 2400-CR106

Crosswalks involving the CAS segment must be calculated by subtracting the adjustment given in the CAS from the amount billed for the service line or claim (billed - adjustment = paid) or other similar computation. Crosswalks for original amounts are obtained by comparing the amounts received on the original COB claim with that received in the adjusted COB claim.

1.4.5

Crosswalking COB Data Elements

This section has been added to the 837 Health Care Claims professional implementation guide in the event that a trading partner wishes to automate their COB process. Trading partners who may be interested in automating the COB process include payers and providers or their representatives. Refer to final HIPAA rules for information about any mandates for payer-to-payer coordination of benefits (COB) in an electronic format. With the exception of Medicaid and Medicare crossover claims, most payers (with some notable exceptions) only accept COB claims from providers. Although it is possible to do COB in the 4010 version of the 837 it is somewhat awkward (which the workgroup intends to study and remedy if necessary in the future). The purpose of the discussion below is to clarify exactly which data must be moved around within the 837 to facilitate an automation of COB. Either payers or providers can elect to use this strategy. For the purposes of this discussion there are two types of payers in the 837 (1) the destination payer, i.e., that payer receiving the claim who is defined in the 2010BB loop, and (2) any other payers, i.e., those defined in the 2330B loop(s). The destination payer or the other payers may be the primary, secondary or any other position payer in terms of when they are paying on the claim - the payment position is not particularly important in discussing how to manage the 837 in a COB situation. For this discussion, it is only important to distinguish between the destination payer and any other payer contained in the claim. In a COB situation each payer in the claim takes a turn at being the destination payer. As the destination payer changes, the information that is identified with that payer must stay associated with them. The same is true of all the other payers, who will each, in turn, become the destination payer as the claim is forwarded to them. It is the purpose of the example detailed below to demonstrate exactly how payer specific information stays associated with the correct payer as the destination payer rotates through the various COB payers. Business Model: The destination payer is defined as the payer that is described in the 2010BB loop. All the information contained in the 2300, 2310, 2400 and 2420 loops (not other sub-loops just those specific loops) is specific to the destination payer. Information specific to other payers is contained in the 2320, 2330 and 2430 loops. Data that may be specific to a payer are shown in Table 1 below. The table details where this data is carried for the destination payer and where it is carried for any other payers who might be included in the claim for the professional implementation guide. Example: A claim is filed which involves three payers A, B, and C. In any 837 one payer is always the destination payer (the payer receiving the claim); the two other pay-

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ers in this example are carried in the 2320/2330 loops. In this example, the claim is first sent to payer A; payers B and C are carried in the 2320/2330 loops. In Table 1 the information specific to the destination payer is carried in the elements indicated in the second column (Destination Payer Location). Information specific to the non-destination payers is carried in the elements listed in the third column (Other Payer Location). TABLE 1. Which elements are specific to the destination and other payers in the 837.
Data Element Name Destination Payer Location Loop - Segment Element Other Payer Location Loop - Segment Element

Subscriber Last/Org Name Subscriber First Name Subscriber Middle Name Subscriber Suffix Name Subscriber Identification Number Subscriber Street Address (1) Subscriber Street Address (2) Subscriber City Subscriber State Subscriber ZIP Code Payer Name Payer ID Patient Identification Number Relationship of subscriber to patient 2 Assignment of Benefits Indicator Patients Signature Source Code Release of Information Prior Authorization or Referral Number - claim level Provider identification number(s) - claim level Payer specific amounts

2010BA | NM103 2010BA | NM104 2010BA | NM105 2010BA | NM107 2010BA | NM108/09 2010BA | N301 2010BA | N302 2010BA | N401 2010BA | N402 2010BA | N403 2010BB | NM103 2010BB | NM108/09 2010CA | NM108/09 2000B | SBR02 2300 - CLM08 2300 - CLM10 2300 - CLM09 2300 | REF01/02 2310A-E | REF01/02 NO ELEMENTS1

2330A | NM103 2330A | NM104 2330A | NM105 2330A | NM107 2330A | NM108/09 2330A | N301 2330A | N302 2330A | N401 2330A | N402 2330A | N403 2330B | NM103 2330B | NM108/09 2330C | NM108/09 2320 | SBR02 2320 | OI03 2320 | OI04 2320 | OI06 2330C | REF01/02 of Prior Auth/Referral REF. 2330D-H | REF01/02 of other Payer Provider Identifiers. All AMTs in the 2320 loop are specific to the payer identified in the 2330B loop of that iteration of the 2320 loop. 2420G | REF01/02 of Prior Authorization or Referral REF

Prior Auth/Referral Number line level

2400 | REF01/02

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Provider identification number(s) line level

1

2420A-G | REF01/02

Not Crosswalked

All payer specific amounts apply only to payers who have already adjudicated the claim. The destination payer has yet to adjudicate the claim so there are no payer specific amounts that apply to the destination payer. As the subscriber information changes it may be necessary to change the value in 2000C PAT01 - Relationship of Patient to the Subscriber.

Once payer A has adjudicated the claim, whoever submits the claim to the second payer (B) then needs to move the information specific to payer A into the other payer location elements (column 3). Payer Bs information is moved to the destination payer location (column 2). Payer Cs information remains in the other payer location (column 3). Table 2 illustrates how the various payers take turns being the destination and other payers. TABLE 2. Distinguishing the destination payer from the other payer(s)
Destination Payer Other Payer

When Payer A is the Destination Payer, then Payer B & C are the Other Payers When Payer B is the Destination Payer, then Payer C & A are the Other Payers When Payer C is the Destination Payer, then Payer B & A are the Other Payers Once payer B has adjudicated the claim, whoever submits the claim to the third payer (C) then needs to move the information specific to payer B back into the other payer location elements. Payer Cs information is moved to the destination payer location elements. Payer As information remains in the other payer location elements.

1.5

Property and Casualty

To ensure timely processing, specific information needs to be included when submitting bills to Property and Casualty payers (e.g. Automobile, Homeowners, or Workers Compensation insurers and related entities). Section 4.2 of this Implementation Guide explains these requirements.

2 Data Overview
The data overview introduces the 837 transaction set structure and describes the positioning of business data within the structure. The implementation guide developers recommend familiarity with ASC X12 nomenclature, segments, data elements, hierarchical levels, and looping structure. For a review, see Appendix A, ASC X12 Nomenclature, and Appendix B, EDI Control Directory.

2.1

Overall Data Architecture

Two formats, or views, are used to present the transaction set the implementation view and the standard view. The implementation view of the transaction set is presented in Section 2.1, Overall Data Architecture. See figure 3, 837 Transaction Set Listing, for the implementation view. Figure 4 displays only the segments described in this implementation guide and their designated health care names.

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Table 1 - Header
POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

005 010 015

ST BHT REF

Transaction Set Header Beginning of Hierarchical Transaction Transmission Type Identification ...

R R R

1 1 1

Table 2 - Detail, Billing/Pay-to Provider Hierarchical Level

POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

001 003 010 015 020 025 030 035

HL PRV CUR NM1 N2 N3 N4 REF

LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL R Billing/Pay-to Provider Hierarchical Level S Billing/Pay-to Provider Information S Foreign Currency Information LOOP ID - 2010A BILLING PROVIDER NAME Billing Provider Name Additional Billing Provider Name Information Billing Provider Address Billing Provider City/State/ZIP Code Billing Provider Secondary Identification ... Transaction Set Trailer R S R R S

>1 1 1 1 1 1 1 1 1 5

555

SE

Figure 3. 837 Transaction Set Listing

The standard view, which is presented in Section 3, Transaction Set, displays all segments available within the transaction set and their assigned ASC X12 names. The intent of the implementation view is to clarify the segments purpose and use by restricting the view to display only those segments used with their assigned health care names.

2.2

Loop Labeling and Use

For the users convenience, the 837 transaction uses two naming conventions for loops. Loops are labeled with a descriptive name as well as with a shorthand label. Loop ID-2000A BILLING/PAY-TO PROVIDER LEVEL contains information about the billing and pay-to providers. The descriptive name - BILLING/PAY-TO PROVIDER LEVEL - informs the user of the overall focus of the loop. The short-hand name 2000A - gives, at a glance, the position of the loop within the overall transaction. Billing and pay-to providers have their own subloops labeled Loop ID-2010AA BILLING PROVIDER and Loop ID-2010AB PAY-TO PROVIDER. The shorthand labels for these loops are 2010AA and 2010AB because they are subloops of loop 2000A. When a loop is used more than once a letter is appended to its numeric portion to allow the user to distinguish the various iterations of that loop when using the shorthand name of the loop. For example, loop 2000 has three possible iterations: Billing/Pay-to Provider, Subscriber and Patient. These loops are labeled 2000A, 2000B and 2000C respectively. Because the 2000 loops involve the hierarchical structure, it is required that they be used in order. The order of equivalent loops is less important. Equivalent subloops do not need to be sent in the same order in which they appear in this implementation guide. In this transaction, subloops are those with a number that does not end in 00 (e.g., Loop ID-

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2010, Loop ID-2420, etc.). For example, loop 2310 has five possible uses identified: referring provider, rendering provider, purchased service provider, service facility location, and supervising provider. These loops are labeled 2310A, 2310B, 2310C, 2310D, and 2310E . Each of these 2310 loops is an equivalent loop. Because they do not specify an HL, it is not necessary to use them in any particular order. In a similar fashion, it is acceptable to send subloops 2010BB, 2010BD, 2010BA, and 2010BC in that order as long as they all belong to the same subloop. However, it is not acceptable to send subloop 2330 before loop 2310 because these are not equivalent subloops. In a similar manner, if a single loop has many iterations (repetitions) of a particular segment all the iterations of that segment are equivalent. For example there are many DTP segments in the 2300 loop. These are equivalent segments. It is not required that Order Date be sent before Initial Treatment date. However, it is required that the DTP segment in the 2300 loop come after the CLM segment because it carried in a different position within the 2300 loop. Translators should distinguish between equivalent subloops and segments by qualifier codes (e.g., the value carried in NM101 in loops 2010BA, 2010 BB, and 2010BC; the values in the DTP01s in the 2300 loop), not by the position of the subloop or segment in the transaction. The number of times a loop or segment can be repeated is indicated in the detail information on that portion of the transaction.

2.2.1

Required and Situational Loops

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. The usage designator of a loops beginning segment indicates the usage of the loop. If a loop is used, the first segment of that loop is required even if it is marked Situational. An example of this is the 2010AB - Pay-to Provider loop. In the 837 Professional Implementation Guide loops that are required on all claims/encounters are the Header, 1000A - Submitter Name, 1000B - Receiver Name, 2000A - Billing/Pay-to Provider Hierarchical Level, 2010AA - Billing Provider Name, 2000B - Subscriber Hierarchical Level, 2010BA -Subscriber Name, 2010BB - Payer Name, 2300 - Claim Level Information, and 2400 Service Line. The use of all other loops is dependent upon the nature of the claim/encounter. If the usage of the first segment in a loop is marked Required, the loop must occur at least once unless it is nested in a loop that is not being used. An example of this is Loop ID-2330A - Other Subscriber Name. Loop 2330A is required only when Loop ID-2320 - Other Subscriber Information is used, i.e., if the claim involves coordination of benefits information. A parallel situation exists with the Loop ID-2330B - Other Payer Name. A note on the Required initial segment of a nested loop will indicate dependency on the higher level loop. If the first segment is Situational, there will be 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. For an example of this see Loop ID-2010AB Pay-to Provider. In the 2010AB loop, if the loop is used, the initial segment, NM1 Pay-to Provider Name must be used. Use of the N2 and REF segments are optional, but the N3 and N4 segments are required.

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2.3

Data Use by Business Use

The 837 is divided into two levels, or tables. The Header level, Table 1, contains transaction control information. The Detail level, Table 2, contains the detail information for the transactions business function and is presented in 2.3.2, Table 2 Detail Information.

2.3.1

Table 1 Transaction Control Information

Table 1 is named the Header level (see figure 4, Header Level). Table 1 identifies the start of a transaction, the specific transaction set, and the transactions business purpose. Additionally, when a transaction set uses a hierarchical data structure, a data element in the header BHT01 the Hierarchical Structure Code relates the type of business data expected to be found within each level.

Table 1 - Header
POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

005 ST 010 BHT 015 REF

Transaction Set Header Beginning of Hierarchical Transaction Transmission Type Identification ...

R R R

1 1 1

Figure 4. Table 1 Header Level

2.3.1.1

837 Table 1 Header Level

The following is a coding example of Table 1 in the 837. Refer to Appendix A, ASC X12 Nomenclature, for descriptions of data element separators (e.g., *) and segment terminators (e.g., ~).

ST*837*0001~
837 = Transaction set identifier code 0001 = Transaction set control number

BHT*0019*00*98766Y*19970315*0001*CH~
0019 = Hierarchical structure code (information source, subscriber, dependent) 00 = Original 98766Y = Submitters batch control number 19970315 = Date of file creation 0001 = Time of file creation CH = Chargeable (claims)

REF*87*004010X098~
87 = Functional category 004010X098 = Professional Implementation Guide The Transaction Set Header (ST) segment identifies the transaction set by using 837 as the data value for the transaction set identifier code data element, ST01. The transaction set originator assigns the unique transaction set control number ST02, shown in the previous example as 0001. In the example, the health care provider is the transaction set originator. The Beginning of Hierarchical Transaction (BHT) segment indicates that the transaction uses a hierarchical data structure. The value of 0019 in the hierarchi-

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cal structure code data element, BHT01, describes the order of the hierarchical levels and the business purpose of each level. See Section 2.3.1.2, Hierarchical Level Data Structure, for additional information about the BHT01 data element. The BHT segment also contains the transaction set purpose code, BHT02, which indicates original transaction by using data value 00. The submitters business application system generates the following fields: BHT03, originators reference number; BHT04, date of transaction creation; BHT05, time of transaction creation. BHT02 is used to indicate the status of the transaction batch, i.e., is the batch an original transmission or a reissue (resubmitted) batch. BHT06 is used to indicate the type of billed service being sent: fee-for-service (claim) or encounter or a mixed bag of both. Because the 837 is multi-functional, it is important for the receiver to know which business purpose is served, so the REF in the Header is used. A data value of 87 in REF 01 indicates the functional category, or type, of 837 being sent. Appropriate values for REF02 are as follows: 004010X098 for a Professional 837 transaction, 004010X097 for Dental, and 004010X096 for Institutional. The Functional Group Header (GS) segment also identifies the business purpose of multi-functional transaction sets. See Appendix A, ASC X12 Nomenclature, for a detailed description of the elements in the GS segment.

2.3.1.2

Hierarchical Level Data Structure

The hierarchical level (HL) structure identifies and relates the participants involved in the transaction. The participants identified in the 837 Professional transaction are generally billing/pay-to provider, subscriber, and patient (when the patient is not the same person as the subscriber). The 0019 value in the BHT hierarchical structure code (BHT01) describes the appearance order of subsequent loops within the transaction set and refers to these participants, respectively, in the following terms: information source (billing provider) subscriber (can be the patient when the patient is the subscriber) dependent (patient, when the patient is not the subscriber) The term billing provider indicates the information source HL. The term patient indicates the dependent HL.

2.3.2

Table 2 Detail Information

Table 2 uses the hierarchical level structure. Each hierarchical level is comprised of a series of loops. Numbers identify the loops. The hierarchical level that identifies the participants and the relationship to other participants is Loop ID-2000. The individual or entity information is contained in Loop ID-2010.

2.3.2.1

HL Segment
The following information illustrates claim/encounter submissions when the patient is the subscriber and when the patient is not the subscriber.

NOTE Specific claim detail information can be given in either the Subscriber or the Dependent hierarchical level. Because of this, the claim information is said to float.
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Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information is placed at the subscriber hierarchical level when the patient is the subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the subscriber. Claim/encounter submission when the patient is the subscriber: Billing provider (HL03=20) Subscriber (HL03=22) Claim level information Line level information Claim/encounter submission when the patient is not the subscriber: Billing provider (HL03=20) Subscriber (HL03=22) Patient (HL03=23) Claim level information Line level information The Billing Provider or Subscriber HLs may contain multiple child HLs. A child HL indicates an HL that is nested within (subordinate to) the previous HL. Hierarchical levels may also have a parent HL. A parent HL is the HL that is one level out in the nesting structure. An example follows. Parent HL to the Subscriber HL Billing provider HL Parent HL to the Patient HL; Child HL to the Billing Subscriber HL Provider HL Child HL to the Subscriber HL Patient HL For the subscriber HL, the billing provider HL is the parent. The patient HL is the child. The subscriber HL is contained within the billing provider HL. The patient HL is contained within the subscriber HL. If the billing provider is submitting claims for more than one subscriber, each of whom may or may not have dependents, the HL structure between the transaction set header and trailer (STSE) could look like the following: BILLING PROVIDER SUBSCRIBER #1 (Patient #1) Claim level information Line level information, as needed SUBSCRIBER #2 PATIENT #P2.1 (e.g., subscriber #2 spouse) Claim level information Line level information, as needed PATIENT #P2.2 (e.g., subscriber #2 first child) Claim level information Line level information, as needed PATIENT #P2.3 (e.g., subscriber #2 second child) Claim level information Line level information, as needed SUBSCRIBER #3 (Patient #3) Claim level information Line level information, as needed SUBSCRIBER #4 (Patient #4) Claim level information Line level information, as needed

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PATIENT #P4.1 (e.g., #4 subscribers first child) Claim level information Line level information, as needed Based on the previous example, the HL structure looks like the following:

HL*1**20*1~ (indicates the billing provider)

1 = HL sequence number (HL numbering must begin with 1.) **(blank) = there is no parent HL (characteristic of the billing provider HL) 20 = information source 1 = there is at least one child HL to this HL

HL*2*1*22*0~ (indicates subscriber #1 for whom there are no dependents)

2 = HL sequence number 1 = parent HL 22 = subscriber 0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level data follows)

HL*3*1*22*1~ (indicates subscriber #2 for whom there are dependents) 3 = HL sequence number 1 = parent HL 22 = subscriber 1 = there is at least one child HL to this HL HL*4*3*23*0~ (indicates patient #P2.1)
4 = HL sequence number 3 = parent HL 23 = patient 0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level data follows)

HL*5*3*23*0~ (indicates patient #P2.2)

5 = HL sequence number 3 = parent HL 23 = dependent 0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level data follows)

HL*6*3*23*0~ (indicates patient #P2.3) 6 = HL sequence number 3 = parent HL 23 = dependent 0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level data follows) HL*7*1*22*0~ (indicates subscriber #3 for whom there are no dependents)
7 = HL sequence number 1 = parent HL 22 = subscriber 0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level data follows)

HL*8*1*22*1~(indicates subscriber #4 who is a patient in their own right and for whom there are dependents) 8 = HL sequence number 1 = parent HL
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22 = subscriber 1 = there is at least one child HL to this HL (claim level data follows for #4 after which comes HL*9)

HL*9*8*23*0~ (indicates patient #P4.1 for subscriber #4)

9 = HL sequence number 8 = parent HL 23 = dependent 0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level data follows) If another billing provider is listed in the same STSE transaction, it could be listed as follows: HL*100**20*1~.The HL sequence number of 100 indicates that there are 99 previous HL segments, but it is billing provider level HL (HL02 = **(blank)) and is a different entity than the first billing provider listed. From a review of these examples, the following information is noted: HLs are numbered sequentially beginning with 1. The sequential number is found in HL01, which is the first data element in the HL segment. Sequence number must be numeric. The second element, HL02, indicates the sequential number of the parent hierarchical level to which this hierarchical level (HL01) is subordinate. The billing provider/information source has no parent. If the data value in HL02 is equal to **(blank), it is known that this is the highest hierarchical level for all the contained subordinate levels. The billing provider level is not subordinate to any hierarchical level. The data value in data element HL03 describes the hierarchical level entity. For example, when HL03 equals 20, the hierarchical level is the billing provider; when HL03 equals 23, the hierarchical level is the dependent (patient). Data element HL04 indicates whether or not subordinate hierarchical levels exist. A value of 1" indicates subsequent hierarchical levels. A value of 0" or absence of a data value indicates no subordinate hierarchical levels follow. For the subscriber HL, claim data may follow even when HL04=1 (see subscriber #4 in the above example). HLs must be transmitted in order.

2.4

Loop ID-1000
Use of Loop ID-1000 is difficult to accurately define or describe. Originally, Loop ID-1000 was conceived of as an audit trail loop. (The original instructions for Loop ID-1000 directed that anyone who opened the envelope of a transaction should include another iteration of Loop ID-1000 so that it would be possible to identify all the entities who had an opportunity to change the data inside the enveloping structure.) The audit trail concept is difficult to implement for a variety of reasons, and the developers of this implementation guide do not recommend using Loop ID-1000 as an audit trail in this transaction. Instead, the developers recommend using Loop ID-1000 to record the transaction submitter and the receiver. However, the submitter and receiver concepts are difficult to define accurately. The transaction submitter and receiver are not necessarily the two entities who may be passing the transaction between them. Given the complexity of transmission pathways, it is critical to define the original submitter and final receiver somewhere in the transmission.

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Figure 5. Loop ID-1000 Example 1

Several figures follow to help clarify the difficulty in defining the terms submitter and receiver. In figure 5, Loop ID-1000 Example 1, the submitter is not the service provider. The submitter could be a billing service, an automated clearing house, or another entity who formats the claims into the 837. The original submitter can be thought of as the entity who initially formats the claim data into the ASC X12N transaction and begins the transmission chain, which ultimately ends at the payer. It is possible that the communication between the provider and the submitter is in the form of paper or some other non-standard EDI transaction. The receiver is more difficult to define. Figure 5, Loop ID-1000 Example 1, shows that the receiver is not necessarily the destination payer. The receiver is the entity who receives the claim transmission on behalf of perhaps many payer

Provider/Submitter C

Provider/Submitter D

Figure 6. Loop ID-1000 Example 2

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Figure 7. Loop ID-1000 Example 3

organizations. In figure 6, the receiver can be a Preferred Provider Organization (PPO), a repricer, or any of several other payer-associated entities. These entities can perform a variety of functions for the payer. Entities A, B, and C can be any of a variety of types of EDI transmission organizations Value-Added Networks (VANs), Automated Clearing Houses (ACHs), transmission nodes who may or may not open the envelope. Their EDI addresses are carried in the Interchange Control Header (ISA) segment of the transmission. (See Appendix B, EDI Control Directory, for an explanation of the ISA segment.) However, the implementation guide developers do not recommend that such entities put information in Loop ID-1000. The claim originator (the submitter) defines, by trading partner agreement, who the claim receiver is. As shown in figure 6, the claim receiver may not be the next transmission entity in the transmission chain. The submitter is the one who completes Loop ID-1000 and identifies the transmission receiver. It is possible that the provider is the submitter, and the payer the receiver. Figure 6, Loop ID-1000 Example 2, and figure 7, Loop ID-1000 Example 3, demonstrate alternate types of transmission pathways where the provider and the payer function as submitter and receiver. In figure 6, Loop ID-1000 Example 2, providers C and D function as submitters because they format their own claim data into an ASC X12N claim transmission package. Providers A and B use submitter E to perform that function and are therefore, not submitters. In figure 7, payers A and B function as their own transmission receivers. Because there is not a clear definition of submitter and receiver at this time, the developers of this implementation guide recommend that the submitter and receiver be clearly determined by trading partner agreement.

2.5

The Claim
After the HL structure is defined, the specific claim services are identified in Loop ID-2300. Loop ID-2305 identifies services that are specific to home health care. Loop ID-2310 identifies various providers who may have been involved in the

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health care services being reported in the transaction. Loop ID-2320 identifies all other insurance entities (coordination of benefits). Within Loop ID-2320, Loop ID2330 identifies all the parties associated with the other insurance entities. Loop ID-2400 is required and identifies service line information. Loop ID-2420 identifies any service line providers who are different than the corresponding claim level providers. Loop ID-2430 identifies any service line adjudication information (from a previous payer), and Loop ID-2440 is used to send information from specific forms.

2.6
2.6.1

Interactions with Other Transactions

An overview of transactions that interact with the 837 is presented here.

Functional Acknowledgment (997)

The Functional Acknowledgment (997) transaction is used as the first response to receiving an 837. The 997 informs the 837 submitter that the transmission arrived. In addition, the 997 can be constructed to send information about the syntactical quality of the 837 transmission.

2.6.2

Unsolicited Claim Status (277)

The Unsolicited Claim Status (277) transaction may be used as the second response to receiving an 837. The 277 transmission may be used to indicate to the provider which claims in an 837 batch were received electronically but not yet accepted into the adjudication system, which were accepted into the adjudication system (i.e., which claims passed the front-end edits) and which claims were rejected before entering the adjudication system. Certain information is taken from the 837 and used in, or crosswalked into, the 277 (e.g., the providers claim identification number, the amount billed, etc.). This discussion is not intended to imply that the Unsolicited Claim Status (277) transaction is part of HIPAA - it is not. However, this discussion is included in this implementation guide because trading partners may decide to implement the Unsolicited Claim Status (277) transaction as a prudent business decision outside of the HIPAA mandates to automate the front-end accept-reject report process.

2.6.3

Remittance Advice (835)

Information in the Remittance Advice (835) transaction is generated by the payers adjudication system. However, in a coordination of benefits (COB) situation where the provider is sending an 837 to a secondary payer, information from the 835 may be included in the secondary 837. As shown 1.4.2.2, Coordination of Benefits Correction Detail, data from specific segments/elements in the 835 is crosswalked directly into the subsequent 837.

2.7

National Uniform Claim Committee

This implementation guide includes information about the National Uniform Claim Committee (NUCC) in Appendix I, National Uniform Claim Committee Recommendations. The NUCC is working to establish a minimal data set for professional claims submission. This work will be published in a separate volume titled

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The National Uniform Claim Committee Data Set, NUCC-DS. For additional information about the NUCC data set, contact the NUCC, c/o American Medical Association, 515 North State Street, Chicago, IL 60610

2.8

Limitations to the Size of a Claim/Encounter (837) Transaction

Receiving trading partners may have system limitations regarding the size of the transmission they can receive. Some submitters may have the capability and the desire to transmit enormous 837 transactions with thousands of claims contained in them. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.

2.9

Use of Data Segment and Elements Marked Situational

Professional claims span an enormous variety of health care professional specialities and payment situations. Because of this, it is difficult to set a single list of data elements that are required for all types of professional health care claims. To meet the divergent needs of professional claim submitters, many data segments and elements included in this implementation guide are marked situational. All situational segments and elements now have notes attached specifying when they should be used. To the greatest degree possible, situational segments and elements have had their required use specified. Some elements (e.g., procedure code modifiers) are used at the discretion of the claim submitter - their use is based on the specific health care provided. See the Health Insurance Portability and Accountability Act of 1996 and its associated rules for further information about standardized use of this transaction.

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

3 Transaction Set
NOTE See Appendix A, ASC X12 Nomenclature, to review the transaction set structure, including descriptions of segments, data elements, levels, and loops.

3.1

Presentation Examples
The ASC X12 standards are generic. For example, multiple trading communities use the same PER segment to specify administrative communication contacts. Each community decides which elements to use and which code values in those elements are applicable. This implementation guide uses a format that depicts both the generalized standard and the trading community-specific implementation. The transaction set detail is comprised of two main sections with subsections within the main sections. Transaction Set Listing Implementation Standard Segment Detail Implementation Standard Diagram Element Summary The examples in figures 8 through 13 define the presentation of the transaction set that follows. The following pages provide illustrations, in the same order they appear in the guide, to describe the format. The examples are drawn from the 835 Health Care Claim Payment/Advice Transaction Set, but all principles apply.

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IMPLEMENTATION

Indicates that this section is the implementation and not the standard

835
NAME

Health Care Claim Payment/Advice

Table 1 - Header
PAGE # POS. # SEG. ID USAGE REPEAT LOOP REPEAT

53 54 60 62 65 66 68 70 72 75 76 78 79 81 82 84

010 020 040 050 060 060 070 080 100 110 120 130 080 100 110 120

ST BPR TRN CUR REF REF DTM N1 N3 N4 REF PER N1 N3 N4 REF

835 Header Financial Information Reassociation Key Non-US Dollars Currency Receiver ID Version Number Production Date

Each segment is assigned an industry specific name. Not used segments do not appear Each loop is assigned an industry specific name

R R R S S S S R S S S S R S S S

1 1 1 1 1 1 1 1 1 1 1 1

Segment repeats and loop repeats reflect actual usage

PAYER NAME Payer Name Payer Address Payer City, State, Zip Additional Payer Reference Number Payer Contact PAYEE NAME Payee Name Payee Address Payee City, State, Zip Payee Additional Reference Number

1 R=Required S=Situational

1 1 1 1 >1

Position Numbers and Segment IDs retain their X12 values

Individual segments and entire loops are repeated

Figure 8. Transaction Set Key Implementation

STANDARD

Indicates that this section is identical to the ASC X12 standard See Appendix A, ASC X12 Nomenclature for a complete description of the standard

835

Health Care Claim Payment/Advice

Functional Group ID:

HP

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution.

Table 1 - Header
POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

010 020 030 040

ST BPR NTE TRN

Transaction Set Header Beginning Segment for Payment Order/Remittance Advice Note/Special Instruction Trace

M M O O

1 1 >1 1

Figure 9. Transaction Set Key Standard

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

PAYER NAME
Loop: PAYER NAME Repeat: 1 Usage: Repeat: Advisory: Notes:

Industry assigned Segment Name Industry Loop Repeat

Industry Notes

SITUATIONAL Industry assigned Loop Name 1 Under most circumstances, this segment is expected to be sent. 1. This N1 loop provides the name/address information for the payer. The payers secondary identifying reference number should be provided in N104, if necessary.

Example: N1VPRVINSURANCE COMPANY OF TIMBUCKTUVNIV88888888~

Example

Figure 10. Segment Key Implementation

STANDARD

N1 Name

X12 ID and Name

X12 Level Level: Header X12 Position Number Position: 080 X12 Loop Information Loop: N1 Repeat: 200 X12 Requirement Requirement: Optional X12 Maximum Use Max Use: 1 Purpose: To identify a party by type of organization, name and code Syntax: 1 R0203 At least one of N102 or N103 is required. 2 P0304 If either N103 or N104 is present, then the other is required. X12 Syntax Notes

Figure 11. Segment Key Standard

DIAGRAM Indicates a Required Element

N101 98 N102

Element Delimiter
93 N103

Abbreviated Element Name

66 N104 67 N105 706 N106

Segment Terminator
98

N1 V
Segment ID

Entity ID Code
M ID 2/2

V
X

Name
AN 1/35

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/20

Entity V V Relat Code

O ID 2/2

Entity ID Code
O ID 2/2

Requirement Designator

Minimum/ Maximum Length

Data Type

Indicates a Not Used Element

Figure 12. Segment Key - Diagram

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ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

SVC01

C003

Industry Usages: See the following page for complete descriptions X12 Semantic Note Industry Note

COMPOSITE MEDICAL PROCEDURE M IDENTIFIER To identify a medical procedure by its standardized codes and applicable modifiers
SEMANTIC NOTES

03 04 05 06 07 SVC01 - 1 235

C003-03 modifies the value in C003-02. C003-04 modifies the value in C003-02. C003-05 modifies the value in C003-02. C003-06 modifies the value in C003-02. C003-07 is the description of the procedure identified in C003-02. Product/Service ID Qualifier M ID 2/2 Code identifying the type/source of the descriptive number used in Product/Service ID (234)
DEFINITION

90147
REQUIRED

Use the adjudicated Medical Procedure Code.

Selected Code Values See Appendix C for external code source reference

CODE

AD

CODE SOURCE 135:

American Dental Association Codes American Dental Association Codes

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N101

98

Reference Designator

SITUATIONAL

N102

93

Data Element Number

Entity Identifier Code M ID Code identifying an organizational entity, a physical location, property or an individual Name X AN Free-form name
SYNTAX:

2/3

1/60

R0203

SITUATIONAL

N103

66

Identification Code Qualifier X ID 1/2 Code designating the system/method of code structure used for Identification Code (67) Identification Code Code identifying a party or other code
SYNTAX:

SITUATIONAL

N104

67

AN

2/20

P0304 most circumstances, this element is expected to be sent.

X12 Syntax Note X12 Comment

ADVISORY: Under

COMMENT: This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the ID Code (N104) must provide a key to the table maintained by the transaction processing party.

Figure 13. Segment Key Element Summary

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

Industry Usages: Required Not Used Situational This item must be used to be compliant with this implementation guide. This item should not be used when complying with this implementation guide. The use of this item varies, depending on data content and business context. The defining rule is generally documented in a syntax or usage note attached to the item.* The item should be used whenever the situation defined in the note is true; otherwise, the item should not be used. * NOTE If no rule appears in the notes, the item should be sent if the data is available to the sender.

Loop Usages: 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. The usage designator of a loops beginning segment indicates the usage of the loop. Segments within a loop cannot be sent without the beginning segment of that loop. If the first segment is Required, the loop must occur at least once unless it is nested in a loop that is not being used. A note on the Required first segment of a nested loop will indicate dependency on the higher level loop. If the first segment is Situational, there will be 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. Similarly, nested loops only occur when the higher level loop is used.

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004010X098 837

004010X098 837

JUNE 15, 2000 IMPLEMENTATION

837

Health Care Claim: Professional

1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Billing providers who sort claims using this hierarchy will use the 837 more efficiently because information that applies to all lower levels in the hierarchy will not have to be repeated within the transaction. 2. This standard is also recommended for the submission of similar data within a pre-paid managed care context. Referred to as capitated encounters, this data usually does not result in a payment, though it is possible to submit a mixed claim that includes both pre-paid and request for payment services. This standard will allow for the submission of data from providers of health care products and services to a Managed Care Organization or other payer. This standard may also be used by payers to share data with plan sponsors, employers, regulatory entities and Community Health Information Networks. 3. This standard can, also, be used as a transaction set in support of the coordination of benefits claims process. Additional looped segments can be used within both the claim and service line levels to transfer each payers adjudication information to subsequent payers.

Table 1 - Header
PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

62 63 66 67 70 71 74 76

005 010 015 020 025 045 020 025

ST BHT REF NM1 N2 PER NM1 N2

Transaction Set Header Beginning of Hierarchical Transaction Transmission Type Identification LOOP ID - 1000A SUBMITTER NAME Submitter Name Additional Submitter Name Information Submitter EDI Contact Information LOOP ID - 1000B RECEIVER NAME Receiver Name Receiver Additional Name Information

R R R R S R R S

1 1 1 1 1 1 2 1 1 1

Table 2 - Detail, Billing/Pay-to Provider Hierarchical Level

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

77 79 81 84 87 88 89 91 94 96 99 102

001 003 010 015 020 025 030 035 035 040 015 020

HL PRV CUR NM1 N2 N3 N4 REF REF PER NM1 N2

LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Billing/Pay-to Provider Hierarchical Level Billing/Pay-to Provider Specialty Information Foreign Currency Information LOOP ID - 2010AA BILLING PROVIDER NAME Billing Provider Name Additional Billing Provider Name Information Billing Provider Address Billing Provider City/State/ZIP Code Billing Provider Secondary Identification Credit/Debit Card Billing Information Billing Provider Contact Information LOOP ID - 2010AB PAY-TO PROVIDER NAME Pay-to Provider Name Additional Pay-to Provider Name Information

>1 R S S R S R R S S S S S 1 1 1 1 1 1 1 1 8 8 2 1 1 1

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004010X098 837 103 104 106 025 030 035 N3 N4 REF Pay-to Provider Address Pay-to Provider City/State/ZIP Code Pay-to-Provider Secondary Identification

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE R R S 1 1 5

Table 2 - Detail, Subscriber Hierarchical Level

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

108 110 114 117 120 121 122 124 126 128 130 133 134 135 137 139 142 143 144

001 005 007 015 020 025 030 032 035 035 015 020 025 030 035 015 020 025 030

HL SBR PAT NM1 N2 N3 N4 DMG REF REF NM1 N2 N3 N4 REF NM1 N2 N3 N4

LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL Subscriber Hierarchical Level Subscriber Information Patient Information LOOP ID - 2010BA SUBSCRIBER NAME Subscriber Name Additional Subscriber Name Information Subscriber Address Subscriber City/State/ZIP Code Subscriber Demographic Information Subscriber Secondary Identification Property and Casualty Claim Number LOOP ID - 2010BB PAYER NAME Payer Name Additional Payer Name Information Payer Address Payer City/State/ZIP Code Payer Secondary Identification LOOP ID - 2010BC RESPONSIBLE PARTY NAME Responsible Party Name Additional Responsible Party Name Information Responsible Party Address Responsible Party City/State/ZIP Code LOOP ID - 2010BD CREDIT/DEBIT CARD HOLDER NAME Credit/Debit Card Holder Name Additional Credit/Debit Card Holder Name Information Credit/Debit Card Information

>1 R R S R S S S S S S R S S S S S S R R 1 1 1 1 1 1 1 1 1 4 1 1 1 1 1 1 3 1 1 1 1 1 1 S S S 1 1 2

146 149 150

015 020 035

NM1 N2 REF

Table 2 - Detail, Patient Hierarchical Level

For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this the claim information is said to float. Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is the subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See 2.3.2.1, HL Segment, for details.
PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

152 154

001 007

HL PAT

LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL Patient Hierarchical Level Patient Information

>1 S R 1 1

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP ID - 2010CA PATIENT NAME Patient Name Additional Patient Name Information Patient Address Patient City/State/ZIP Code Patient Demographic Information Patient Secondary Identification Property and Casualty Claim Number LOOP ID - 2300 CLAIM INFORMATION Claim Information Date - Order Date Date - Initial Treatment Date - Referral Date Date - Date Last Seen Date - Onset of Current Illness/Symptom Date - Acute Manifestation Date - Similar Illness/Symptom Onset Date - Accident Date - Last Menstrual Period Date - Last X-ray Date - Estimated Date of Birth Date - Hearing and Vision Prescription Date Date - Disability Begin Date - Disability End Date - Last Worked Date - Authorized Return to Work Date - Admission Date - Discharge Date - Assumed and Relinquished Care Dates Claim Supplemental Information Contract Information Credit/Debit Card Maximum Amount Patient Amount Paid Total Purchased Service Amount Service Authorization Exception Code Mandatory Medicare (Section 4081) Crossover Indicator Mammography Certification Number Prior Authorization or Referral Number Original Reference Number (ICN/DCN) Clinical Laboratory Improvement Amendment (CLIA) Number Repriced Claim Number Adjusted Repriced Claim Number Investigational Device Exemption Number Claim Identification Number for Clearing Houses and Other Transmission Intermediaries Ambulatory Patient Group (APG) Medical Record Number Demonstration Project Identifier File Information Claim Note Ambulance Transport Information Spinal Manipulation Service Information Ambulance Certification Patient Condition Information: Vision Homebound Indicator

004010X098 837 1 R S R R R S S R S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S 1 1 1 1 1 5 1 100 1 1 1 1 1 1 5 10 10 1 1 1 1 5 5 1 1 1 1 2 10 1 1 1 1 1 1 1 2 1 3 1 1 1 1 4 1 1 10 1 1 1 3 3 1

157 160 161 162 164 166 168 170 180 182 184 186 188 190 192 194 196 197 199 200 201 203 205 206 208 210 212 214 217 219 220 221 222 224 226 227 229 231 233 235 236 238 240 241 242 244 246 248 251 257 260 263 MAY 2000

015 020 025 030 032 035 035 130 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 155 160 175 175 175 180 180 180 180 180 180 180 180 180 180 180 180 180 185 190 195 200 220 220 220

NM1 N2 N3 N4 DMG REF REF CLM DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP PWK CN1 AMT AMT AMT REF REF REF REF REF REF REF REF REF REF REF REF REF K3 NTE CR1 CR2 CRC CRC CRC

53

004010X098 837 265 271 231 241 HI HCP Health Care Diagnosis Code Claim Pricing/Repricing Information LOOP ID - 2305 HOME HEALTH CARE PLAN INFORMATION Home Health Care Plan Information Health Care Services Delivery LOOP ID - 2310A REFERRING PROVIDER NAME Referring Provider Name Referring Provider Specialty Information Additional Referring Provider Name Information Referring Provider Secondary Identification LOOP ID - 2310B RENDERING PROVIDER NAME Rendering Provider Name Rendering Provider Specialty Information Additional Rendering Provider Name Information Rendering Provider Secondary Identification LOOP ID - 2310C PURCHASED SERVICE PROVIDER NAME Purchased Service Provider Name Purchased Service Provider Secondary Identification LOOP ID - 2310D SERVICE FACILITY LOCATION Service Facility Location Additional Service Facility Location Name Information Service Facility Location Address Service Facility Location City/State/ZIP Service Facility Location Secondary Identification LOOP ID - 2310E SUPERVISING PROVIDER NAME Supervising Provider Name Additional Supervising Provider Name Information Supervising Provider Secondary Identification LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION Other Subscriber Information Claim Level Adjustments Coordination of Benefits (COB) Payer Paid Amount Coordination of Benefits (COB) Approved Amount Coordination of Benefits (COB) Allowed Amount Coordination of Benefits (COB) Patient Responsibility Amount Coordination of Benefits (COB) Covered Amount Coordination of Benefits (COB) Discount Amount Coordination of Benefits (COB) Per Day Limit Amount Coordination of Benefits (COB) Patient Paid Amount Coordination of Benefits (COB) Tax Amount Coordination of Benefits (COB) Total Claim Before Taxes Amount Subscriber Demographic Information Other Insurance Coverage Information Medicare Outpatient Adjudication Information LOOP ID - 2330A OTHER SUBSCRIBER NAME Other Subscriber Name Additional Other Subscriber Name Information Other Subscriber Address Other Subscriber City/State/ZIP Code

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE S S 1 1 6 S S S S S S S R S S 1 3 2 1 1 1 5 1 1 1 1 5 1 S S S S R R S S S S S S S S S S S S S S S S S R S R S S S 1 5 1 1 1 1 1 5 1 1 1 5 10 1 5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

276 278 282 285 287 288 290 293 295 296

242 243 250 255 260 271 250 255 260 271

CR7 HSD NM1 PRV N2 REF NM1 PRV N2 REF

298 301 303 306 307 308 310 312 315 316 318 323 332 333 334 335 336 337 338 339 340 341 342 344 347 350 353 354 355

250 271 250 260 265 270 271 250 260 271 290 295 300 300 300 300 300 300 300 300 300 300 305 310 320 325 330 332 340

NM1 REF NM1 N2 N3 N4 REF NM1 N2 REF SBR CAS AMT AMT AMT AMT AMT AMT AMT AMT AMT AMT DMG OI MOA NM1 N2 N3 N4

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 357 359 362 363 366 368 370 372 355 325 330 345 345 355 355 355 REF NM1 N2 PER DTP REF REF REF Other Subscriber Secondary Identification LOOP ID - 2330B OTHER PAYER NAME Other Payer Name Additional Other Payer Name Information Other Payer Contact Information Claim Adjudication Date Other Payer Secondary Identifier Other Payer Prior Authorization or Referral Number Other Payer Claim Adjustment Indicator LOOP ID - 2330C OTHER PAYER PATIENT INFORMATION Other Payer Patient Information Other Payer Patient Identification LOOP ID - 2330D OTHER PAYER REFERRING PROVIDER Other Payer Referring Provider Other Payer Referring Provider Identification LOOP ID - 2330E OTHER PAYER RENDERING PROVIDER Other Payer Rendering Provider Other Payer Rendering Provider Secondary Identification LOOP ID - 2330F OTHER PAYER PURCHASED SERVICE PROVIDER Other Payer Purchased Service Provider Other Payer Purchased Service Provider Identification LOOP ID - 2330G OTHER PAYER SERVICE FACILITY LOCATION Other Payer Service Facility Location Other Payer Service Facility Location Identification LOOP ID - 2330H OTHER PAYER SUPERVISING PROVIDER Other Payer Supervising Provider Other Payer Supervising Provider Identification LOOP ID - 2400 SERVICE LINE Service Line Professional Service Prescription Number DMERC CMN Indicator Ambulance Transport Information Spinal Manipulation Service Information Durable Medical Equipment Certification Home Oxygen Therapy Information Ambulance Certification Hospice Employee Indicator DMERC Condition Indicator Date - Service Date Date - Certification Revision Date Date - Referral Date Date - Begin Therapy Date Date - Last Certification Date Date - Order Date Date - Date Last Seen Date - Test Date - Oxygen Saturation/Arterial Blood Gas Test Date - Shipped S R S S S S S S 3

004010X098 837

1 1 1 2 1 2 2 2 1 S S 1 3 2 S R 1 3 1 S R 1 3 1 S R 1 3 1 S R 1 3 1 S R R R S S S S S S S S S R S S S S S S S S S 1 3 50 1 1 1 1 1 5 1 1 3 1 2 1 1 1 1 1 1 1 2 3 1

374 376

325 355

NM1 REF

378 380

325 355

NM1 REF

382 384

325 355

NM1 REF

386 388

325 355

NM1 REF

390 392

325 355

NM1 REF

394 396 398 400 408 410 412 415 421 423 427 430 432 435 437 439 440 442 444 445 447 449 451

325 355 365 370 385 420 425 430 435 445 450 450 450 455 455 455 455 455 455 455 455 455 455

NM1 REF LX SV1 SV4 PWK CR1 CR2 CR3 CR5 CRC CRC CRC DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP

MAY 2000

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004010X098 837 452 454 456 458 460 462 464 466 468 469 470 472 474 475 477 478 479 480 482 484 485 486 487 488 489 491 495 501 504 506 507 455 455 455 455 455 460 462 465 470 470 470 470 470 470 470 470 470 470 470 475 475 475 480 485 488 491 492 500 505 510 525 DTP DTP DTP DTP DTP QTY MEA CN1 REF REF REF REF REF REF REF REF REF REF REF AMT AMT AMT K3 NTE PS1 HSD HCP NM1 PRV N2 REF Date - Onset of Current Symptom/Illness Date - Last X-ray Date - Acute Manifestation Date - Initial Treatment Date - Similar Illness/Symptom Onset Anesthesia Modifying Units Test Result Contract Information Repriced Line Item Reference Number Adjusted Repriced Line Item Reference Number Prior Authorization or Referral Number Line Item Control Number Mammography Certification Number Clinical Laboratory Improvement Amendment (CLIA) Identification Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Immunization Batch Number Ambulatory Patient Group (APG) Oxygen Flow Rate Universal Product Number (UPN) Sales Tax Amount Approved Amount Postage Claimed Amount File Information Line Note Purchased Service Information Health Care Services Delivery Line Pricing/Repricing Information LOOP ID - 2420A RENDERING PROVIDER NAME Rendering Provider Name Rendering Provider Specialty Information Additional Rendering Provider Name Information Rendering Provider Secondary Identification LOOP ID - 2420B PURCHASED SERVICE PROVIDER NAME Purchased Service Provider Name Purchased Service Provider Secondary Identification LOOP ID - 2420C SERVICE FACILITY LOCATION Service Facility Location Additional Service Facility Location Name Information Service Facility Location Address Service Facility Location City/State/ZIP Service Facility Location Secondary Identification LOOP ID - 2420D SUPERVISING PROVIDER NAME Supervising Provider Name Additional Supervising Provider Name Information Supervising Provider Secondary Identification LOOP ID - 2420E ORDERING PROVIDER NAME Ordering Provider Name Additional Ordering Provider Name Information Ordering Provider Address Ordering Provider City/State/ZIP Code

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE S S S S S S S S S S S S S S S S S S S S S S S S S S S S R S S 1 1 1 1 1 5 20 1 1 1 2 1 1 1 1 1 4 1 1 1 1 1 10 1 1 1 1 1 1 1 1 5 1 S S S S R R S S S S S S S S 1 5 1 1 1 1 1 5 1 1 1 5 1 1 1 1 1

509 512 514 517 518 519 521 523 526 527 529 532 533 534

500 525 500 510 514 520 525 500 510 525 500 510 514 520

NM1 REF NM1 N2 N3 N4 REF NM1 N2 REF NM1 N2 N3 N4

56

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 536 538 541 544 546 547 525 530 500 505 510 525 REF PER NM1 PRV N2 REF Ordering Provider Secondary Identification Ordering Provider Contact Information LOOP ID - 2420F REFERRING PROVIDER NAME Referring Provider Name Referring Provider Specialty Information Additional Referring Provider Name Information Referring Provider Secondary Identification LOOP ID - 2420G OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Other Payer Prior Authorization or Referral Number Other Payer Prior Authorization or Referral Number LOOP ID - 2430 LINE ADJUDICATION INFORMATION Line Adjudication Information Line Adjustment Line Adjudication Date LOOP ID - 2440 FORM IDENTIFICATION CODE Form Identification Code Supporting Documentation Transaction Set Trailer S S S S S S 5 1

004010X098 837

2 1 1 1 5 4 S R S S R S R R 1 2 25 1 99 1 5 1 99 1

549 552 554 558 566 567 569 572

500 525 540 545 550 551 552 555

NM1 REF SVD CAS DTP LQ FRM SE

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004010X098 837 STANDARD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

837

Health Care Claim

Functional Group ID: HC
This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

Table 1 - Header
PAGE #
POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

005 010 015 020 025 030 035 040 045

ST BHT REF NM1 N2 N3 N4 REF PER

Transaction Set Header Beginning of Hierarchical Transaction Reference Identification LOOP ID - 1000 Individual or Organizational Name Additional Name Information Address Information Geographic Location Reference Identification Administrative Communications Contact

M M O O O O O O O

1 1 3 10 1 2 2 1 2 2

Table 2 - Detail
PAGE #
POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

001 003 005 007 009 010 015 020

HL PRV SBR PAT DTP CUR NM1 N2

LOOP ID - 2000 Hierarchical Level Provider Information Subscriber Information Patient Information Date or Time or Period Currency LOOP ID - 2010 Individual or Organizational Name Additional Name Information

>1 M O O O O O O O 1 1 1 1 5 1 10 1 2 MAY 2000

58

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 025 030 032 035 040 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 216 219 220 231 240 241 242 243 250 255 260 265 270 271 275 290 295 300 305 310 315 320 325 330 332 340 345 N3 N4 DMG REF PER CLM DTP CL1 DN1 DN2 PWK CN1 DSB UR AMT REF K3 NTE CR1 CR2 CR3 CR4 CR5 CR6 CR8 CRC HI QTY HCP CR7 HSD NM1 PRV N2 N3 N4 REF PER SBR CAS AMT DMG OI MIA MOA NM1 N2 N3 N4 PER Address Information Geographic Location Demographic Information Reference Identification Administrative Communications Contact LOOP ID - 2300 Health Claim Date or Time or Period Claim Codes Orthodontic Information Tooth Summary Paperwork Contract Information Disability Information Peer Review Organization or Utilization Review Monetary Amount Reference Identification File Information Note/Special Instruction Ambulance Certification Chiropractic Certification Durable Medical Equipment Certification Enteral or Parenteral Therapy Certification Oxygen Therapy Certification Home Health Care Certification Pacemaker Certification Conditions Indicator Health Care Information Codes Quantity Health Care Pricing LOOP ID - 2305 Home Health Treatment Plan Certification Health Care Services Delivery LOOP ID - 2310 Individual or Organizational Name Provider Information Additional Name Information Address Information Geographic Location Reference Identification Administrative Communications Contact LOOP ID - 2320 Subscriber Information Claims Adjustment Monetary Amount Demographic Information Other Health Insurance Information Medicare Inpatient Adjudication Medicare Outpatient Adjudication LOOP ID - 2330 Individual or Organizational Name Additional Name Information Address Information Geographic Location Administrative Communications Contact O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 2 1 1 20 2

004010X098 837

100 1 150 1 1 35 10 1 1 1 40 30 10 20 1 1 1 3 1 1 1 100 25 10 1 6 1 12 9 1 1 2 2 1 20 2 10 1 99 15 1 1 1 1 10 1 2 2 1 2

MAY 2000

59

004010X098 837 350 355 365 370 375 380 382 385 400 405 410 415 420 425 430 435 440 445 450 455 460 462 465 470 475 480 485 488 490 491 492 494 495 496 500 505 510 514 520 525 530 540 545 550 551 552 555 DTP REF LX SV1 SV2 SV3 TOO SV4 SV5 SV6 SV7 HI PWK CR1 CR2 CR3 CR4 CR5 CRC DTP QTY MEA CN1 REF AMT K3 NTE PS1 IMM HSD HCP LIN CTP REF NM1 PRV N2 N3 N4 REF PER SVD CAS DTP LQ FRM SE Date or Time or Period Reference Identification LOOP ID - 2400 Assigned Number Professional Service Institutional Service Dental Service Tooth Identification Drug Service Durable Medical Equipment Service Anesthesia Service Drug Adjudication Health Care Information Codes Paperwork Ambulance Certification Chiropractic Certification Durable Medical Equipment Certification Enteral or Parenteral Therapy Certification Oxygen Therapy Certification Conditions Indicator Date or Time or Period Quantity Measurements Contract Information Reference Identification Monetary Amount File Information Note/Special Instruction Purchase Service Immunization Status Code Health Care Services Delivery Health Care Pricing LOOP ID - 2410 Item Identification Pricing Information Reference Identification LOOP ID - 2420 Individual or Organizational Name Provider Information Additional Name Information Address Information Geographic Location Reference Identification Administrative Communications Contact LOOP ID - 2430 Service Line Adjudication Claims Adjustment Date or Time or Period LOOP ID - 2440 Industry Code Supporting Documentation Transaction Set Trailer

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O M M 9 3 >1 1 1 1 1 32 1 1 1 1 25 10 1 5 1 3 1 3 15 5 20 1 30 15 10 10 1 >1 1 1 >1 1 1 1 10 1 1 2 2 1 20 2 >1 1 99 9 >1 1 99 1

60

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837

NOTES: 1/020 Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop. 2/015 Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 2/195 The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level. 2/250 Loop 2310 contains information about the rendering, referring, or attending provider. 2/290 Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber. 2/325 Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 2/365 Loop 2400 contains Service Line information. 2/425 The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level. 2/494 Loop 2410 contains compound drug components, quantities and prices. 2/500 Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 2/540 SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer. 2/551 Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/370. 2/552 FRM segment provides question numbers and responses for the questions on the medical necessity information form identified in LQ position 551.

MAY 2000

61

004010X098 837 ST TRANSACTION SET HEADER

TRANSACTION SET HEADER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ST

TRANSACTION SET HEADER 004010X098 837 ST

IMPLEMENTATION

TRANSACTION SET HEADER

Usage: REQUIRED Repeat: 1

0 103
STANDARD

Example: STV837V987654~

ST Transaction Set Header

Level: Header Position: 005 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To indicate the start of a transaction set and to assign a control number
DIAGRAM

ST01

143

ST02

329

ST

V
M

TS ID Code
ID 3/3

TS Control Number
M AN 4/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

ST01

143

Transaction Set Identifier Code

Code uniquely identifying a Transaction Set
SEMANTIC:

ID

3/3

The transaction set identifier (ST01) used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).

1838

The only valid value within this transaction set for ST01 is 837.
CODE DEFINITION

837

Health Care Claim REQUIRED

REQUIRED

ST02

329

Transaction Set Control Number

AN

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
ALIAS: Transaction

Set Control Number

1839

The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Submitters could begin sending transactions using the number 0001 in this element and increment from there. The number must be unique within a specific functional group (GS-GE) and interchange (ISA-IEA), but can repeat in other groups and interchanges.

62

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

BEGINNING OF HIERARCHICAL TRANSACTION

004010X098 837 BHT BEGINNING OF HIERARCHICAL TRANSACTION

BHT

004010X098 OF HIERARCHICAL TRANSACTION BEGINNING 837 BHT

IMPLEMENTATION

BEGINNING OF HIERARCHICAL TRANSACTION

Usage: REQUIRED Repeat: 1

9 130 9 113 0 131

STANDARD

Notes:

1. The second example denotes the case where the entire transaction set contains ENCOUNTERS.

Example: BHTV0019V00V0123V19970618V0932VCH~ Example: BHTV0019V00V44445V19970213V0345VRP~

BHT Beginning of Hierarchical Transaction

Level: Header Position: 010 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
DIAGRAM

BHT01

1005

BHT02

353

BHT03

127

BHT04

373

BHT05

337

BHT06

640

BHT V

Hierarch Struct Code

M ID 4/4

TS Purpose Code
M ID 2/2

Reference Ident
O AN 1/30

V
O

Date
DT 8/8

V
O

Time
TM 4/8

Transaction Type Code

O ID 2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

BHT01

1005

Hierarchical Structure Code

ID

4/4

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
CODE DEFINITION

0019

Information Source, Subscriber, Dependent

MAY 2000

63

004010X098 837 BHT BEGINNING OF HIERARCHICAL TRANSACTION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

BHT02

353

Transaction Set Purpose Code

Code identifying purpose of transaction set
ALIAS: Transaction

ID

2/2

Set Purpose Code

2350 2350 1247

NSF Reference: AA0-23.0 BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms original and reissue refer to the electronic transmission status of the 837 batch, not the billing status. ORIGINAL: Original transmissions are claims/encounters which have never been sent to the receiver. Generally nearly all transmissions to a payer entity (as the ultimate destination of the transaction) are original. REISSUE: In the case where a transmission was disrupted the receiver can request that the batch be sent again. Use Reissue when resending transmission batches that have been previously sent.
CODE DEFINITION

00 18 REQUIRED BHT03 127

Original Reissue O AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Originator
SEMANTIC:

Application Transaction Identifier

BHT03 is the number assigned by the originator to identify the transaction within the originators business application system.

1396 1396 1000

NSF Reference: AA0-05.0 The inventory file number of the tape or transmission assigned by the submitters system. This number operates as a batch control number. It may or may not be identical to the number carried in ST02. BHT04 373 Date
Date expressed as CCYYMMDD
INDUSTRY: Transaction
SEMANTIC:

REQUIRED

DT

8/8

Set Creation Date

BHT04 is the date the transaction was created within the business application system.

1397 1397 1001

NSF Reference: AA0-15.0 Identifies the date that the submitter created the file.

64

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 BHT BEGINNING OF HIERARCHICAL TRANSACTION

REQUIRED

BHT05

337

Time

TM

4/8

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

Set Creation Time

BHT05 is the time the transaction was created within the business application system.

1398 1398 1002

REQUIRED BHT06 640

NSF Reference: AA0-16.0 Use this time to identify the time of day that the submitter created the file. Transaction Type Code
Code specifying the type of transaction
INDUSTRY: Claim ALIAS: Claim

ID

2/2

or Encounter Identifier

or Encounter Indicator

1852

Although this element is required, submitters are not necessarily required to accurately batch claims and encounters at this level. Generally CH is used for claims and RP is used for encounters. However, if an ST-SE envelope contains both claims and encounters use CH. Some trading partner agreements may specify using only one code.
CODE DEFINITION

CH

Chargeable Use this code when the transaction contains only fee-for-service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or encounters, or if the transaction contains a mix of claims and encounters, the developers of this implementation guide recommend using code CH.

1676

RP

Reporting Use RP when the entire ST-SE envelope contains encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal providerpayer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes.

2351

MAY 2000

65

004010X098 837 REF TRANSMISSION TYPE IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

TRANSMISSION TYPE IDENTIFICATION 004010X098 837 REF

IMPLEMENTATION

TRANSMISSION TYPE IDENTIFICATION

Usage: REQUIRED Repeat: 1

2 103
STANDARD

Example: REFV87V004010X098D~

REF Reference Identification

Level: Header Position: 015 Loop: ____ Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

87 REQUIRED REF02 127

Functional Category X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Transmission
SYNTAX:

Type Code

R0203

2352
NOT USED NOT USED

When piloting the transaction set, this value is 004010X098D. When sending the transaction set in a production mode, this value is 004010X098. REF03 REF04 352 C040 Description REFERENCE IDENTIFIER X O AN 1/80

66

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 1000A NM1 SUBMITTER NAME

NM1

004010X098 837 1000A NM1 SUBMITTER NAME

IMPLEMENTATION

SUBMITTER NAME
Loop: 1000A SUBMITTER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

6 174

Notes:

1. The example in this NM1 and the subsequent N2 demonstrate how a name that is more than 35 characters long could be handled between the NM1 and N2 segments. 2. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore the Set Notes below. 3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules.

8 180 6 221 2 106

STANDARD

Example: NM1V41V2VCRAMMER, DOLE, PALMER, AND JOHANSONVVVVV46VW7933THU~

NM1 Individual or Organizational Name

Level: Header Position: 020 Loop: 1000 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

67

004010X098 837 1000A NM1 SUBMITTER NAME ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

41 REQUIRED NM102 1065

Submitter M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Submitter ALIAS: Submitter

Last or Organization Name

Name

1815 1815
SITUATIONAL NM104 1036

NSF Reference: AA0-06.0 Name First

Individual first name
INDUSTRY: Submitter ALIAS: Submitter

AN

1/25

First Name

Name

1245
SITUATIONAL NM105 1037

Required if NM102=1 (person). Name Middle

Individual middle name or initial
INDUSTRY: Submitter ALIAS: Submitter

AN

1/25

Middle Name

Name

1848
NOT USED NOT USED REQUIRED NM106 NM107 NM108 1038 1039 66

Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix Identification Code Qualifier O O X AN AN ID 1/10 1/10 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

46

Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement.

2353

68

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 1000A NM1 SUBMITTER NAME

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Submitter ALIAS: Submitter
SYNTAX:

AN

2/80

Identifier

Primary Identification Number

P0809

1820 1820
NOT USED NOT USED NM110 NM111 706 98

NSF Reference: AA0-02.0, ZA0-02.0 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

69

004010X098 837 1000A N2 ADDITIONAL SUBMITTER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 1000A N2 004010X098 SUBMITTER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL SUBMITTER NAME INFORMATION

Loop: 1000A SUBMITTER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

2 114
STANDARD

Example: N2VN ASSOCIATES, INC~

N2 Additional Name Information

Level: Header Position: 025 Loop: 1000 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Additional

AN

1/60

Submitter Name
O AN 1/60

NOT USED

N202

93

Name

70

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADMINISTRATIVE COMMUNICATIONS CONTACT

004010X098 837 1000A PER SUBMITTER EDI CONTACT INFORMATION

PER

SUBMITTER EDI CONTACT PER 004010X098 837 1000A INFORMATION

IMPLEMENTATION

SUBMITTER EDI CONTACT INFORMATION

Loop: 1000A SUBMITTER NAME Usage: REQUIRED Repeat: 2

3 100

Notes:

1. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g., (534) 224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number. 2. The contact information in this segment should point to the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. 3. There are 2 repetitions of the PER segment to allow for six possible combination of communication numbers including extensions.

0 183

9 009 100 5 103

STANDARD

Example: PERVICVJANE DOEVTEV9005555555~

PER Administrative Communications Contact

Level: Header Position: 045 Loop: 1000 Requirement: Optional Max Use: 2 Purpose: To identify a person or office to whom administrative communications should be directed Syntax: 1. P0304 If either PER03 or PER04 is present, then the other is required. 2. P0506 If either PER05 or PER06 is present, then the other is required. 3. P0708 If either PER07 or PER08 is present, then the other is required.

MAY 2000

71

004010X098 837 1000A PER SUBMITTER EDI CONTACT INFORMATION DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PER01

366

PER02

93

PER03

365

PER04

364

PER05

365

PER06

364

PER

Contact Funct Code

M ID 2/2

V
O

Name
AN 1/60

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

PER07

365

PER08

364

PER09

443

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

V Contact Inq
Reference
O AN 1/20

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PER01

366

Contact Function Code

CODE DEFINITION

ID

2/2

Code identifying the major duty or responsibility of the person or group named

IC REQUIRED PER02 93 Name

Free-form name

Information Contact O AN 1/60

INDUSTRY: Submitter

Contact Name

1816 1816 2792

REQUIRED

NSF Reference: AA0-13.0 Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER03 365 Communication Number Qualifier
Code identifying the type of communication number
SYNTAX:

ID

2/2

P0304
DEFINITION

CODE

ED EM FX TE REQUIRED PER04 364

Electronic Data Interchange Access Number Electronic Mail Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0304

1817 1817

NSF Reference: AA0-14.0

72

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 1000A PER SUBMITTER EDI CONTACT INFORMATION

SITUATIONAL

PER05

365

Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0506

2204

Used at the discretion of the submitter.

CODE DEFINITION

ED EM EX FX TE SITUATIONAL PER06 364

Electronic Data Interchange Access Number Electronic Mail Telephone Extension Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0506

2204
SITUATIONAL PER07 365

Used at the discretion of the submitter. Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0708

2204

Used at the discretion of the submitter.

CODE DEFINITION

ED EM EX FX TE SITUATIONAL PER08 364

Electronic Data Interchange Access Number Electronic Mail Telephone Extension Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0708

2204
NOT USED PER09 443

Used at the discretion of the submitter. Contact Inquiry Reference O AN 1/20

MAY 2000

73

004010X098 837 1000B NM1 RECEIVER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 1000B NM1 RECEIVER NAME

IMPLEMENTATION

RECEIVER NAME
Loop: 1000B RECEIVER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

6 221 5 106
STANDARD

Notes:

1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules.

Example: NM1V40V2VUNION MUTUAL OF OREGONVVVVV46V11122333~

NM1 Individual or Organizational Name

Level: Header Position: 020 Loop: 1000 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

74

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 1000B NM1 RECEIVER NAME

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

40 REQUIRED NM102 1065

Receiver M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 REQUIRED NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Receiver

Name
O O O O X AN AN AN AN ID 1/25 1/25 1/10 1/10 1/2

NOT USED NOT USED NOT USED NOT USED REQUIRED

NM104 NM105 NM106 NM107 NM108

1036 1037 1038 1039 66

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

46 REQUIRED NM109 67

Electronic Transmitter Identification Number (ETIN) X AN 2/80

Identification Code
Code identifying a party or other code
INDUSTRY: Receiver ALIAS: Receiver
SYNTAX:

Primary Identifier

Primary Identification Number

P0809

1822 1822
NOT USED NOT USED NM110 NM111 706 98

NSF Reference: AA0-17.0, ZA0-04.0 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

75

004010X098 837 1000B N2 RECEIVER ADDITIONAL NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

RECEIVER ADDITIONAL NAME 004010X098 837 1000B N2 INFORMATION

IMPLEMENTATION

RECEIVER ADDITIONAL NAME INFORMATION

Loop: 1000B RECEIVER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Header Position: 025 Loop: 1000 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Receiver ALIAS: Receiver

AN

1/60

Additional Name

Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

76

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HIERARCHICAL LEVEL

004010X098 837 2000A HL BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL

HL

BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL 004010X098 837 2000A HL

IMPLEMENTATION

BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL

Loop: 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Repeat: >1 Usage: REQUIRED Repeat: 1

5 184

Notes:

1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to the destination payer identified in Loop ID-2010BB. The billing provider entity may be a health care provider, a billing service, or some other representative of the provider. 2. The NSF fields shown in Loop ID-2010AA and Loop ID-2010AB are intended to carry billing provider information, not billing service information. Refer to your NSF manual for proper use of these fields. If Loop 2010AA contains information on a billing service (rather than a billing provider), do not map the information in that loop to the NSF billing provider fields for Medicare claims. 3. The Billing/Pay-to Provider HL may contain information about the Payto Provider entity. If the Pay-to Provider entity is the same as the Billing Provider entity, then only use Loop ID-2010AA. 4. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules. 5. Receiving trading partners may have system limitations regarding the size of the transmission they can receive. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While the implementation guide sets no specific limit to the number of Billing/Pay-to Provider Hierarchical Level loops, there is an implied maximum of 5000. 6. If the Billing or Pay-to Provider is also the Rendering Provider and Loop ID-2310A is not used, the Loop ID-2000 PRV must be used to indicate which entity (Billing or Pay-to) is the Rendering Provider.

3 203

4 203

6 221 5 235

4 235

2 120
STANDARD

Example: HLV1VV20V1~

HL Hierarchical Level
Level: Detail Position: 001 Loop: 2000 Repeat: >1 Requirement: Mandatory Max Use: 1

MAY 2000

77

004010X098 837 2000A HL BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
DIAGRAM

HL01

628

HL02

734

HL03

735

HL04

736

HL V

Hierarch ID Number
M AN 1/12

V
O

Hierarch Parent ID
AN 1/12

Hierarch Level Code

M ID 1/2

Hierarch Child Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

AN

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be 1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.

2356
NOT USED REQUIRED

HL01 must begin with 1" and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01. HL02 HL03 734 735 Hierarchical Parent ID Number Hierarchical Level Code O M AN ID 1/12 1/2

Code defining the characteristic of a level in a hierarchical structure

COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or itemlevel information. CODE DEFINITION

20 REQUIRED HL04 736

Information Source O ID 1/1

Hierarchical Child Code

Code indicating if there are hierarchical child data segments subordinate to the level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. CODE DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

78

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PROVIDER INFORMATION

004010X098 837 2000A PRV BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION

PRV

BILLING/PAY-TO PROVIDER PRV 004010X098 837 2000A SPECIALTY INFORMATION

IMPLEMENTATION

BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION

Loop: 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Usage: SITUATIONAL Repeat: 1

5 203

Notes:

1. Required if the Rendering Provider is the same entity as the Billing Provider and/or the Pay-to Provider. In these cases, the Rendering Provider is being identified at this level for all subsequent claims/encounters in this HL and Loop ID-2310B is not used. 2. This PRV is not used when the Billing or Pay-to Provider is a group and the individual Rendering Provider is in loop 2310B. The PRV segment is then coded with the Rendering Provider in loop 2310B. 3. PRV02 qualifies PRV03.

8 235

3 279 5 279
STANDARD

Example: PRVVBIVZZV203BA050N~

PRV Provider Information

Level: Detail Position: 003 Loop: 2000 Requirement: Optional Max Use: 1 Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

PRV02

128

PRV03

127

PRV04

156

PRV05

C035

PRV06

1223

PRV V
M

Provider Code
ID 1/3

Reference Ident Qual

M ID 2/3

Reference Ident
M AN 1/30

State or Prov Code

O ID 2/2

V
O

Provider Spec. Inf.

V
O

Provider Org Code

ID 3/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code
Code indentifying the type of provider
CODE DEFINITION

ID

1/3

BI PT

Billing Pay-To

MAY 2000

79

004010X098 837 2000A PRV BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

PRV02

128

Reference Identification Qualifier

Code qualifying the Reference Identification

ID

2/3

2360

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

ZZ

Mutually Defined Health Care Provider Taxonomy Code list

2359
REQUIRED PRV03 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Provider ALIAS: Provider

Taxonomy Code

Specialty Code

1000084 1000084
NOT USED NOT USED NOT USED PRV04 PRV05 PRV06 156 C035 1223

NSF Reference: BA0-22.0 State or Province Code PROVIDER SPECIALTY INFORMATION Provider Organization Code O O O ID 3/3 ID 2/2

80

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CURRENCY

004010X098 837 2000A CUR FOREIGN CURRENCY INFORMATION

CUR

FOREIGN CURRENCY INFORMATION 004010X098 837 2000A CUR

IMPLEMENTATION

FOREIGN CURRENCY INFORMATION

Loop: 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Usage: SITUATIONAL Repeat: 1

4 100

Notes:

1. The CUR segment is required if financial amounts submitted in this ST-SE envelop are for services provided in a currency that is NOT normally used by the receiver for processing claims. For example, claims submitted by United States (U.S.) providers to U.S. receivers are assumed to be in U.S. dollars. Claims submitted by Canadian providers to Canadian receivers are assumed to be in Canadian dollars. Claims submitted by Canadian providers to U.S. receivers are assumed to be in Canadian dollars. In that case the CUR would be used to indicate that the billed amounts are in Canadian dollars. In cases where COB is involved, adjudicated adjustments and amounts must also be in the currency indicated here.

6 108
STANDARD

Example: CURV85VCAN~

CUR Currency
Level: Detail Position: 010 Loop: 2000 Requirement: Optional Max Use: 1 Purpose: To specify the currency (dollars, pounds, francs, etc.) used in a transaction Syntax: 1. C0807 If CUR08 is present, then CUR07 is required. 2. C0907 If CUR09 is present, then CUR07 is required. 3. L101112 If CUR10 is present, then at least one of CUR11 or CUR12 are required. 4. C1110 If CUR11 is present, then CUR10 is required. 5. C1210 If CUR12 is present, then CUR10 is required. 6. L131415 If CUR13 is present, then at least one of CUR14 or CUR15 are required. 7. C1413 If CUR14 is present, then CUR13 is required.

MAY 2000

81

004010X098 837 2000A CUR FOREIGN CURRENCY INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

8. C1513 If CUR15 is present, then CUR13 is required. 9. L161718 If CUR16 is present, then at least one of CUR17 or CUR18 are required. 10. C1716 If CUR17 is present, then CUR16 is required. 11. C1816 If CUR18 is present, then CUR16 is required. 12. L192021 If CUR19 is present, then at least one of CUR20 or CUR21 are required. 13. C2019 If CUR20 is present, then CUR19 is required. 14. C2119 If CUR21 is present, then CUR19 is required.
DIAGRAM

CUR01

98

CUR02

100

CUR03

280

CUR04

98

CUR05

100

CUR06

669

CUR V
M

Entity ID Code
ID 2/3

V
M

Currency Code
ID 3/3

V
O

Exchange Rate
R 4/10

V
O

Entity ID Code
ID 2/3

V
O

Currency Code
ID 3/3

V Curr Market /Exchg Code

O ID 3/3

CUR07

374

CUR08

373

CUR09

337

CUR10

374

CUR11

373

CUR12

337

V
X

Date/Time Qualifier
ID 3/3

V
O

Date
DT 8/8

V
O

Time
TM 4/8

V
X

Date/Time Qualifier
ID 3/3

V
X

Date
DT 8/8

V
X

Time
TM 4/8

CUR13

374

CUR14

373

CUR15

337

CUR16

374

CUR17

373

CUR18

337

V
X

Date/Time Qualifier
ID 3/3

V
X

Date
DT 8/8

V
X

Time
TM 4/8

V
X

Date/Time Qualifier
ID 3/3

V
X

Date
DT 8/8

V
X

Time
TM 4/8

CUR19

374

CUR20

373

CUR21

337

V
X

Date/Time Qualifier
ID 3/3

V
X

Date
DT 8/8

V
X

Time
TM 4/8

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CUR01

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

85 REQUIRED CUR02 100 Currency Code

CODE SOURCE 5:

Billing Provider M ID 3/3

Code (Standard ISO) for country in whose currency the charges are specified Countries, Currencies and Funds

NOT USED

CUR03

280

Exchange Rate

4/10

82

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2000A CUR FOREIGN CURRENCY INFORMATION

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

CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21

98 100 669 374 373 337 374 373 337 374 373 337 374 373 337 374 373 337

Entity Identifier Code Currency Code Currency Market/Exchange Code 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

O O O X O O X X X X X X X X X X X X

ID ID ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM

2/3 3/3 3/3 3/3 8/8 4/8 3/3 8/8 4/8 3/3 8/8 4/8 3/3 8/8 4/8 3/3 8/8 4/8

MAY 2000

83

004010X098 837 2010AA NM1 BILLING PROVIDER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 NAME NM1 BILLING PROVIDER 2010AA

IMPLEMENTATION

BILLING PROVIDER NAME

Loop: 2010AA BILLING PROVIDER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

7 107

Notes:

1. Although the name of this loop/segment is Billing Provider the loop/segment really identifies the billing entity. The billing entity does not have to be a health care provider to use this loop. However, some payers do not accept claims from non-provider billing entities. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules.

6 221 1 236
STANDARD

Example: NM1V85V2VCRAMMER, DOLE, PALMER, AND JOHNANSEVVVVV24V111223333~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

84

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2010AA NM1 BILLING PROVIDER NAME

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

85

Billing Provider Use this code to indicate billing provider, billing submitter, and encounter reporting entity.

1066
REQUIRED NM102 1065

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

ID

1/1

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Billing ALIAS: Billing

Provider Last or Organizational Name

Provider Name

1400 1400
SITUATIONAL NM104 1036

NSF Reference: BA0-18.0 or BA0-19.0 Name First

Individual first name
INDUSTRY: Billing ALIAS: Billing

AN

1/25

Provider First Name

Provider Name

1401 1401 1245

SITUATIONAL NM105 1037

NSF Reference: BA0-20.0 Required if NM102=1 (person). Name Middle

Individual middle name or initial
INDUSTRY: Billing ALIAS: Billing

AN

1/25

Provider Middle Name

Provider Name

1402 1402 1848

NOT USED NM106 1038

NSF Reference: BA0-21.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix O AN 1/10

MAY 2000

85

004010X098 837 2010AA NM1 BILLING PROVIDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

NM107

1039

Name Suffix
Suffix to individual name
INDUSTRY: Billing ALIAS: Billing

AN

1/10

Provider Name Suffix

Provider Name

1058
REQUIRED NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2372

If XX - NPI is used, then either the Employers Identification Number or the Social Security Number of the provider must be carried in the REF in this loop.
CODE DEFINITION

24 34 XX

Employers Identification Number Social Security Number Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Billing ALIAS: Billing

Provider Identifier

Provider Primary Identification Number

SYNTAX: P0809

2371 2371
NOT USED NOT USED

NSF Reference: BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA010.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0 NM110 NM111 706 98 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

86

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2010AA N2 ADDITIONAL BILLING PROVIDER NAME INFORMATION

N2

ADDITIONAL 837 2010AA N2 004010X098 BILLING PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL BILLING PROVIDER NAME INFORMATION

Loop: 2010AA BILLING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

2 114
STANDARD

Example: N2VN ASSOCIATES, INC~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Billing

AN

1/60

Provider Additional Name

O AN 1/60

NOT USED

N202

93

Name

MAY 2000

87

004010X098 837 2010AA N3 BILLING PROVIDER ADDRESS

ADDRESS INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N3

BILLING PROVIDER ADDRESS 004010X098 837 2010AA N3

IMPLEMENTATION

BILLING PROVIDER ADDRESS

Loop: 2010AA BILLING PROVIDER NAME Usage: REQUIRED Repeat: 1

8 103
STANDARD

Example: N3V225 MAIN STREETVBARKLEY BUILDING~

N3 Address Information
Level: Detail Position: 025 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Billing ALIAS: Billing

AN

1/55

Provider Address Line

Provider Address 1

2109 2109
SITUATIONAL N302 166

NSF Reference: BA1-07.0, BA1-13.0 Address Information

Address information
INDUSTRY: Billing ALIAS: Billing

AN

1/55

Provider Address Line

Provider Address 2

2110 2110 2205

NSF Reference: BA1-08.0, BA1-14.0 Required if a second address line exists.

88

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GEOGRAPHIC LOCATION

004010X098 837 2010AA N4 BILLING PROVIDER CITY/STATE/ZIP CODE

N4

BILLING PROVIDER 2010AA N4 004010X098 837 CITY/STATE/ZIP CODE

IMPLEMENTATION

BILLING PROVIDER CITY/STATE/ZIP CODE

Loop: 2010AA BILLING PROVIDER NAME Usage: REQUIRED Repeat: 1

9 103
STANDARD

Example: N4VCENTERVILLEVPAV17111~

N4 Geographic Location
Level: Detail Position: 030 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Billing ALIAS: Billing

AN

2/30

Provider City Name

Providers City

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

2111 2111

NSF Reference: BA1-09.0, BA1-15.0

MAY 2000

89

004010X098 837 2010AA N4 BILLING PROVIDER CITY/STATE/ZIP CODE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

N402

156

State or Province Code

INDUSTRY: Billing ALIAS: Billing
COMMENT:

ID

2/2

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

Provider State or Province Code

Providers State
States and Outlying Areas of the U.S.

N402 is required only if city name (N401) is in the U.S. or Canada.

CODE SOURCE 22:

2112 2112
REQUIRED N403 116

NSF Reference: BA1-10.0, BA1-16.0 Postal Code O ID 3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Billing ALIAS: Billing

Provider Postal Zone or ZIP Code

Providers Zip Code

ZIP Code

CODE SOURCE 51:

2113 2113
SITUATIONAL N404 26

NSF Reference: BA1-11.0, BA1-17.0 Country Code

Code identifying the country
ALIAS: Billing

ID

2/3

Provider Country Code

Countries, Currencies and Funds

CODE SOURCE 5:

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

90

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2010AA REF BILLING PROVIDER SECONDARY IDENTIFICATION

REF

BILLING PROVIDER 2010AA REF 004010X098 837 SECONDARY IDENTIFICATION

IMPLEMENTATION

BILLING PROVIDER SECONDARY IDENTIFICATION

Loop: 2010AA BILLING PROVIDER NAME Usage: SITUATIONAL Repeat: 8

3 237

Notes:

1. Required when a secondary identification number is necessary to identify the entity. The primary identification number should be carried in NM108/9 in this loop. 2. If the reason the number is being used in this REF can be met by the NPI, carried in the NM108/09 of this loop, then this REF is not used. 3. If code XX - NPI is used in the NM108/09 of this loop, then either the Employers Identification Number or the Social Security Number of the provider must be carried in this REF. The number sent is the one which is used on the 1099. If additional numbers are needed the REF can be run up to 8 times.

4 237 5 237

0 104
STANDARD

Example: REFV1GV98765~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

MAY 2000

91

004010X098 837 2010AA REF BILLING PROVIDER SECONDARY IDENTIFICATION ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY

State License Number Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number Facility ID Number Preferred Provider Organization Number Health Maintenance Organization Code Number Employers Identification Number Clinic Number Provider Commercial Number Provider Site Number Location Number Social Security Number The social security number may not be used for Medicare.

2376
U3 X5 REQUIRED REF02 127

Unique Supplier Identification Number (USIN) State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Billing ALIAS: Billing
SYNTAX:

Provider Additional Identifier

Provider Secondary Identification Number

R0203

2211 2211
NOT USED

NSF Reference: CA0-28.0, BA0-02.0, BA1-02.0, YA0-06.0, BA0-06.0, BA0-10.0, BA012.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, BA0-08.0, YA0-02.0 REF03 352 Description X AN 1/80

92

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010AA REF BILLING PROVIDER SECONDARY IDENTIFICATION

NOT USED

REF04

C040

REFERENCE IDENTIFIER

MAY 2000

93

004010X098 837 2010AA REF CREDIT/DEBIT CARD BILLING INFORMATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

CREDIT/DEBIT CARD BILLING INFORMATION 004010X098 837 2010AA REF

IMPLEMENTATION

CREDIT/DEBIT CARD BILLING INFORMATION

Loop: 2010AA BILLING PROVIDER NAME Usage: SITUATIONAL Repeat: 8

4 212 6 238

Notes:

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

9 182
STANDARD

Example: REFV8UV1112223333~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

V Description V
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

06 8U EM IJ

System Number Bank Assigned Security Identifier Electronic Payment Reference Number Standard Industry Classification (SIC) Code

94

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010AA REF CREDIT/DEBIT CARD BILLING INFORMATION

LU RB ST TT REQUIRED REF02 127

Location Number Rate code number Store Number Terminal Code X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Billing
SYNTAX:

Provider Credit Card Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

95

004010X098 837 2010AA PER BILLING PROVIDER CONTACT INFORMATION

ADMINISTRATIVE COMMUNICATIONS CONTACT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PER

BILLING PROVIDER 2010AA PER 004010X098 837 CONTACT INFORMATION

IMPLEMENTATION

BILLING PROVIDER CONTACT INFORMATION

Loop: 2010AA BILLING PROVIDER NAME Usage: SITUATIONAL Repeat: 2

3 221 3 100

Notes:

1. Required if this information is different that that contained in the Loop 1000A - Submitter PER segment. 2. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g., (534) 224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number. 3. There are 2 repetitions of the PER segment to allow for six possible combination of communication numbers including extensions.

9 009 100 8 106

STANDARD

Example: PERVICVJIMVTEV8007775555~

PER Administrative Communications Contact

Level: Detail Position: 040 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To identify a person or office to whom administrative communications should be directed Syntax: 1. P0304 If either PER03 or PER04 is present, then the other is required. 2. P0506 If either PER05 or PER06 is present, then the other is required. 3. P0708 If either PER07 or PER08 is present, then the other is required.

96

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2010AA PER BILLING PROVIDER CONTACT INFORMATION

PER01

366

PER02

93

PER03

365

PER04

364

PER05

365

PER06

364

PER

Contact Funct Code

M ID 2/2

V
O

Name
AN 1/60

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

PER07

365

PER08

364

PER09

443

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

V Contact Inq
Reference
O AN 1/20

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PER01

366

Contact Function Code

CODE DEFINITION

ID

2/2

Code identifying the major duty or responsibility of the person or group named

IC REQUIRED PER02 93 Name

Free-form name
INDUSTRY: Billing

Information Contact O AN 1/60

Provider Contact Name

2792
REQUIRED

Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER03 365 Communication Number Qualifier
Code identifying the type of communication number
SYNTAX:

ID

2/2

P0304
DEFINITION

CODE

EM FX TE REQUIRED PER04 364

Electronic Mail Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0304

2116 2116
SITUATIONAL PER05 365

NSF Reference: BA1-12.0, BA1-18.0 Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0506

2214

Used at the discretion of the billing provider.

CODE DEFINITION

EM

Electronic Mail

MAY 2000

97

004010X098 837 2010AA PER BILLING PROVIDER CONTACT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

EX FX TE SITUATIONAL PER06 364

Telephone Extension Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0506

2214
SITUATIONAL PER07 365

Used at the discretion of the billing provider. Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0708

2214

Used at the discretion of the billing provider.

CODE DEFINITION

EM EX FX TE SITUATIONAL PER08 364

Electronic Mail Telephone Extension Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0708

2214
NOT USED PER09 443

Used at the discretion of the billing provider. Contact Inquiry Reference O AN 1/20

98

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2010AB NM1 PAY-TO PROVIDER NAME

NM1

004010X098 837 NAME NM1 PAY-TO PROVIDER 2010AB

IMPLEMENTATION

PAY-TO PROVIDER NAME

Loop: 2010AB PAY-TO PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

5 221 7 221

Notes:

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

7 103
STANDARD

Example: NM1V87V1VCRAMMERVJOSEPHVVVVXXV09876543~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

99

004010X098 837 2010AB NM1 PAY-TO PROVIDER NAME ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

87 REQUIRED NM102 1065

Pay-to Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

Person If Person is used and if the pay-to provider is the same person as the rendering provider, it is not necessary to use the Rendering Provider NM1 loop at the claim loop (Loop ID-2300).

1679

Non-Person Entity If Non-Person Entity is used then the rendering provider NM1 loop (Loop ID-2310B) must be used when appropriate to identify the person who rendered the services.

1680

REQUIRED

NM103

1035

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Pay-to

AN

1/35

Provider Last or Organizational Name

1400 1400
SITUATIONAL NM104 1036

NSF Reference: BA0-18.0 or BA0-19.0 Name First

Individual first name
INDUSTRY: Pay-to

AN

1/25

Provider First Name

1401 1401 1245

SITUATIONAL NM105 1037

NSF Reference: BA0-20.0 Required if NM102=1 (person). Name Middle

Individual middle name or initial
INDUSTRY: Pay-to

AN

1/25

Provider Middle Name

1402 1402 1848

NOT USED NM106 1038

NSF Reference: BA0-21.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix O AN 1/10

100

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010AB NM1 PAY-TO PROVIDER NAME

SITUATIONAL

NM107

1039

Name Suffix
Suffix to individual name
INDUSTRY: Pay-to

AN

1/10

Provider Name Suffix

1058
REQUIRED NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2388

If XX - NPI is used, then either the Employers Identification Number or the Social Security Number of the provider must be carried in the REF in this loop.
CODE DEFINITION

24 34

Employers Identification Number Social Security Number The social security number may not be used for Medicare.

2387
XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Pay-to ALIAS: Pay-to
SYNTAX:

Provider Identifier

Provider Primary Identification Number

P0809

2389 2389
NOT USED NOT USED

NSF Reference: BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA010.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0 NM110 NM111 706 98 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

101

004010X098 837 2010AB N2 ADDITIONAL PAY-TO PROVIDER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2010AB N2 004010X098 PAY-TO PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL PAY-TO PROVIDER NAME INFORMATION

Loop: 2010AB PAY-TO PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Pay-to

AN

1/60

Provider Additional Name

O AN 1/60

NOT USED

N202

93

Name

102

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDRESS INFORMATION

004010X098 837 2010AB N3 PAY-TO PROVIDER ADDRESS

N3

PAY-TO PROVIDER 2010AB N3 004010X098 837 ADDRESS

IMPLEMENTATION

PAY-TO PROVIDER ADDRESS

Loop: 2010AB PAY-TO PROVIDER NAME Usage: REQUIRED Repeat: 1

8 103
STANDARD

Example: N3V225 MAIN STREETVBARKLEY BUILDING~

N3 Address Information
Level: Detail Position: 025 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Pay-to ALIAS: Pay-to

AN

1/55

Provider Address Line

Provider Address 1

2117 2117
SITUATIONAL N302 166

NSF Reference: BA1-13.0, BA1-07.0 Address Information

Address information
INDUSTRY: Pay-to ALIAS: Pay-to

AN

1/55

Provider Address Line

Provider Address 2

2118 2118 2205

NSF Reference: BA1-14.0, BA1-08.0 Required if a second address line exists.

MAY 2000

103

004010X098 837 2010AB N4 PAY-TO PROVIDER CITY/STATE/ZIP CODE

GEOGRAPHIC LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N4

PAY-TO PROVIDER 2010AB N4 004010X098 837 CITY/STATE/ZIP CODE

IMPLEMENTATION

PAY-TO PROVIDER CITY/STATE/ZIP CODE

Loop: 2010AB PAY-TO PROVIDER NAME Usage: REQUIRED Repeat: 1

9 103
STANDARD

Example: N4VCENTERVILLEVPAV17111~

N4 Geographic Location
Level: Detail Position: 030 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Pay-to

AN

2/30

Provider City Name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

2119 2119
REQUIRED N402 156

NSF Reference: BA1-15.0, BA1-09.0 State or Province Code

INDUSTRY: Pay-to
COMMENT:

ID

2/2

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

Provider State Code

N402 is required only if city name (N401) is in the U.S. or Canada. States and Outlying Areas of the U.S.

CODE SOURCE 22:

2120 2120

NSF Reference: BA1-16.0, BA1-10.0

104

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010AB N4 PAY-TO PROVIDER CITY/STATE/ZIP CODE

REQUIRED

N403

116

Postal Code

ID

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Pay-to ALIAS: Pay-to

Provider Postal Zone or ZIP Code

Provider Zip Code

ZIP Code

CODE SOURCE 51:

2121 2121
SITUATIONAL N404 26

NSF Reference: BA1-17.0, BA1-11.0 Country Code

Code identifying the country
ALIAS: Pay-to

ID

2/3

Provider Country Code

Countries, Currencies and Funds

CODE SOURCE 5:

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

MAY 2000

105

004010X098 837 2010AB REF PAY-TO-PROVIDER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

PAY-TO-PROVIDER 2010AB REF 004010X098 837 SECONDARY IDENTIFICATION

IMPLEMENTATION

PAY-TO-PROVIDER SECONDARY IDENTIFICATION

Loop: 2010AB PAY-TO PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

3 239

0 104
STANDARD

Example: REFV1GV98765~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

V Description V
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1A

State License Number Blue Cross Provider Number

106

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010AB REF PAY-TO-PROVIDER SECONDARY IDENTIFICATION

1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY

Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number Facility ID Number Preferred Provider Organization Number Health Maintenance Organization Code Number Employers Identification Number Clinic Number Provider Commercial Number Provider Site Number Location Number Social Security Number The social security number may not be used for Medicare.

2395
U3 X5 REQUIRED REF02 127

Unique Supplier Identification Number (USIN) State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Pay-to ALIAS: Pay-to
SYNTAX:

Provider Identifier

Provider Additional Identifier

R0203

2394 2394
NOT USED NOT USED

NSF Reference: BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA010.0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0 REF03 REF04 352 C040 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

107

004010X098 837 2000B HL SUBSCRIBER HIERARCHICAL LEVEL

HIERARCHICAL LEVEL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HL

SUBSCRIBER HIERARCHICAL 004010X098 837 2000B HLLEVEL

IMPLEMENTATION

SUBSCRIBER HIERARCHICAL LEVEL

Loop: 2000B SUBSCRIBER HIERARCHICAL LEVEL Repeat: >1 Usage: REQUIRED Repeat: 1

1 131

Notes:

1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip the subsequent (PATIENT) HL, and proceed directly to Loop ID-2300. 2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for the destination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber (Loop ID-2010BA), his or her insurance (Loop ID-2010BB), and responsible party (Loop ID-2010BC). In addition, information about the credit/debit card holder is placed in this HL (Loop ID2010BD). The credit/debit card holder may or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using Loop ID-2010BD. 3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules. 4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While the implementation guide sets no specific limit to the number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.

6 184

6 221 6 239

1 120
STANDARD

Example: HLV2V1V22V1~

HL Hierarchical Level
Level: Detail Position: 001 Loop: 2000 Repeat: >1 Requirement: Mandatory Max Use: 1 Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
DIAGRAM

HL01

628

HL02

734

HL03

735

HL04

736

HL V
108

Hierarch ID Number
M AN 1/12

V
O

Hierarch Parent ID
AN 1/12

Hierarch Level Code

M ID 1/2

Hierarch Child Code

O ID 1/1

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2000B HL SUBSCRIBER HIERARCHICAL LEVEL

USAGE

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

AN

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be 1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.

REQUIRED

HL02

734

Hierarchical Parent ID Number

AN

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

REQUIRED

HL03

735

Hierarchical Level Code

ID

1/2

Code defining the characteristic of a level in a hierarchical structure

COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or itemlevel information. CODE DEFINITION

22 REQUIRED HL04 736

Subscriber O ID 1/1

Hierarchical Child Code

Code indicating if there are hierarchical child data segments subordinate to the level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

1200

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

No Subordinate HL Segment in This Hierarchical Structure. Additional Subordinate HL Data Segment in This Hierarchical Structure.

MAY 2000

109

004010X098 837 2000B SBR SUBSCRIBER INFORMATION

SUBSCRIBER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SBR

SUBSCRIBER INFORMATION 004010X098 837 2000B SBR

IMPLEMENTATION

SUBSCRIBER INFORMATION
Loop: 2000B SUBSCRIBER HIERARCHICAL LEVEL Usage: REQUIRED Repeat: 1

6 114
STANDARD

Example: SBRVPVVGRP01020102VVVVVVMB~

SBR Subscriber Information

Level: Detail Position: 005 Loop: 2000 Requirement: Optional Max Use: 1 Purpose: To record information specific to the primary insured and the insurance carrier for that insured
DIAGRAM

SBR01

1138

SBR02

1069

SBR03

127

SBR04

93

SBR05

1336

SBR06

1143

SBR

V Payer Resp V Seq No Code

M ID 1/1

Individual Relat Code

O ID 2/2

Reference Ident
O AN 1/30

V
O

Name
AN 1/60

Insurance Type Code

O ID 1/3

Benefits V Coord Code

O ID 1/1

SBR07

1073

SBR08

584

SBR09

1032

V Yes/No Cond V Employment V Resp Code Status Code

O ID 1/1 O ID 2/2 O

Claim File Ind Code

ID 1/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

SBR01

1138

Payer Responsibility Sequence Number Code

ID

1/1

Code identifying the insurance carriers level of responsibility for a payment of a claim
ALIAS: Payer

Responsibility Sequence Number Code

1517 1517

NSF Reference: DA1-02.0, DA0-02.0, DA2-02.0

CODE DEFINITION

P S T

Primary Secondary Tertiary Use to indicate payer of last resort.

2397

110

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2000B SBR SUBSCRIBER INFORMATION

SITUATIONAL

SBR02

1069

Individual Relationship Code

ALIAS: Relationship
SEMANTIC:

ID

2/2

Code indicating the relationship between two individuals or entities

Code

SBR02 specifies the relationship to the person insured.

1416 1416 2698

NSF Reference: DA0-17.0 Required when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element.
CODE DEFINITION

18 SITUATIONAL SBR03 127

Self O AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Insured ALIAS: Group
SEMANTIC:

Group or Policy Number

or Policy Number

SBR03 is policy or group number.

2398 2398 1096

NSF Reference: DA0-10.0 Required if the subscribers payer identification includes Group or Plan Number. This data element is intended to carry the subscribers Group Number, not the number that uniquely identifies the subscriber (Subscriber ID, Loop 2010BA-NM109). SBR04 93 Name
Free-form name
INDUSTRY: Insured ALIAS: Group
SEMANTIC:

SITUATIONAL

AN

1/60

Group Name

or Plan Name

SBR04 is plan name.

2399 2399 1240

SITUATIONAL SBR05 1336

NSF Reference: DA0-11.0 Required if the subscribers payer identification includes a Group or Plan Name. Insurance Type Code
ALIAS: Insurance

ID

1/3

Code identifying the type of insurance policy within a specific insurance program

type code

1417 1417 1386

NSF Reference: DA0-06.0 Required when the destination payer (Loop 2010BB) is Medicare and Medicare is not the primary payer (SBR01 equals S or T).
CODE DEFINITION

12

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

MAY 2000

111

004010X098 837 2000B SBR SUBSCRIBER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

13

Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employers group health plan Medicare Secondary, No-fault Insurance including Auto is Primary Medicare Secondary Workers Compensation Medicare Secondary Public Health Service (PHS)or Other Federal Agency Medicare Secondary Black Lung Medicare Secondary Veterans Administration Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) Medicare Secondary, Other Liability Insurance is Primary O O O O ID ID ID ID 1/1 1/1 2/2 1/2

14

15 16

41 42 43

47 NOT USED NOT USED NOT USED SITUATIONAL

SBR06 SBR07 SBR08 SBR09

1143 1073 584 1032

Coordination of Benefits Code Yes/No Condition or Response Code Employment Status Code Claim Filing Indicator Code
Code identifying type of claim
ALIAS: Claim

Filing Indicator Code

2520

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

09 10

Self-pay Central Certification

NSF Reference:

1725 1725
11 12 13 14 15 16

CA0-23.0 (K), DA0-05.0 (K) Other Non-Federal Programs Preferred Provider Organization (PPO) Point of Service (POS) Exclusive Provider Organization (EPO) Indemnity Insurance Health Maintenance Organization (HMO) Medicare Risk Automobile Medical Blue Cross/Blue Shield
NSF Reference:

AM BL

1418 1418

CA0-23.0 (G), DA0-05.0 (G), CA0-23.0 (P), DA0-05.0 (P)

112

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2000B SBR SUBSCRIBER INFORMATION

CH

Champus
NSF Reference:

1649 1649
CI

CA0-23.0 (H), DA0-05.0 (H) Commercial Insurance Co.

NSF Reference:

1650 1650
DS HM

CA0-23.0 (F), DA0-05.0 (F) Disability Health Maintenance Organization

NSF Reference:

1651 1651
LI LM MB

CA0-23.0 (I), DA0-05.0 (I) Liability Liability Medical Medicare Part B

NSF Reference:

1652 1652
MC

CA0-23.0 (C), DA0-05.0 (C) Medicaid

NSF Reference:

1653 1653
OF

CA0-23.0 (D), DA0-05.0 (D) Other Federal Program

NSF Reference:

1654 1654
TV

CA0-23.0 (E), DA0-05.0 (E) Title V

NSF Reference:

1655 1655
VA

DA0-05.0 (T) Veteran Administration Plan Refers to Veterans Affairs Plan.

NSF Reference:

2376 1656 1656

WC

DA0-05.0 (V) Workers Compensation Health Claim

NSF Reference:

1657 1657
ZZ

CA0-23.0 (B), DA0-05.0 (B) Mutually Defined Unknown

NSF Reference:

2376 1726 1726

CA0-23.0 (Z), DA0-05.0 (Z)

MAY 2000

113

004010X098 837 2000B PAT PATIENT INFORMATION

PATIENT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PAT

PATIENT INFORMATION 004010X098 837 2000B PAT

IMPLEMENTATION

PATIENT INFORMATION
Loop: 2000B SUBSCRIBER HIERARCHICAL LEVEL Usage: SITUATIONAL Repeat: 1

0 240

Notes:

1. Required if the subscriber is the same person as the patient (Loop ID2000B SBR02=18), and information in this PAT segment (date of death, and/or patient weight) is necessary to file the claim/encounter (see PAT05, 06, 07, and 08).

5 139
STANDARD

Example: PATVVVVVD8V19970314V01V146~

PAT Patient Information

Level: Detail Position: 007 Loop: 2000 Requirement: Optional Max Use: 1 Purpose: To supply patient information Syntax: 1. P0506 If either PAT05 or PAT06 is present, then the other is required. 2. P0708 If either PAT07 or PAT08 is present, then the other is required.
DIAGRAM

PAT01

1069

PAT02

1384

PAT03

584

PAT04

1220

PAT05

1250

PAT06

1251

PAT V
V

Individual Relat Code

O ID 2/2

Patient Loc Code

O ID 1/1

Student V Employment V V Status Code Status Code

O ID 2/2 O ID 1/1

Date Time format Qual

X ID 2/3

V
X

Date Time Period

AN 1/35

PAT07

355

PAT08

81

PAT09

1073

Unit/Basis Meas Code

X ID 2/2

V
X

Weight
R 1/10

V Yes/No Cond ~ Resp Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

NOT USED NOT USED NOT USED NOT USED

PAT01 PAT02 PAT03 PAT04

1069 1384 584 1220

Individual Relationship Code Patient Location Code Employment Status Code Student Status Code

O O O O

ID ID ID ID

2/2 1/1 2/2 1/1

114

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2000B PAT PATIENT INFORMATION

SITUATIONAL

PAT05

1250

Date Time Period Format Qualifier

SYNTAX:

ID

2/3

Code indicating the date format, time format, or date and time format P0506

1798

Required if patient is known to be deceased.

CODE DEFINITION

D8 SITUATIONAL PAT06 1251

Date Expressed in Format CCYYMMDD X AN 1/35

Date Time Period

INDUSTRY: Insured ALIAS: Date
SYNTAX:

Expression of a date, a time, or range of dates, times or dates and times

Individual Death Date

of Death

P0506 PAT06 is the date of death.

SEMANTIC:

1419 1419 1798

SITUATIONAL PAT07 355

NSF Reference: CA0-21.0 Required if patient is known to be deceased. Unit or Basis for Measurement Code X ID 2/2
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0708

1000098

Required on claims/encounters for delivery services (newborns birthweight).

CODE DEFINITION

GR

Gram This data element is used when the patients age is less than 29 days old.

2401
SITUATIONAL PAT08 81 Weight

1/10

Numeric value of weight

INDUSTRY: Patient
SYNTAX:

Weight

P0708 PAT08 is the patients weight.

SEMANTIC:

2403 2403 1823

NSF Reference: FA0-44.0, GU0-17.0 This data element is used when the patients age is less than 29 days. Required on (1) claims/encounters for delivery services (newborns birthweight) and (2) claims/encounters involving EPO (epoetin) for patients on dialysis and Medicare Durable Medical Equipment Regional Carriers certificate of medical necessity (DMERC CMN) 02.03 and 10.02.

MAY 2000

115

004010X098 837 2000B PAT PATIENT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

PAT09

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Pregnancy
SEMANTIC:

ID

1/1

Indicator

PAT09 indicates whether the patient is pregnant or not pregnant. Code Y indicates the patient is pregnant; code N indicates the patient is not pregnant.

2402

Required when required by state law (e.g., Indiana Medicaid). The Y code indicates the patient/subscriber is pregnant. If PAT09 is not used it indicates that the patient/subscriber is not pregnant.
CODE DEFINITION

Yes

116

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2010BA NM1 SUBSCRIBER NAME

NM1

004010X098 837 2010BA NM1 SUBSCRIBER NAME

IMPLEMENTATION

SUBSCRIBER NAME
Loop: 2010BA SUBSCRIBER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

4 240

Notes:

1. In workers compensation or other property and casualty claims, the subscriber may be a non-person entity (i.e., the employer). However, this varies by state. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules.

6 221 1 116
STANDARD

Example: NM1VILV1VDOEVJOHNVTVVJRVMIV123456~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

117

004010X098 837 2010BA NM1 SUBSCRIBER NAME ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

IL REQUIRED NM102 1065

Insured or Subscriber M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Subscriber

Last Name

1422 1422
SITUATIONAL NM104 1036

NSF Reference: CA0-04.0, DA0-19.0 Name First

Individual first name
INDUSTRY: Subscriber

AN

1/25

First Name

1424 1424 1245

SITUATIONAL NM105 1037

NSF Reference: CA0-05.0, DA0-20.0 Required if NM102=1 (person). Name Middle

Individual middle name or initial
INDUSTRY: Subscriber

AN

1/25

Middle Name

1426 1426 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: CA0-06.0, DA0-21.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Subscriber ALIAS: Subscriber

O O

AN AN

1/10 1/10

Name Suffix

Generation

1428 1428 1058 1166

NSF Reference: CA0-07.0, DA0-22.0 Required if known. Examples: I, II, III, IV, Jr, Sr

118

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BA NM1 SUBSCRIBER NAME

SITUATIONAL

NM108

66

Identification Code Qualifier

ID

1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2406

Required if NM102 = 1 (person)

CODE DEFINITION

MI

Member Identification Number The code MI is intended to be the subscribers identification number as assigned by the payer. Payers use different terminology to convey the same number. Therefore the 837 Professional Workgroup recommends using MI - Member Identification Number to convey the following terms: Insureds ID, Subscribers ID, Health Insurance Claim Number (HIC), etc. MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number is also available on an IHS/CHS claim, put the SSN in REF02.

2407

ZZ

Mutually Defined The value ZZ, when used in this data element shall be defined as HIPAA Individual Identifier once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of the Department of Health and Human Services must adopt a standard individual identifier for use in this transaction.

2405

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Subscriber
SYNTAX:

AN

2/80

Primary Identifier

P0809

2338 2338 2406

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: DA0-18.0, CA1-05.0, CA1-06.0 Required if NM102 = 1 (person) Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

119

004010X098 837 2010BA N2 ADDITIONAL SUBSCRIBER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2010BA N2 004010X098 SUBSCRIBER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL SUBSCRIBER NAME INFORMATION

Loop: 2010BA SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Subscriber ALIAS: Subscribers

AN

1/60

Supplemental Description

Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

120

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDRESS INFORMATION

004010X098 837 2010BA N3 SUBSCRIBER ADDRESS

N3

SUBSCRIBER ADDRESS 004010X098 837 2010BA N3

IMPLEMENTATION

SUBSCRIBER ADDRESS
Loop: 2010BA SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

8 240 7 114
STANDARD

Notes:

1. Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18 (self)).

Example: N3V125 CITY AVENUE~

N3 Address Information
Level: Detail Position: 025 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Subscriber ALIAS: Subscriber

AN

1/55

Address Line

Address 1

1431 1431
SITUATIONAL N302 166

NSF Reference: CA0-11.0, DA2-04.0 Address Information

Address information
INDUSTRY: Subscriber ALIAS: Subscriber

AN

1/55

Address Line

Address 2

1432 1432 2205

NSF Reference: CA0-12.0, DA2-05.0 Required if a second address line exists.

MAY 2000

121

004010X098 837 2010BA N4 SUBSCRIBER CITY/STATE/ZIP CODE

GEOGRAPHIC LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N4

SUBSCRIBER CITY/STATE/ZIP CODE 004010X098 837 2010BA N4

IMPLEMENTATION

SUBSCRIBER CITY/STATE/ZIP CODE

Loop: 2010BA SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

8 240 9 103
STANDARD

Notes:

1. Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18 (self)).

Example: N4VCENTERVILLEVPAV17111~

N4 Geographic Location
Level: Detail Position: 030 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Subscriber

AN

2/30

City Name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1458 1458

NSF Reference: DA2-06.0, CA0-13.0

122

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BA N4 SUBSCRIBER CITY/STATE/ZIP CODE

REQUIRED

N402

156

State or Province Code

INDUSTRY: Subscriber
COMMENT:

ID

2/2

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

State Code

N402 is required only if city name (N401) is in the U.S. or Canada. States and Outlying Areas of the U.S.

CODE SOURCE 22:

1435 1435
REQUIRED N403 116

NSF Reference: CA0-14.0, DA2-07.0 Postal Code O ID 3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Subscriber ALIAS: Subscriber
CODE SOURCE 51:

Postal Zone or ZIP Code

Zip Code

ZIP Code

1437 1437
SITUATIONAL N404 26

NSF Reference: CA0-15.0, DA2-08.0 Country Code

Code identifying the country
ALIAS: Subscriber
CODE SOURCE 5:

ID

2/3

Country Code

Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

MAY 2000

123

004010X098 837 2010BA DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

DEMOGRAPHIC INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DMG

SUBSCRIBER DEMOGRAPHIC INFORMATION 004010X098 837 2010BA DMG

IMPLEMENTATION

SUBSCRIBER DEMOGRAPHIC INFORMATION

Loop: 2010BA SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

8 240 1 104
STANDARD

Notes:

1. Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18 (self)).

Example: DMGVD8V19330706VM~

DMG Demographic Information

Level: Detail Position: 032 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To supply demographic information Syntax:
DIAGRAM

1. P0102 If either DMG01 or DMG02 is present, then the other is required.

DMG01

1250

DMG02

1251

DMG03

1068

DMG04

1067

DMG05

1109

DMG06

1066

DMG V
V

Date Time format Qual

X ID 2/3

V
X

Date Time Period

AN 1/35

V
O

Gender Code
ID 1/1

Marital Race or V V V Citizenship Status Code Ethnic Code Status Code

O ID 1/1 O ID 1/1 O ID 1/2

DMG07

26

DMG08

659

DMG09

380

Country Code
O ID 2/3

Basis of Verif Code

O ID 1/2

V
O

Quantity
R 1/15

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

SYNTAX:

ID

2/3

Code indicating the date format, time format, or date and time format P0102
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

124

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BA DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

REQUIRED

DMG02

1251

Date Time Period

INDUSTRY: Subscriber ALIAS: Date
SYNTAX:

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Birth Date

of Birth - Patient

P0102 DMG02 is the date of birth.

SEMANTIC:

1439 1439
REQUIRED DMG03 1068

NSF Reference: CA0-08.0, DA0-24.0 Gender Code

Code indicating the sex of the individual
INDUSTRY: Subscriber ALIAS: Gender

ID

1/1

Gender Code

- Patient

1441 1441

NSF Reference: CA0-09.0, DA0-23.0

CODE DEFINITION

F M U NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 1067 1109 1066 26 659 380

Female Male Unknown O O O O O O ID ID ID ID ID R 1/1 1/1 1/2 2/3 1/2 1/15

Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity

MAY 2000

125

004010X098 837 2010BA REF SUBSCRIBER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

SUBSCRIBER SECONDARY IDENTIFICATION 004010X098 837 2010BA REF

IMPLEMENTATION

SUBSCRIBER SECONDARY IDENTIFICATION

Loop: 2010BA SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 4

6 220

Notes:

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

9 106
STANDARD

Example: REFVSYV528446666~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1W

Member Identification Number If NM108 = M1 do not use this code.

1000100
23

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

2413

126

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BA REF SUBSCRIBER SECONDARY IDENTIFICATION

IG SY

Insurance Policy Number Social Security Number The social security number may not be used for Medicare.

2414
REQUIRED REF02 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Subscriber
SYNTAX:

Supplemental Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

127

004010X098 837 2010BA REF PROPERTY AND CASUALTY CLAIM NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

PROPERTY 837 2010BA REF 004010X098 AND CASUALTY CLAIM NUMBER

IMPLEMENTATION

PROPERTY AND CASUALTY CLAIM NUMBER

Loop: 2010BA SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

3 106

Notes:

1. In the case where the patient is the same person as the subscriber, the property and casualty claim number is placed in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is placed in Loop ID-2010CA. This number should be transmitted in only one place. 2. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 4.2, Property and Casualty, for additional information about property and casualty claims.

7 185

5 241
STANDARD

Example: REFVY4V4445555~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

Y4

Agency Claim Number

128

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BA REF PROPERTY AND CASUALTY CLAIM NUMBER

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Property
SYNTAX:

Casualty Claim Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

129

004010X098 837 2010BB NM1 PAYER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2010BB NM1 PAYER NAME

IMPLEMENTATION

PAYER NAME
Loop: 2010BB PAYER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

4 131 6 221 5 107

STANDARD

Notes:

1. This is the destination payer. 2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules.

Example: NM1VPRV2VUNION MUTUAL OF OREGONVVVVVPIV11122333~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

130

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2010BB NM1 PAYER NAME

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

PR REQUIRED NM102 1065

Payer M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 REQUIRED NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Payer

Name

1443 1443
NOT USED NOT USED NOT USED NOT USED REQUIRED NM104 NM105 NM106 NM107 NM108 1036 1037 1038 1039 66

NSF Reference: DA0-09.0 Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier O O O O X AN AN AN AN ID 1/25 1/25 1/10 1/10 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

PI XV

Payor Identification Health Care Financing Administration National PlanID Required if the National PlanID is mandated for use. Otherwise, one of the other listed codes may be used.
CODE SOURCE 540:

Health Care Financing Administration

National PlanID

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Payer ALIAS: Payer
SYNTAX:

AN

2/80

Identifier

Primary Identifier

P0809

2417 2417
NOT USED NM110 706

NSF Reference: DA0-07.0 Entity Relationship Code X ID 2/2

MAY 2000

131

004010X098 837 2010BB NM1 PAYER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NOT USED

NM111

98

Entity Identifier Code

ID

2/3

132

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2010BB N2 ADDITIONAL PAYER NAME INFORMATION

N2

ADDITIONAL 837 2010BB N2 004010X098 PAYER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL PAYER NAME INFORMATION

Loop: 2010BB PAYER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Payer ALIAS: Payer

AN

1/60

Additional Name

Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

MAY 2000

133

004010X098 837 2010BB N3 PAYER ADDRESS

ADDRESS INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N3

PAYER ADDRESS 004010X098 837 2010BB N3

IMPLEMENTATION

PAYER ADDRESS
Loop: 2010BB PAYER NAME Usage: SITUATIONAL Repeat: 1

8 241 4 114
STANDARD

Notes:

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

Example: N3V225 MAIN STREETVBARKLEY BUILDING~

N3 Address Information
Level: Detail Position: 025 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Payer ALIAS: Payer

AN

1/55

Address Line

Address 1

1444 1444
SITUATIONAL N302 166

NSF Reference: DA1-04.0 Address Information

Address information
INDUSTRY: Payer ALIAS: Payer

AN

1/55

Address Line

Address 2

1445 1445 2205

NSF Reference: DA1-05.0 Required if a second address line exists.

134

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GEOGRAPHIC LOCATION

004010X098 837 2010BB N4 PAYER CITY/STATE/ZIP CODE

N4

PAYER CITY/STATE/ZIP CODE 004010X098 837 2010BB N4

IMPLEMENTATION

PAYER CITY/STATE/ZIP CODE

Loop: 2010BB PAYER NAME Usage: SITUATIONAL Repeat: 1

8 241 5 114
STANDARD

Notes:

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

Example: N4VCENTERVILLEVPAV17111~

N4 Geographic Location
Level: Detail Position: 030 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Payer

AN

2/30

City Name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1446 1446

NSF Reference: DA1-06.0

MAY 2000

135

004010X098 837 2010BB N4 PAYER CITY/STATE/ZIP CODE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

N402

156

State or Province Code

INDUSTRY: Payer
COMMENT:

ID

2/2

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

State Code
States and Outlying Areas of the U.S.

N402 is required only if city name (N401) is in the U.S. or Canada.

CODE SOURCE 22:

1447 1447
REQUIRED N403 116

NSF Reference: DA1-07.0 Postal Code O ID 3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Payer ALIAS: Payer

Postal Zone or ZIP Code

Zip Code
ZIP Code

CODE SOURCE 51:

1448 1448
SITUATIONAL N404 26

NSF Reference: DA1-08.0 Country Code

Code identifying the country
ALIAS: Payer

ID

2/3

Country Code
Countries, Currencies and Funds

CODE SOURCE 5:

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

136

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2010BB REF PAYER SECONDARY IDENTIFICATION

REF

PAYER SECONDARY IDENTIFICATION 004010X098 837 2010BB REF

IMPLEMENTATION

PAYER SECONDARY IDENTIFICATION

Loop: 2010BB PAYER NAME Usage: SITUATIONAL Repeat: 3

9 241

Notes:

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

5 115
STANDARD

Example: REFVFYV435261708~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

2U

Payer Identification Number Used to identify any payer.

2699
FY NF

Claim Office Number National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE 245:

National Association of Insurance Commissioners (NAIC) Code

TJ

Federal Taxpayers Identification Number

MAY 2000

137

004010X098 837 2010BB REF PAYER SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Payer
SYNTAX:

Additional Identifier

R0203

1000091 1000091
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: DA0-08.0 Description REFERENCE IDENTIFIER X O AN 1/80

138

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2010BC NM1 RESPONSIBLE PARTY NAME

NM1

004010X098 837 2010BC NM1 RESPONSIBLE PARTY NAME

IMPLEMENTATION

RESPONSIBLE PARTY NAME

Loop: 2010BC RESPONSIBLE PARTY NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

8 167 7 221

Notes:

1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financial responsibility for the bill. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. Required for Medicare claims where there is a representative but the provider of medical services has neither the responsible partys signature nor the patients signature on file. When a Medicare beneficiary is unable to execute a request for payment because of a mental or physical condition, the request may be executed on the beneficiarys behalf by a legal guardian, representative payee, relative, friend, an employee of the institution providing care, or an employee of a governmental agency providing assistance. In this circumstance, unless the requester is a representative payee for the beneficiary, the claim must show the signature and address of the requester with an attached statement explaining the relationship between the requester and the beneficiary, and why the beneficiary cant sign. This information must be on the claim unless it is on file with the provider.

0 242

9 118
STANDARD

Example: NM1VQDV1VJONESVLISA~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

Syntax:

MAY 2000

139

004010X098 837 2010BC NM1 RESPONSIBLE PARTY NAME DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1691 1691

NSF Reference: CA0-25.0

CODE DEFINITION

QD REQUIRED NM102 1065

Responsible Party M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Responsible

Party Last or Organization Name

1464 1464
SITUATIONAL NM104 1036

NSF Reference: CB0-04.0 Name First

Individual first name
INDUSTRY: Responsible

AN

1/25

Party First Name

1465 1465 1245

NSF Reference: CB0-05.0 Required if NM102=1 (person).

140

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BC NM1 RESPONSIBLE PARTY NAME

SITUATIONAL

NM105

1037

Name Middle
Individual middle name or initial
INDUSTRY: Responsible

AN

1/25

Party Middle Name

1466 1466 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: CB0-06.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Responsible ALIAS: Responsible

O O

AN AN

1/10 1/10

Party Suffix Name

Party Generation

1058
NOT USED NOT USED NOT USED NOT USED NM108 NM109 NM110 NM111 66 67 706 98

Required if known. Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code X X X O ID AN ID ID 1/2 2/80 2/2 2/3

MAY 2000

141

004010X098 837 2010BC N2 ADDITIONAL RESPONSIBLE PARTY NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2010BC PARTY NAME INFORMATION 004010X098 RESPONSIBLE N2

IMPLEMENTATION

ADDITIONAL RESPONSIBLE PARTY NAME INFORMATION

Loop: 2010BC RESPONSIBLE PARTY NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

1 138
STANDARD

Example: N2VADDITIONAL NAME~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Responsible ALIAS: Responsible

AN

1/60

Party Additional Name

Party Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

142

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDRESS INFORMATION

004010X098 837 2010BC N3 RESPONSIBLE PARTY ADDRESS

N3

RESPONSIBLE PARTY ADDRESS 004010X098 837 2010BC N3

IMPLEMENTATION

RESPONSIBLE PARTY ADDRESS

Loop: 2010BC RESPONSIBLE PARTY NAME Usage: REQUIRED Repeat: 1

3 103
STANDARD

Example: N3V123 MAIN STREET~

N3 Address Information
Level: Detail Position: 025 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Responsible ALIAS: Responsible

AN

1/55

Party Address Line

Party Address 1

1467 1467
SITUATIONAL N302 166

NSF Reference: CB0-07.0 Address Information

Address information
INDUSTRY: Responsible ALIAS: Responsible

AN

1/55

Party Address Line

Party Address 2

1468 1468 2205

NSF Reference: CB0-08.0 Required if a second address line exists.

MAY 2000

143

004010X098 837 2010BC N4 RESPONSIBLE PARTY CITY/STATE/ZIP CODE

GEOGRAPHIC LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N4

RESPONSIBLE PARTY CITY/STATE/ZIP CODE 004010X098 837 2010BC N4

IMPLEMENTATION

RESPONSIBLE PARTY CITY/STATE/ZIP CODE

Loop: 2010BC RESPONSIBLE PARTY NAME Usage: REQUIRED Repeat: 1

4 103
STANDARD

Example: N4VANY TOWNVTXV75123~

N4 Geographic Location
Level: Detail Position: 030 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Responsible

AN

2/30

Party City Name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1469 1469
REQUIRED N402 156

NSF Reference: CB0-09.0 State or Province Code

INDUSTRY: Responsible
COMMENT:

ID

2/2

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

Party State Code

N402 is required only if city name (N401) is in the U.S. or Canada. States and Outlying Areas of the U.S.

CODE SOURCE 22:

1470 1470

NSF Reference: CB0-10.0

144

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BC N4 RESPONSIBLE PARTY CITY/STATE/ZIP CODE

REQUIRED

N403

116

Postal Code

ID

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Responsible ALIAS: Responsible
CODE SOURCE 51:

Party Postal Zone or ZIP Code

Party Zip Code

ZIP Code

1471 1471
SITUATIONAL N404 26

NSF Reference: CB0-11.0 Country Code

Code identifying the country
ALIAS: Responsible
CODE SOURCE 5:

ID

2/3

Party Country Code

Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

MAY 2000

145

004010X098 837 2010BD NM1 CREDIT/DEBIT CARD HOLDER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2010BD NM1 CREDIT/DEBIT CARD HOLDER NAME

IMPLEMENTATION

CREDIT/DEBIT CARD HOLDER NAME

Loop: 2010BD CREDIT/DEBIT CARD HOLDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

2 221

Notes:

1. It is not intended that credit/debit card information be conveyed to a health care payer. Trading partners are responsible for ensuring that no federal or state privacy regulations are violated if credit/debit card information is carried in the transmission. 2. The information carried under this segment must never be sent to the payer. This information is only for use between a provider and a service organization offering patient collection services. In this case, it is the responsibility of the collection service organization to remove this segment before forwarding the claim to the payer.

2 242

6 182
STANDARD

Example: NM1VAOV1VSMITHVJANEVLVVVMIV0000000000000000000~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

146

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2010BD NM1 CREDIT/DEBIT CARD HOLDER NAME

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

AO REQUIRED NM102 1065

Account Of M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Credit

or Debit Card Holder Last or Organizational Name Card Holder Name

O AN 1/25

ALIAS: Credit/Debit

SITUATIONAL

NM104

1036

Name First
Individual first name
INDUSTRY: Credit

or Debit Card Holder First Name Card Holder Name

ALIAS: Credit/Debit

1245
SITUATIONAL NM105 1037

Required if NM102=1 (person). Name Middle

Individual middle name or initial
INDUSTRY: Credit

AN

1/25

or Debit Card Holder Middle Name Card Holder Name

ALIAS: Credit/Debit

1848
NOT USED SITUATIONAL NM106 NM107 1038 1039

Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Credit

O O

AN AN

1/10 1/10

or Debit Card Holder Name Suffix Card Holder Name

ALIAS: Credit/Debit

1058
REQUIRED NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

MI

Member Identification Number

MAY 2000

147

004010X098 837 2010BD NM1 CREDIT/DEBIT CARD HOLDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Credit

AN

2/80

or Debit Card Number Card Number

ALIAS: Credit/Debit
SYNTAX:

P0809

NOT USED NOT USED

NM110 NM111

706 98

Entity Relationship Code Entity Identifier Code

X O

ID ID

2/2 2/3

148

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2010BD N2 ADDITIONAL CREDIT/DEBIT CARD HOLDER NAME INFORMATION

N2

ADDITIONAL 837 2010BD CARD 004010X098 CREDIT/DEBIT N2 HOLDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL CREDIT/DEBIT CARD HOLDER NAME INFORMATION

Loop: 2010BD CREDIT/DEBIT CARD HOLDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names. 2. The information carried under this segment must never be sent to the payer. This information is only for use between a provider and a service organization offering patient collection services. In this case, it is the responsibility of the collection service organization to remove this segment before forwarding the claim to the payer.

2 242

1 138
STANDARD

Example: N2VADDITIONAL NAME~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Credit

AN

1/60

or Debit Card Holder Additional Name Card Holder Additional Name Information
O AN 1/60

ALIAS: Credit-Debit

NOT USED

N202

93

Name

MAY 2000

149

004010X098 837 2010BD REF CREDIT/DEBIT CARD INFORMATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

CREDIT/DEBIT CARD INFORMATION 004010X098 837 2010BD REF

IMPLEMENTATION

CREDIT/DEBIT CARD INFORMATION

Loop: 2010BD CREDIT/DEBIT CARD HOLDER NAME Usage: SITUATIONAL Repeat: 2

2 242

Notes:

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

3 242
STANDARD

Example: REFVBBV111222333334~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

AB BB REQUIRED REF02 127

Acceptable Source Purchaser ID Authorization Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Credit
SYNTAX:

or Debit Card Authorization Number

R0203

150

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010BD REF CREDIT/DEBIT CARD INFORMATION

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

151

004010X098 837 2000C HL PATIENT HIERARCHICAL LEVEL

HIERARCHICAL LEVEL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HL

PATIENT HIERARCHICAL HL 004010X098 837 2000CLEVEL

IMPLEMENTATION

PATIENT HIERARCHICAL LEVEL

Loop: 2000C PATIENT HIERARCHICAL LEVEL Repeat: >1 Usage: SITUATIONAL Repeat: 1

5 242 7 221

Notes:

1. This HL is required when the patient is a different person than the subscriber. There are no HLs subordinate to the Patient HL. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. While the implementation guide sets no specific limit to the number of Patient Hierarchical Level loops, there is an implied maximum of 5000.

6 242

0 114
STANDARD

Example: HLV3V2V23V0~

HL Hierarchical Level
Level: Detail Position: 001 Loop: 2000 Repeat: >1 Requirement: Mandatory Max Use: 1 Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
DIAGRAM

HL01

628

HL02

734

HL03

735

HL04

736

HL V

Hierarch ID Number
M AN 1/12

V
O

Hierarch Parent ID
AN 1/12

Hierarch Level Code

M ID 1/2

Hierarch Child Code

O ID 1/1

152

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2000C HL PATIENT HIERARCHICAL LEVEL

USAGE

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

AN

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be 1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.

REQUIRED

HL02

734

Hierarchical Parent ID Number

AN

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

REQUIRED

HL03

735

Hierarchical Level Code

ID

1/2

Code defining the characteristic of a level in a hierarchical structure

COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or itemlevel information. CODE DEFINITION

23

Dependent The code DEPENDENT is meant to convey that the information in this HL applies to the patient when the subscriber and the patient are not the same person.

1681

REQUIRED

HL04

736

Hierarchical Child Code

ID

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. CODE DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

MAY 2000

153

004010X098 837 2000C PAT PATIENT INFORMATION

PATIENT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PAT

PATIENT INFORMATION 004010X098 837 2000C PAT

IMPLEMENTATION

PATIENT INFORMATION
Loop: 2000C PATIENT HIERARCHICAL LEVEL Usage: REQUIRED Repeat: 1

2 104
STANDARD

Example: PATV01VVVVVV01V145~

PAT Patient Information

Level: Detail Position: 007 Loop: 2000 Requirement: Optional Max Use: 1 Purpose: To supply patient information Syntax: 1. P0506 If either PAT05 or PAT06 is present, then the other is required. 2. P0708 If either PAT07 or PAT08 is present, then the other is required.
DIAGRAM

PAT01

1069

PAT02

1384

PAT03

584

PAT04

1220

PAT05

1250

PAT06

1251

PAT

Individual Relat Code

O ID 2/2

Patient Loc Code

O ID 1/1

V Employment V
Status Code
ID O 2/2

Student V Status Code

O ID 1/1

Date Time format Qual

X ID 2/3

V
X

Date Time Period

AN 1/35

PAT07

355

PAT08

81

PAT09

1073

Unit/Basis Meas Code

X ID 2/2

V
X

Weight
R 1/10

V Yes/No Cond ~ Resp Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PAT01

1069

Individual Relationship Code

ALIAS: Patients

ID

2/2

Code indicating the relationship between two individuals or entities

Relationship to Insured

1449 1449

NSF Reference: DA0-17.0

CODE DEFINITION

01 04

Spouse Grandfather or Grandmother

154

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2000C PAT PATIENT INFORMATION

05 07 09 10 15 17 19 20 21 22 23 24 29 32 33 34 36 39 40 41 43 53 G8 NOT USED NOT USED NOT USED SITUATIONAL PAT02 PAT03 PAT04 PAT05 1384 584 1220 1250

Grandson or Granddaughter Nephew or Niece Adopted Child Foster Child Ward Stepson or Stepdaughter Child Employee Unknown Handicapped Dependent Sponsored Dependent Dependent of a Minor Dependent Significant Other Mother Father Other Adult Emancipated Minor Organ Donor Cadaver Donor Injured Plaintiff Child Where Insured Has No Financial Responsibility Life Partner Other Relationship O O O X ID ID ID ID 1/1 2/2 1/1 2/3

Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier
SYNTAX:

Code indicating the date format, time format, or date and time format P0506

1798

Required if patient is known to be deceased.

CODE DEFINITION

D8

Date Expressed in Format CCYYMMDD

MAY 2000

155

004010X098 837 2000C PAT PATIENT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

PAT06

1251

Date Time Period

INDUSTRY: Patient ALIAS: Date
SYNTAX:

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Death Date

of Death

P0506 PAT06 is the date of death.

SEMANTIC:

1450 1450 1798

SITUATIONAL PAT07 355

NSF Reference: CA0-21.0 Required if patient is known to be deceased. Unit or Basis for Measurement Code X ID 2/2
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0708

1000098

Required on claims/encounters for delivery services (newborns birthweight).

CODE DEFINITION

GR

Gram This data element is used when the patients age is less than 29 days old.

2428
SITUATIONAL PAT08 81 Weight

1/10

Numeric value of weight

INDUSTRY: Patient
SYNTAX:

Weight

P0708 PAT08 is the patients weight.

SEMANTIC:

2427 2427 1000101

SITUATIONAL PAT09 1073

NSF Reference: FA0-44.0, GU0-17.0 Required on claims/encounters where the patients age is less than 29 days. Yes/No Condition or Response Code
Code indicating a Yes or No condition or response
INDUSTRY: Pregnancy
SEMANTIC:

ID

1/1

Indicator

PAT09 indicates whether the patient is pregnant or not pregnant. Code Y indicates the patient is pregnant; code N indicates the patient is not pregnant.

2429

Required when required by state law (e.g., Indiana Medicaid). The Y code indicates that the patient is pregnant. If PAT09 is not used it means the patient is not pregnant.
CODE DEFINITION

Yes

156

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2010CA NM1 PATIENT NAME

NM1

004010X098 837 2010CA NM1 PATIENT NAME

IMPLEMENTATION

PATIENT NAME
Loop: 2010CA PATIENT NAME Repeat: 1 Usage: REQUIRED Repeat: 1

3 104
STANDARD

Example: NM1VQCV1VDOEVSALLYVJVVVMIVSJD11111~

NM1 Individual or Organizational Name

Level: Detail Position: 015 Loop: 2010 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

QC

Patient

MAY 2000

157

004010X098 837 2010CA NM1 PATIENT NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

NM102

1065

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

ID

1/1

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Patient

Last Name

1452 1452
REQUIRED NM104 1036

NSF Reference: CA0-04.0 Name First

Individual first name
INDUSTRY: Patient

AN

1/25

First Name

1453 1453
SITUATIONAL NM105 1037

NSF Reference: CA0-05.0 Name Middle

Individual middle name or initial
INDUSTRY: Patient ALIAS: Patient

AN

1/25

Middle Name

Middle Initial

1454 1454 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: CA0-06.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Patient ALIAS: Patient

O O

AN AN

1/10 1/10

Name Suffix

Generation

1455 1455 1058

NSF Reference: CA0-07.0 Required if known.

158

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010CA NM1 PATIENT NAME

SITUATIONAL

NM108

66

Identification Code Qualifier

ID

1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

1853

Required if the patient identifier is different than the subscriber identifier.

CODE DEFINITION

MI

Member Identification Number The code MI is intended to be the subscribers identification number as assigned by the payer. Payers use different terminology to convey the same number. Therefore the 837 Professional Workgroup recommends using MI - Member Identification Number to convey the following terms: Insureds ID, Subscribers ID, Health Insurance Claim Number (HIC), etc.

1000102

ZZ

Mutually Defined The value ZZ, when used in this data element shall be defined as HIPAA Individual Identifier once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of the Department of Health and Human Services must adopt a standard individual identifier for use in this transaction.

2219

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Patient ALIAS: Patients
SYNTAX:

AN

2/80

Primary Identifier

Primary Identification Number

P0809

1463 1463 1853

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: DA0-18.0 Required if the patient identifier is different than the subscriber identifier. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

159

004010X098 837 2010CA N2 ADDITIONAL PATIENT NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2010CA N2 004010X098 PATIENT NAME INFORMATION

IMPLEMENTATION

ADDITIONAL PATIENT NAME INFORMATION

Loop: 2010CA PATIENT NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

1 138
STANDARD

Example: N2VADDITIONAL NAME~

N2 Additional Name Information

Level: Detail Position: 020 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Patient ALIAS: Patient

AN

1/60

Additional Name

Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

160

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDRESS INFORMATION

004010X098 837 2010CA N3 PATIENT ADDRESS

N3

PATIENT ADDRESS 004010X098 837 2010CA N3

IMPLEMENTATION

PATIENT ADDRESS
Loop: 2010CA PATIENT NAME Usage: REQUIRED Repeat: 1

4 104
STANDARD

Example: N3VRFD 10V100 COUNTRY LANE~

N3 Address Information
Level: Detail Position: 025 Loop: 2010 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Patient ALIAS: Patient

AN

1/55

Address Line

Address 1

1456 1456
SITUATIONAL N302 166

NSF Reference: CA0-11.0 Address Information

Address information
INDUSTRY: Patient ALIAS: Patient

AN

1/55

Address Line

Address 2

1457 1457 2205

NSF Reference: CA0-12.0 Required if a second address line exists.

MAY 2000

161

004010X098 837 2010CA N4 PATIENT CITY/STATE/ZIP CODE

GEOGRAPHIC LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N4

PATIENT CITY/STATE/ZIP CODE 004010X098 837 2010CA N4

IMPLEMENTATION

PATIENT CITY/STATE/ZIP CODE

Loop: 2010CA PATIENT NAME Usage: REQUIRED Repeat: 1

5 104
STANDARD

Example: N4VCORNFIELD TOWNSHIPVIAV99999~

N4 Geographic Location
Level: Detail Position: 030 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Patient

AN

2/30

City Name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1458 1458
REQUIRED N402 156

NSF Reference: CA0-13.0 State or Province Code

INDUSTRY: Patient
COMMENT:

ID

2/2

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

State Code

N402 is required only if city name (N401) is in the U.S. or Canada. States and Outlying Areas of the U.S.

CODE SOURCE 22:

1459 1459

NSF Reference: CA0-14.0

162

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010CA N4 PATIENT CITY/STATE/ZIP CODE

REQUIRED

N403

116

Postal Code

ID

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Patient ALIAS: Patient

Postal Zone or ZIP Code

Zip Code
ZIP Code

CODE SOURCE 51:

1460 1460
SITUATIONAL N404 26

NSF Reference: CA0-15.0 Country Code

Code identifying the country
ALIAS: Patient
CODE SOURCE 5:

ID

2/3

Country Code
Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

MAY 2000

163

004010X098 837 2010CA DMG PATIENT DEMOGRAPHIC INFORMATION

DEMOGRAPHIC INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DMG

PATIENT DEMOGRAPHIC INFORMATION 004010X098 837 2010CA DMG

IMPLEMENTATION

PATIENT DEMOGRAPHIC INFORMATION

Loop: 2010CA PATIENT NAME Usage: REQUIRED Repeat: 1

8 114
STANDARD

Example: DMGVD8V19530101VF~

DMG Demographic Information

Level: Detail Position: 032 Loop: 2010 Requirement: Optional Max Use: 1 Purpose: To supply demographic information Syntax:
DIAGRAM

1. P0102 If either DMG01 or DMG02 is present, then the other is required.

DMG01

1250

DMG02

1251

DMG03

1068

DMG04

1067

DMG05

1109

DMG06

1066

DMG V
V

Date Time format Qual

X ID 2/3

V
X

Date Time Period

AN 1/35

V
O

Gender Code
ID 1/1

Marital Race or V V V Citizenship Status Code Ethnic Code Status Code

O ID 1/1 O ID 1/1 O ID 1/2

DMG07

26

DMG08

659

DMG09

380

Country Code
O ID 2/3

Basis of Verif Code

O ID 1/2

V
O

Quantity
R 1/15

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

SYNTAX:

ID

2/3

Code indicating the date format, time format, or date and time format P0102
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

164

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010CA DMG PATIENT DEMOGRAPHIC INFORMATION

REQUIRED

DMG02

1251

Date Time Period

INDUSTRY: Patient ALIAS: Date
SYNTAX:

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Birth Date

of Birth

P0102 DMG02 is the date of birth.

SEMANTIC:

1461 1461
REQUIRED DMG03 1068

NSF Reference: CA0-08.0 Gender Code

Code indicating the sex of the individual
INDUSTRY: Patient ALIAS: Gender

ID

1/1

Gender Code

- Patient

1462 1462

NSF Reference: CA0-09.0

CODE DEFINITION

F M U NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 1067 1109 1066 26 659 380

Female Male Unknown O O O O O O ID ID ID ID ID R 1/1 1/1 1/2 2/3 1/2 1/15

Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity

MAY 2000

165

004010X098 837 2010CA REF PATIENT SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

PATIENT SECONDARY IDENTIFICATION 004010X098 837 2010CA REF

IMPLEMENTATION

PATIENT SECONDARY IDENTIFICATION

Loop: 2010CA PATIENT NAME Usage: SITUATIONAL Repeat: 5

9 170 9 114
STANDARD

Notes:

1. Required if additional identification numbers are necessary to adjudicate the claim/encounter.

Example: REFVSYV528779999~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1W

Member Identification Number If NM108 = M1 do not use this code.

1000100
23

Client Number This code is intended to be used only in claims submitted to the Indian Health Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose of reporting the Health Record Number.

1000103

IG

Insurance Policy Number

166

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010CA REF PATIENT SECONDARY IDENTIFICATION

SY

Social Security Number The social security number may not be used for Medicare.

2430
REQUIRED REF02 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Patient
SYNTAX:

Secondary Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

167

004010X098 837 2010CA REF PROPERTY AND CASUALTY CLAIM NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

PROPERTY 837 2010CA REF 004010X098 AND CASUALTY CLAIM NUMBER

IMPLEMENTATION

PROPERTY AND CASUALTY CLAIM NUMBER

Loop: 2010CA PATIENT NAME Usage: SITUATIONAL Repeat: 1

3 106

Notes:

1. In the case where the patient is the same person as the subscriber, the property and casualty claim number is placed in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is placed in Loop ID-2010CA. This number should be transmitted in only one place. 2. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 4.2, Property and Casualty, for additional information about property and casualty claims.

7 185

5 241
STANDARD

Example: REFVY4V4445555~

REF Reference Identification

Level: Detail Position: 035 Loop: 2010 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

Y4

Agency Claim Number

168

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2010CA REF PROPERTY AND CASUALTY CLAIM NUMBER

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Property
SYNTAX:

Casualty Claim Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

169

004010X098 837 2300 CLM CLAIM INFORMATION

HEALTH CLAIM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CLM

CLAIM INFORMATION 004010X098 837 2300 CLM

IMPLEMENTATION

CLAIM INFORMATION
Loop: 2300 CLAIM INFORMATION Repeat: 100 Usage: REQUIRED Repeat: 1

6 221 2 243

Notes:

1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules. 2. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher. 3. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this the claim information is said to float. Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is the subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See 2.3.2.1, HL Segment, for details.

4 009 100

6 104
STANDARD

Example: CLMVA37YH556V500VVV11::1VYVAVYVYVC~

CLM Health Claim

Level: Detail Position: 130 Loop: 2300 Repeat: 100 Requirement: Optional Max Use: 1 Purpose: To specify basic data about the claim

170

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2300 CLM CLAIM INFORMATION

CLM01

1028

CLM02

782

CLM03

1032

CLM04

1343

CLM05

C023

CLM06

1073

CLM

V Claim Submt V
Identifier
M AN 1/38 O

Monetary Amount
R 1/18

V
O

Claim File Ind Code

ID 1/2

Non-Inst Claim Code

O ID 1/2

V Health Care V Yes/No Cond

Serv Loc. Resp Code
ID O O 1/1

CLM07

1359

CLM08

1073

CLM09

1363

CLM10

1351

CLM11

C024

CLM12

1366

Provider V Yes/No Cond V Accept Code Resp Code

O ID 1/1 O ID 1/1

Release of Info Code

O ID 1/1

Patient Sig Related V Source Code Causes Info

O ID 1/1 O

Special Prog Code

O ID 2/3

CLM13

1073

CLM14

1338

CLM15

1073

CLM16

1360

CLM17

1029

CLM18

1073

V Yes/No Cond V Resp Code

O ID 1/1

Level of Serv Code

O ID 1/3

V Yes/No Cond V Resp Code

O ID 1/1

Provider Agree Code

O ID 1/1

Claim V V Yes/No Cond Status Code Resp Code

O ID 1/2 O ID 1/1

CLM19

1383

CLM20

1514

Delay V Claim Submt V ~ Reason Code Reason Code

O ID 2/2 O ID 1/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CLM01

1028

Claim Submitters Identifier

AN

1/38

Identifier used to track a claim from creation by the health care provider through payment
INDUSTRY: Patient

Account Number

1729 1729

NSF Reference: CA0-03.0, CB0-03.0, DA0-03.0, DA1-03.0, DA2-03.0, EA0-03.0, EA103.0, EA2-03.0, FA0-03.0, FB0-03.0, FB1-03.0, FB2-03.0, FD0-03.0, FE0-03.0, GA0-03.0, GC0-03.0, GX0-03.0, GX2-03.0, XA0-03.0, CA103.0, GU0-03.0, HA0-03.0 The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitters system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitters patient management system. The developers of this implementation guide strongly recommend that submitters use completely unique numbers for this field for each individual claim. The maximum number of characters to be supported for this field is 20. A provider may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any responding system is 20. Characters beyond 20 are not required to be stored nor returned by any 837-receiving system.

1005

2434

MAY 2000

171

004010X098 837 2300 CLM CLAIM INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

CLM02

782

Monetary Amount
Monetary amount
INDUSTRY: Total ALIAS: Total
SEMANTIC:

1/18

Claim Charge Amount

Submitted Charges

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

1473 1473 1858

NOT USED NOT USED REQUIRED CLM03 CLM04 CLM05 1032 1343 C023

NSF Reference: XA0-12.0 For encounter transmissions, zero (0) may be a valid amount. Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION O O O ID ID 1/2 1/2

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

1133 1474 1474 1207

ALIAS: Place

of Service Code

NSF Reference: FA0-07.0 CLM05 applies to all service lines unless it is over written at the line level.

172

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CLM CLAIM INFORMATION

REQUIRED

CLM05 - 1

1331

Facility Code Value

AN

1/2

Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format
INDUSTRY: Facility

Type Code

2435

Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here. 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 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/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 50 Federally Qualified Health Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation 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 Laboratory 99 Other Unlisted Facility CLM05 - 2 CLM05 - 3 1332 1325 Facility Code Qualifier Claim Frequency Type Code O O ID ID 1/2 1/1

NOT USED REQUIRED

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

Frequency Code

Submission Reason Code

Claim Frequency Type Code

CODE SOURCE 235:

2811

Code 8 may only be used where permitted by state law (e.g. New York Medicaid). See the NUBC UB92 manual for definitions of these codes.

MAY 2000

173

004010X098 837 2300 CLM CLAIM INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

1000093 2810

With the exception of #1 (Original) use 6, 7, and 8 for claims that have already been finalized in the payers system. Permissible code values for this subelement: 1 - ORIGINAL (Admit thru Discharge Claim) 6 - CORRECTED (Adjustment of Prior Claim) 7 - REPLACEMENT (Replacement of Prior Claim) 8 - VOID (Void/Cancel of Prior Claim)

REQUIRED

CLM06

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Provider ALIAS: Provider
SEMANTIC:

ID

1/1

or Supplier Signature Indicator

Signature on File

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

1475 1475

NSF Reference: EA0-37.0

CODE DEFINITION

N Y REQUIRED CLM07 1359

No Yes O ID 1/1

Provider Accept Assignment Code

Code indicating whether the provider accepts assignment
INDUSTRY: Medicare

Assignment Code

2438 2438 1208 2439

NSF Reference: EA0-36.0, FA0-59.0 CLM07 indicates whether the provider accepts Medicare assignment. The NSF mapping to FA0-59.0 occurs only in payer-to-payer COB situations.
CODE DEFINITION

A B C P

Assigned Assignment Accepted on Clinical Lab Services Only Not Assigned Patient Refuses to Assign Benefits

174

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CLM CLAIM INFORMATION

REQUIRED

CLM08

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Benefits

ID

1/1

Assignment Certification Indicator of Benefits Indicator

ALIAS: Assignment
SEMANTIC:

CLM08 is assignment of benefits indicator. A Y value indicates insured or authorized person authorizes benefits to be assigned to the provider; an N value indicates benefits have not been assigned to the provider.

1477 1477

NSF Reference: DA0-15.0

CODE DEFINITION

N Y REQUIRED CLM09 1363

No Yes O ID 1/1

Release of Information Code

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

of Information Code

1478 1478

NSF Reference: EA0-13.0

CODE DEFINITION

Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes The Provider has Limited or Restricted Ability to Release Data Related to a Claim No, Provider is Not Allowed to Release Data On file at Payor or at Plan Sponsor Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

N O Y

MAY 2000

175

004010X098 837 2300 CLM CLAIM INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CLM10

1351

Patient Signature Source Code

ID

1/1

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

Signature Source Code

1479 1479 1209

NSF Reference: DA0-16.0 CLM10 is required except in cases where code N is used in CLM09.
CODE DEFINITION

Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file Signed HCFA-1500 Claim Form on file Signed signature authorization form for HCFA-1500 Claim Form block 13 on file Signature generated by provider because the patient was not physically present for services Signed signature authorization form for HCFA-1500 Claim Form block 12 on file O

C M

S SITUATIONAL

CLM11

C024

RELATED CAUSES INFORMATION

ALIAS: Accident/Employment/Related

To identify one or more related causes and associated state or country information

1220 1210

Causes

CLM11-1, CLM11-2, or CLM11-3 are required when the condition being reported is accident or employment related. If CLM11-1, CLM11-2, or CLM11-3 equals AP, then map Yes to EA0-09.0. If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required. CLM11 - 1 1362 Related-Causes Code M ID 2/3
Code identifying an accompanying cause of an illness, injury or an accident
INDUSTRY: Related

2440
REQUIRED

Causes Code

1849 1849

NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 Employment, EA0-09.0 - Responsibility Indicator
CODE DEFINITION

AA AB AP EM OA

Auto Accident Abuse Another Party Responsible Employment Other Accident

176

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CLM CLAIM INFORMATION

SITUATIONAL

CLM11 - 2

1362

Related-Causes Code

ID

2/3

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

INDUSTRY: Related

Causes Code

1849 1849 2442

AA AB AP EM OA SITUATIONAL CLM11 - 3 1362

NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 Employment, EA0-09.0 - Responsibility Indicator Used if more than one code applies.
CODE DEFINITION

Auto Accident Abuse Another Party Responsible Employment Other Accident Related-Causes Code O ID 2/3
Code identifying an accompanying cause of an illness, injury or an accident
INDUSTRY: Related

Causes Code

1849 1849 2442

AA AB AP EM OA SITUATIONAL CLM11 - 4 156

NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 Employment, EA0-09.0 - Responsibility Indicator Used if more than one code applies.
CODE DEFINITION

Auto Accident Abuse Another Party Responsible Employment Other Accident State or Province Code O ID 2/2
Code (Standard State/Province) as defined by appropriate government agency
INDUSTRY: Auto

Accident State or Province Code

States and Outlying Areas of the U.S.

CODE SOURCE 22:

1482 1482 2441

NSF Reference: EA0-10.0 Required if CLM11-1, -2, or -3 = AA to identify the state in which the automobile accident occurred. Use state postal code (CA = California, UT = Utah, etc).

MAY 2000

177

004010X098 837 2300 CLM CLAIM INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CLM11 - 5

26

Country Code
Code identifying the country
CODE SOURCE 5:

ID

2/3

Countries, Currencies and Funds

1006
SITUATIONAL

Required if the automobile accident occurred out of the United States to identify the country in which the accident occurred. CLM12 1366 Special Program Code O ID 2/3
Code indicating the Special Program under which the services rendered to the patient were performed
INDUSTRY: Special ALIAS: Special

Program Indicator

Program Code

1483 1483 2443

NSF Reference: EA0-43.0 Required if the services were rendered under one of the following circumstances/programs/projects.
CODE DEFINITION

01

Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) Physically Handicapped Childrens Program Special Federal Funding Disability Induced Abortion - Danger to Life Induced Abortion - Rape or Incest Second Opinion or Surgery O O O O ID ID ID ID 1/1 1/3 1/1 1/1

02 03 05 07 08 09 NOT USED NOT USED NOT USED SITUATIONAL CLM13 CLM14 CLM15 CLM16 1073 1338 1073 1360

Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code Provider Agreement Code

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

Agreement

2437

Required if a non-participating (non-par) provider is submitting a participating (par) claim/encounter. Sending the P code indicates that a non-par provider is sending a par claim as allowed under certain plans.
CODE DEFINITION

P NOT USED NOT USED NOT USED CLM17 CLM18 CLM19 1029 1073 1383

Participation Agreement O O O ID ID ID 1/2 1/1 2/2

Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code

178

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CLM CLAIM INFORMATION

SITUATIONAL

CLM20

1514

Delay Reason Code

Code indicating the reason why a request was delayed
ALIAS: Delay

ID

1/2

Reason Code

1212

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

1244

1 2 3 4 5 6 7 8 9

Proof of Eligibility Unknown or Unavailable Litigation Authorization Delays Delay in Certifying Provider Delay in Supplying Billing Forms Delay in Delivery of Custom-made Appliances Third Party Processing Delay Delay in Eligibility Determination Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules Administration Delay in the Prior Approval Process Other

10 11

MAY 2000

179

004010X098 837 2300 DTP DATE - ORDER DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ORDER DATE 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - ORDER DATE

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

9 244 7 100

Notes:

1. Required when claim includes an order (i.e., an order for services or supplies is being billed/reported). 2. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

8 244
STANDARD

Example: DTPV938VD8V19970617~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

938 REQUIRED DTP02 1250

Order M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

180

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - ORDER DATE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Order

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Date

MAY 2000

181

004010X098 837 2300 DTP DATE - INITIAL TREATMENT

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - INITIAL TREATMENT 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - INITIAL TREATMENT

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 100

Notes:

1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. 2. Required on all claims involving spinal manipulation.

9 203 9 124
STANDARD

Example: DTPV454VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

454 REQUIRED DTP02 1250

Initial Treatment M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

182

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - INITIAL TREATMENT

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Initial

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Treatment Date

1730 1730

NSF Reference: GC0-05.0

MAY 2000

183

004010X098 837 2300 DTP DATE - REFERRAL DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - REFERRAL 2300 004010X098 837 DATE DTP

IMPLEMENTATION

DATE - REFERRAL DATE

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

2 245 7 100

Notes:

1. Required when claim includes a referral. 2. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

1 245
STANDARD

Example: DTPV330VD8V19970617~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

330 REQUIRED DTP02 1250

Referral Date M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

184

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - REFERRAL DATE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Referral

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Date

MAY 2000

185

004010X098 837 2300 DTP DATE - DATE LAST SEEN

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - DATE 837 2300 004010X098 LAST SEEN DTP

IMPLEMENTATION

DATE - DATE LAST SEEN

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

9 208

Notes:

1. Required when claims involve services from an independent physical therapist, occupational therapist, or physician services involving routine foot care. 2. This is the date that the patient was seen by the attending/supervising physician for the qualifying medical condition related to the services performed.

5 245

0 125
STANDARD

Example: DTPV304VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

304 REQUIRED DTP02 1250

Latest Visit or Consultation M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

186

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - DATE LAST SEEN

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Last

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Seen Date

1484 1484

NSF Reference: EA0-48.0

MAY 2000

187

004010X098 837 2300 DTP DATE - ONSET OF CURRENT ILLNESS/SYMPTOM

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ONSET OF CURRENT ILLNESS/SYMPTOM 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - ONSET OF CURRENT ILLNESS/SYMPTOM

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 100

Notes:

1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. 2. Required when information is available and if different than the date of service. If not used, claim/service date is assumed to be the date of onset of illness/symptoms.

6 245

1 125
STANDARD

Example: DTPV431VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

431

Onset of Current Symptoms or Illness

188

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - ONSET OF CURRENT ILLNESS/SYMPTOM

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

SEMANTIC:

ID

2/3

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Onset

Expression of a date, a time, or range of dates, times or dates and times

of Current Illness or Injury Date

1485 1485

NSF Reference: EA0-07.0

MAY 2000

189

004010X098 837 2300 DTP DATE - ACUTE MANIFESTATION

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ACUTE MANIFESTATION 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - ACUTE MANIFESTATION

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 5

7 100

Notes:

1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. 2. Required when Loop 2300 CR208 = A or M, the claim involves spinal manipulation, and the payer is Medicare.

7 174 2 125
STANDARD

Example: DTPV453VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

453 REQUIRED DTP02 1250

Acute Manifestation of a Chronic Condition M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

190

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - ACUTE MANIFESTATION

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Acute

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Manifestation Date

1486 1486

NSF Reference: GC0-12.0

MAY 2000

191

004010X098 837 2300 DTP DATE - SIMILAR ILLNESS/SYMPTOM ONSET

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - SIMILAR ILLNESS/SYMPTOM ONSET 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - SIMILAR ILLNESS/SYMPTOM ONSET

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 10

7 100

Notes:

1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. 2. Required when claim involves services to a patient experiencing symptoms similar or identical to previously reported symptoms.

6 241 3 125
STANDARD

Example: DTPV438VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

438 REQUIRED DTP02 1250

Onset of Similar Symptoms or Illness M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

192

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - SIMILAR ILLNESS/SYMPTOM ONSET

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Similar

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Illness or Symptom Date

1487 1487

NSF Reference: EA0-16.0

MAY 2000

193

004010X098 837 2300 DTP DATE - ACCIDENT

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ACCIDENT 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - ACCIDENT
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 10

8 174 4 125
STANDARD

Notes:

1. Required if CLM11-1, CLM11-2, or CLM11-3 = AA, AB, AP or OA.

Example: DTPV439VD8V19970114~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

439 REQUIRED DTP02 1250

Accident M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 DT

Date Expressed in Format CCYYMMDD Date and Time Expressed in Format CCYYMMDDHHMM Required if accident hour is known.

2040

194

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - ACCIDENT

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Accident

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Date

2042 2042

NSF Reference: EA0-07.0 - Accident Date, EA0-11.0 Accident Hour (no minutes)

MAY 2000

195

004010X098 837 2300 DTP DATE - LAST MENSTRUAL PERIOD

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - LAST 837 2300 PERIOD 004010X098 MENSTRUAL DTP

IMPLEMENTATION

DATE - LAST MENSTRUAL PERIOD

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

9 174 5 125
STANDARD

Notes:

1. Required when claim involves pregnancy.

Example: DTPV484VD8V19961113~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

484 REQUIRED DTP02 1250

Last Menstrual Period M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Last

Expression of a date, a time, or range of dates, times or dates and times

Menstrual Period Date

1489 1489

NSF Reference: EA0-07.0

196

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2300 DTP DATE - LAST X-RAY

DTP

DATE - LAST 837 004010X098 X-RAY 2300 DTP

IMPLEMENTATION

DATE - LAST X-RAY

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 100

Notes:

1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. 2. Required when claim involves spinal manipulation if an x-ray was taken.

0 175 6 125
STANDARD

Example: DTPV455VD8V19970114~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

455 REQUIRED DTP02 1250

Last X-Ray M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

MAY 2000

197

004010X098 837 2300 DTP DATE - LAST X-RAY

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Last

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

X-Ray Date

1490 1490

NSF Reference: GC0-06.0

198

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2300 DTP DATE - ESTIMATED DATE OF BIRTH

DTP

DATE - ESTIMATED DATE DTP 004010X098 837 2300 OF BIRTH

IMPLEMENTATION

DATE - ESTIMATED DATE OF BIRTH

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

4 245 6 270
STANDARD

Notes:

1. Required when PAT09 is used.

Example: DTPVABCVD8V19970617~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

ABC REQUIRED DTP02 1250

Estimated Date of Birth M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Estimated ALIAS: Estimated

Expression of a date, a time, or range of dates, times or dates and times

Birth Date

Date of Birth

MAY 2000

199

004010X098 837 2300 DTP DATE - HEARING AND VISION PRESCRIPTION DATE
DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - HEARING 2300 DTP 004010X098 837AND VISION PRESCRIPTION DATE

IMPLEMENTATION

DATE - HEARING AND VISION PRESCRIPTION DATE

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 245 8 125
STANDARD

Notes:

1. Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim.

Example: DTPV471VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

471 REQUIRED DTP02 1250

Prescription M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Prescription

Expression of a date, a time, or range of dates, times or dates and times

Date

200

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2300 DTP DATE - DISABILITY BEGIN

DTP

DATE - DISABILITY 2300 004010X098 837 BEGIN DTP

IMPLEMENTATION

DATE - DISABILITY BEGIN

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 5

1 204

Notes:

1. Required on claims involving disability where, in the opinion of the provider, the patient was or will be unable to perform the duties normally associated with his/her work.

9 125
STANDARD

Example: DTPV360VD8V19970114~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

360 REQUIRED DTP02 1250

Disability Begin M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

MAY 2000

201

004010X098 837 2300 DTP DATE - DISABILITY BEGIN

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Disability

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

From Date

1494 1494

NSF Reference: EA0-18.0

202

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2300 DTP DATE - DISABILITY END

DTP

DATE - DISABILITY 2300 004010X098 837 END DTP

IMPLEMENTATION

DATE - DISABILITY END

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 5

8 245

Notes:

1. Required on claims/encounters involving disability where, in the opinion of the provider, the patient, after having been absent from work for reasons related to the disability, was or will be able to perform the duties normally associated with his/her work.

0 126
STANDARD

Example: DTPV361VD8V19970613~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

361 REQUIRED DTP02 1250

Disability End M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

MAY 2000

203

004010X098 837 2300 DTP DATE - DISABILITY END

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Disability

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

To Date

1495 1495

NSF Reference: EA0-19.0

204

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2300 DTP DATE - LAST WORKED

DTP

DATE - LAST 837 2300 004010X098 WORKED DTP

IMPLEMENTATION

DATE - LAST WORKED

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

8 118

Notes:

1. Required on claims where this information is necessary for adjudication of the claim (e.g., workers compensation claims involving absence from work).

1 126
STANDARD

Example: DTPV297VD8V19970114~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

297 REQUIRED DTP02 1250

Date Last Worked M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Last

Expression of a date, a time, or range of dates, times or dates and times

Worked Date

MAY 2000

205

004010X098 837 2300 DTP DATE - AUTHORIZED RETURN TO WORK

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - AUTHORIZED RETURN 004010X098 837 2300 DTP TO WORK

IMPLEMENTATION

DATE - AUTHORIZED RETURN TO WORK

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

8 118

Notes:

1. Required on claims where this information is necessary for adjudication of the claim (e.g., workers compensation claims involving absence from work).

2 126
STANDARD

Example: DTPV296VD8V19970620~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

296

Return to Work This is the date the provider has authorized the patient to return to work.

2459
REQUIRED DTP02 1250

Date Time Period Format Qualifier

SEMANTIC:

ID

2/3

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

206

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - AUTHORIZED RETURN TO WORK

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Work

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Return Date

1703 1703

NSF Reference: EA1-12.0

MAY 2000

207

004010X098 837 2300 DTP DATE - ADMISSION

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ADMISSION 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - ADMISSION
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

1 246

Notes:

1. Required on all ambulance claims/encounters when the patient was known to be admitted to the hospital. Also required on inpatient medical visits claims/encounters.

3 126
STANDARD

Example: DTPV435VD8V19970114~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

435 REQUIRED DTP02 1250

Admission M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

208

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - ADMISSION

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Related

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Hospitalization Admission Date

1496 1496

NSF Reference: GA0-23.0 (for ambulance claims only), EA0-28.0

MAY 2000

209

004010X098 837 2300 DTP DATE - DISCHARGE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - DISCHARGE 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - DISCHARGE
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

2 246 4 126
STANDARD

Notes:

1. Required for inpatient claims when the patient was discharged from the facility and the discharge date is known.

Example: DTPV096VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

096 REQUIRED DTP02 1250

Discharge M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

210

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 DTP DATE - DISCHARGE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Related

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Hospitalization Discharge Date

1497 1497

NSF Reference: GA0-22.0 (for Ambulance Claims only), EA0-29.0

MAY 2000

211

004010X098 837 2300 DTP DATE - ASSUMED AND RELINQUISHED CARE DATES
DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ASSUMED AND RELINQUISHED CARE DATES 004010X098 837 2300 DTP

IMPLEMENTATION

DATE - ASSUMED AND RELINQUISHED CARE DATES

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 2

2 217

Notes:

1. Required on Medicare claims to indicate assumed care date and relinquished care date for situations where providers share postoperative care (global surgery claims). Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. 2. Example: Surgeon A relinquished post-operative care to Physician B five days after surgery. When Surgeon A submits a claim/encounter A will use code 091 - Report End to indicate the day the surgeon relinquished care of this patient to Physician B. When Physician B submits a claim/encounter B will use code 090 - Report Start to indicate the date they assumed care of this patient from Surgeon A.

0 270

1 217
STANDARD

Example: DTPV090VD8V19970214~

DTP Date or Time or Period

Level: Detail Position: 135 Loop: 2300 Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

212

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2300 DTP DATE - ASSUMED AND RELINQUISHED CARE DATES

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

090

Report Start Assumed Care Date - Use code 090 to indicate the date the provider filing this claim assumed care from another provider during post-operative care.

2463

091

Report End Relinquished Care Date - Use code 091 to indicate the date the provider filing this claim relinquished post-operative care to another provider.

2464
REQUIRED

DTP02

1250

Date Time Period Format Qualifier

SEMANTIC:

ID

2/3

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Assumed

Expression of a date, a time, or range of dates, times or dates and times

or Relinquished Care Date

2187 2187

NSF Reference: EA1-25.0 - Provider Assumed Care Date, HA0-05.0 - Provider Relinquished Care Date

MAY 2000

213

004010X098 837 2300 PWK CLAIM SUPPLEMENTAL INFORMATION

PAPERWORK

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PWK

CLAIM SUPPLEMENTAL PWK 004010X098 837 2300INFORMATION

IMPLEMENTATION

CLAIM SUPPLEMENTAL INFORMATION

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 10

4 010 100

Notes:

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

0 123

1 270

8 104
STANDARD

Example: PWKVOBVBMVVVACVDMN0012~

PWK Paperwork
Level: Detail Position: 155 Loop: 2300 Requirement: Optional Max Use: 10 Purpose: To identify the type or transmission or both of paperwork or supporting information Syntax:
DIAGRAM

1. P0506 If either PWK05 or PWK06 is present, then the other is required.

PWK01

755

PWK02

756

PWK03

757

PWK04

98

PWK05

66

PWK06

67

PWK

V Report Type V
Code
ID M 2/2

Report Report V V Copies Need Transm Code

O ID 1/2 O N0 1/2 O

Entity ID Code
ID 2/3

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

PWK07

352

PWK08

C002

PWK09

1525

V Description V
O AN 1/80 O

Actions Indicated

Request Categ Code

O ID 1/2

214

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2300 PWK CLAIM SUPPLEMENTAL INFORMATION

USAGE

NAME

ATTRIBUTES

REQUIRED

PWK01

755

Report Type Code

INDUSTRY: Attachment

ID

2/2

Code indicating the title or contents of a document, report or supporting item

Report Type Code

1498 1498

NSF Reference: EA0-41.0

CODE DEFINITION

77

Support Data for Verification REFERRAL. Use this code to indicate a completed referral form.

2158
AS B2 B3 B4 CT DA DG DS EB

Admission Summary Prescription Physician Order Referral Form Certification Dental Models Diagnostic Report Discharge Summary Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) Models Nursing Notes Operative Note Support Data for Claim Physical Therapy Notes Prosthetics or Orthotic Certification Physical Therapy Certification Radiology Films Radiology Reports Report of Tests and Analysis Report

MT NN OB OZ PN PO PZ RB RR RT

MAY 2000

215

004010X098 837 2300 PWK CLAIM SUPPLEMENTAL INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

PWK02

756

Report Transmission Code

ID

1/2

Code defining timing, transmission method or format by which reports are to be sent
INDUSTRY: Attachment

Transmission Code

1499 1499

NSF Reference: EA0-40.0

CODE DEFINITION

AA

Available on Request at Provider Site This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

2674

BM EL

By Mail Electronically Only Use to indicate that attachment is being transmitted in a separate X12 functional group.

2255
EM FX NOT USED NOT USED SITUATIONAL PWK03 PWK04 PWK05 757 98 66

E-Mail By Fax O O X N0 ID ID 1/2 2/3 1/2

Report Copies Needed Entity Identifier Code Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0506 PWK05 and PWK06 may be used to identify the addressee by a code

COMMENT:

number.

2128

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

CODE DEFINITION

AC SITUATIONAL PWK06 67

Attachment Control Number X AN 2/80

Identification Code
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:

Control Number

P0506

2128
NOT USED NOT USED NOT USED PWK07 PWK08 PWK09 352 C002 1525

Required if PWK02 = BM, EL, EM or FX. Description ACTIONS INDICATED Request Category Code O O O ID 1/2 AN 1/80

216

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONTRACT INFORMATION

004010X098 837 2300 CN1 CONTRACT INFORMATION

CN1

CONTRACT 837 2300 004010X098 INFORMATIONCN1

IMPLEMENTATION

CONTRACT INFORMATION
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

2 107

Notes:

1. The developers of this implementation guide recommend that for noncapitated situations, contract information be maintained in the receivers files and not be transmitted with each claim whenever possible. It is recommended that submitters always include CN1 for encounters that include only capitated services. 2. Required if the provider is contractually obligated to provide contract information on this claim.

4 217 3 107
STANDARD

Example: CN1V02V550~

CN1 Contract Information

Level: Detail Position: 160 Loop: 2300 Requirement: Optional Max Use: 1 Purpose: To specify basic data about the contract or contract line item
DIAGRAM

CN101

1166

CN102

782

CN103

332

CN104

127

CN105

338

CN106

799

CN1 V

Contract Type Code

M ID 2/2

V
O

Monetary Amount
R 1/18

Allow/Chrg Percent
O R 1/6

Reference Ident
O AN 1/30

Terms Disc Percent

O R 1/6

V
O

Version ID
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CN101

1166

Contract Type Code

Code identifying a contract type
ALIAS: Contract
CODE

ID

2/2

Type Code
DEFINITION

02 03 04 05 06

Per Diem Variable Per Diem Flat Capitated Percent

MAY 2000

217

004010X098 837 2300 CN1 CONTRACT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

09 SITUATIONAL CN102 782

Monetary amount

Other O R 1/18

Monetary Amount
INDUSTRY: Contract
SEMANTIC:

Amount

CN102 is the contract amount.

1222
SITUATIONAL CN103 332

Required if the provider is required by contract to supply this information on the claim. Percent
Percent expressed as a percent
INDUSTRY: Contract ALIAS: Contract
SEMANTIC:

1/6

Percentage

Percent

CN103 is the allowance or charge percent.

1112 1222
SITUATIONAL CN104 127

Allowance or charge percent Required if the provider is required by contract to supply this information on the claim. Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Contract
SEMANTIC:

Code

CN104 is the contract code.

1222
SITUATIONAL CN105 338

Required if the provider is required by contract to supply this information on the claim. Terms Discount Percent O R 1/6
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
INDUSTRY: Terms ALIAS: Terms

Discount Percentage

Discount Percent

1222
SITUATIONAL CN106 799

Required if the provider is required by contract to supply this information on the claim. Version Identifier
INDUSTRY: Contract
SEMANTIC:

AN

1/30

Revision level of a particular format, program, technique or algorithm

Version Identifier

CN106 is an additional identifying number for the contract.

1222

Required if the provider is required by contract to supply this information on the claim.

218

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2300 AMT CREDIT/DEBIT CARD MAXIMUM AMOUNT

AMT

CREDIT/DEBIT CARD MAXIMUM 004010X098 837 2300 AMT AMOUNT

IMPLEMENTATION

CREDIT/DEBIT CARD MAXIMUM AMOUNT

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 180

Notes:

1. Use this segment only for claims that contain credit/debit card information. This segment indicates the maximum amount that can be credited to the account indicated in 2010BD - CREDIT/DEBIT CARD HOLDER NAME. 2. The information carried under this segment must never be sent to the payer. This information is only for use between a provider and a service organization offering patient collection services. In this case, it is the responsibility of the collection service organization to remove this segment before forwarding the claim to the payer.

5 246

6 275
STANDARD

Example: AMTVMAV200~

AMT Monetary Amount

Level: Detail Position: 175 Loop: 2300 Requirement: Optional Max Use: 40 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

MA REQUIRED AMT02 782

Monetary amount
INDUSTRY: Credit

Maximum Amount M R 1/18

Monetary Amount

or Debit Card Maximum Amount

O ID 1/1

NOT USED

AMT03

478

Credit/Debit Flag Code

MAY 2000

219

004010X098 837 2300 AMT PATIENT AMOUNT PAID

MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

PATIENT AMOUNT 2300 004010X098 837 PAID AMT

IMPLEMENTATION

PATIENT AMOUNT PAID

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

3 122 2 130 9 215

Notes:

1. Required if the patient has paid any amount towards the claim. 2. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his/her representative(s). 3. The Patient Amount Paid indicated in this segment applies to the entire claim. It is recommended that the Patient Amount Paid AMT segment be used at either the line(s) or claim level but not at both.

5 126
STANDARD

Example: AMTVF5V152.45~

AMT Monetary Amount

Level: Detail Position: 175 Loop: 2300 Requirement: Optional Max Use: 40 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V
Code
ID M 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

F5 REQUIRED AMT02 782

Monetary amount
INDUSTRY: Patient

Patient Amount Paid M R 1/18

Monetary Amount

Amount Paid

1500 1500
NOT USED AMT03 478

NSF Reference: XA0-19.0 Credit/Debit Flag Code O ID 1/1

220

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2300 AMT TOTAL PURCHASED SERVICE AMOUNT

AMT

TOTAL PURCHASED SERVICE 004010X098 837 2300 AMTAMOUNT

IMPLEMENTATION

TOTAL PURCHASED SERVICE AMOUNT

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

1 121 6 126
STANDARD

Notes:

1. Required if there are purchased service components to this claim.

Example: AMTVNEV57.35~

AMT Monetary Amount

Level: Detail Position: 175 Loop: 2300 Requirement: Optional Max Use: 40 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

NE

Net Billed Use this code to indicate Total Purchased Service Charges.

1267
REQUIRED AMT02 782
Monetary amount
INDUSTRY: Total

Monetary Amount

1/18

Purchased Service Amount

1501 1501
NOT USED AMT03 478

NSF Reference: EA0-31.0 Credit/Debit Flag Code O ID 1/1

MAY 2000

221

004010X098 837 2300 REF SERVICE AUTHORIZATION EXCEPTION CODE

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

SERVICE AUTHORIZATION EXCEPTION CODE 004010X098 837 2300 REF

IMPLEMENTATION

SERVICE AUTHORIZATION EXCEPTION CODE

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 267

Notes:

1. Required when providers are required by state law (e.g., New York State Medicaid) to obtain authorization for specific services but, for the reasons listed in REF02, performed the service without obtaining the service authorization. Check with your state Medicaid to see if this applies in your state.

6 267
STANDARD

Example: REFV4NV1~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

4N

Special Payment Reference Number

222

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 REF SERVICE AUTHORIZATION EXCEPTION CODE

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Service
SYNTAX:

Authorization Exception Code

R0203

2678

Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a 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 REF03 REF04 352 C040 Description REFERENCE IDENTIFIER X O AN 1/80

NOT USED NOT USED

MAY 2000

223

004010X098 837 2300 REF MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR
REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

MANDATORY 837 2300 (SECTION 4081) CROSSOVER INDICATOR 004010X098 MEDICARE REF

IMPLEMENTATION

MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

0 268

Notes:

1. Required for Medicare COB crossover claims when Beneficiary Assignment for mandatory Medicare (Section 4081) claim applies. This segment is only completed by Medicare; providers do not use this segment. 2. If this segment is not used that means this situation does not apply.

1 268 8 280
STANDARD

Example: REFVF5VN~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

F5

Medicare Version Code

224

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 REF MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Medicare
SYNTAX:

Section 4081 Indicator

R0203

2683 2683 2682

NOT USED NOT USED

NSF Reference: DA0-30.0 The allowed values for this element are: Y 4081 (NSF Value 1) N Regular crossover (NSF Value 2) REF03 REF04 352 C040 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

225

004010X098 837 2300 REF MAMMOGRAPHY CERTIFICATION NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

MAMMOGRAPHY 2300 REF 004010X098 837CERTIFICATION NUMBER

IMPLEMENTATION

MAMMOGRAPHY CERTIFICATION NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

4 268 8 136
STANDARD

Notes:

1. Required on Medicare claims for all mammography services.

Example: REFVEWVT554~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

EW REQUIRED REF02 127

Mammography Certification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Mammography
SYNTAX:

Certification Number

R0203

1614 1614
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-31.0 Description REFERENCE IDENTIFIER X O AN 1/80

226

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2300 REF PRIOR AUTHORIZATION OR REFERRAL NUMBER

REF

PRIOR AUTHORIZATION REF 004010X098 837 2300 OR REFERRAL NUMBER

IMPLEMENTATION

PRIOR AUTHORIZATION OR REFERRAL NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 2

0 101

Notes:

1. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. 2. Required where services on this claim were preauthorized or where a referral is involved. Generally, preauthorization/referral numbers are those numbers assigned by the payer/UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The referral or prior authorization number carried in this REF is specific to the destination payer reported in the 2010BB loop. If other payers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payers information.

6 246

1 101
STANDARD

Example: REFVG1V13579~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

MAY 2000

227

004010X098 837 2300 REF PRIOR AUTHORIZATION OR REFERRAL NUMBER ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9F G1 REQUIRED REF02 127

Referral Number Prior Authorization Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Prior
SYNTAX:

Authorization or Referral Number

R0203

1502 1502
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: DA0-14.0 Description REFERENCE IDENTIFIER X O AN 1/80

228

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2300 REF ORIGINAL REFERENCE NUMBER (ICN/DCN)

REF

ORIGINAL REFERENCE REF 004010X098 837 2300NUMBER (ICN/DCN)

IMPLEMENTATION

ORIGINAL REFERENCE NUMBER (ICN/DCN)

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

6 131

Notes:

1. Required when CLM05-3 (Claim Submission Reason Code) = 6", 7", or 8" and the payer has assigned a payer number to the claim. The resubmission number is assigned to a previously submitted claim/encounter by the destination payer or receiver. 2. This segment can be used for the payer assigned Original Document Control Number/Internal Control Number (DCN/ICN) assigned to this claim by the payer identified in the 2010BB loop of this claim. This number would be received from a payer in a case where the payer had received the original claim and, for whatever reason, had (1) asked the provider to resubmit the claim and (2) had given the provider the payers claim identification number. In this case the payer is expecting the provider to give them back their (the payers) claim number so that the payer can match it in their adjudication system. By matching this number in the adjudication system, the payer knows this is not a duplicate claim. This information is specific to the destination payer reported in the 2010BB loop. If other payers have a similar number, report that information in the 2330 loop which holds that payers information.

8 246

2 270
STANDARD

Example: REFVF8VR555588~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

MAY 2000

229

004010X098 837 2300 REF ORIGINAL REFERENCE NUMBER (ICN/DCN) ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

F8 REQUIRED REF02 127

Original Reference Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Claim ALIAS: Claim
SYNTAX:

Original Reference Number

Original Reference Number (ICN/DCN)

R0203

1000085 1000085
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: EA0-47.0 Description REFERENCE IDENTIFIER X O AN 1/80

230

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2300 REF CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER

REF

CLINICAL LABORATORY REF 004010X098 837 2300 IMPROVEMENT AMENDMENT (CLIA) NUMBER

IMPLEMENTATION

CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 3

7 138 0 216

Notes:

1. Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act. 2. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. 3. In cases where this claim contains both in-house and outsourced laboratory services: For laboratory services preformed by the billing or rendering provider the CLIA number is reported here; for laboratory services which were outsourced, report that CLIA number at the 2400 loop.

0 247

9 126
STANDARD

Example: REFVX4V12D4567890~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

MAY 2000

231

004010X098 837 2300 REF CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

X4 REQUIRED

Clinical Laboratory Improvement Amendment Number X AN 1/30

REF02

127

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Clinical
SYNTAX: R0203

Laboratory Improvement Amendment Number

1388 1388
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-34.0 Description REFERENCE IDENTIFIER X O AN 1/80

232

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2300 REF REPRICED CLAIM NUMBER

REF

REPRICED 837 NUMBER 004010X098CLAIM 2300 REF

IMPLEMENTATION

REPRICED CLAIM NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

5 185 0 127
STANDARD

Notes:

1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.

Example: REFV9AVRJ55555~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9A REQUIRED REF02 127

Repriced Claim Reference Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Repriced
SYNTAX:

Claim Reference Number

R0203

2471 2471
NOT USED REF03 352

NSF Reference: FE0-06.0 (TPO Reference Number) Description X AN 1/80

MAY 2000

233

004010X098 837 2300 REF REPRICED CLAIM NUMBER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NOT USED

REF04

C040

REFERENCE IDENTIFIER

234

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2300 REF ADJUSTED REPRICED CLAIM NUMBER

REF

ADJUSTED 837 2300 REF 004010X098REPRICED CLAIM NUMBER

IMPLEMENTATION

ADJUSTED REPRICED CLAIM NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

5 185 1 127
STANDARD

Notes:

1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.

Example: REFV9CVRP44444444~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9C REQUIRED REF02 127

Adjusted Repriced Claim Reference Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Adjusted
SYNTAX:

Repriced Claim Reference Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

235

004010X098 837 2300 REF INVESTIGATIONAL DEVICE EXEMPTION NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

INVESTIGATIONAL 2300 EXEMPTION NUMBER 004010X098 837 DEVICEREF

IMPLEMENTATION

INVESTIGATIONAL DEVICE EXEMPTION NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

2 247 2 139
STANDARD

Notes:

1. Required when claim involves an FDA assigned investigational device exemption (IDE) number. Only one IDE per claim is to be reported.

Example: REFVLXVTG334~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

LX REQUIRED REF02 127

Qualified Products List X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Investigational
SYNTAX:

Device Exemption Identifier

R0203

1047 1047
NOT USED REF03 352

NSF Reference: EA0-54.0 Description X AN 1/80

MAY 2000

236

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 REF INVESTIGATIONAL DEVICE EXEMPTION NUMBER

NOT USED

REF04

C040

REFERENCE IDENTIFIER

MAY 2000

237

004010X098 837 2300 REF ASC X12N INSURANCE SUBCOMMITTEE CLAIM ID NO. FOR CLEARING HOUSES AND OTHER TRANSMISSION INTERMEDIARIES IMPLEMENTATION GUIDE
REFERENCE IDENTIFICATION

REF

CLAIM IDENTIFICATION REF 004010X098 837 2300NUMBER FOR CLEARING HOUSES AND OTHER TRANSMISSION INTERMEDIARIES

IMPLEMENTATION

CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES AND OTHER TRANSMISSION INTERMEDIARIES
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

3 270

Notes:

1. Used only by transmission intermediaries (Automated Clearing Houses, and others) who need to attach their own unique claim number. 2. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, 837recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.

4 270

3 247
STANDARD

Example: REFVD9VTJ98UU321~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

V Description V
X AN 1/80

Reference Identifier
O

238

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE 004010X098 837 2300 REF IMPLEMENTATION GUIDE CLAIM ID NO. FOR CLEARING HOUSES AND OTHER TRANSMISSION INTERMEDIARIES ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification

ID

2/3

2474

Number assigned by clearinghouse/van/etc.

CODE DEFINITION

D9 REQUIRED REF02 127

Claim Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Clearinghouse
SYNTAX:

Trace Number

R0203

2475
NOT USED NOT USED REF03 REF04 352 C040

The value carried in this element is limited to a maximum of 20 positions. Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

239

004010X098 837 2300 REF AMBULATORY PATIENT GROUP (APG)

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

AMBULATORY PATIENT REF 004010X098 837 2300 GROUP (APG)

IMPLEMENTATION

AMBULATORY PATIENT GROUP (APG)

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 4

6 247

Notes:

1. Required if the contractual reimbursement arrangement between provider and payer is based on APG and their contractual arrangement requires that the provider send APG information to the payer on each claim.

7 215
STANDARD

Example: REFV1SVXXXXX~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1S REQUIRED REF02 127

Ambulatory Patient Group (APG) Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Ambulatory
SYNTAX:

Patient Group Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

240

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2300 REF MEDICAL RECORD NUMBER

REF

MEDICAL RECORD 2300 REF 004010X098 837 NUMBER

IMPLEMENTATION

MEDICAL RECORD NUMBER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

5 190 3 216
STANDARD

Notes:

1. Used at discretion of submitter.

Example: REFVEAV44444TH56~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

EA REQUIRED REF02 127

Medical Record Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Medical
SYNTAX:

Record Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

241

004010X098 837 2300 REF DEMONSTRATION PROJECT IDENTIFIER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

DEMONSTRATION 2300 REF 004010X098 837 PROJECT IDENTIFIER

IMPLEMENTATION

DEMONSTRATION PROJECT IDENTIFIER

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

7 247

Notes:

1. Required on claims/encounters where a demonstration project is being billed/reported. This information is specific to the destination payer reported in the 2010BB loop. If other payers have a similar number, report that information in the 2330 loop which holds that payers information.

1 225
STANDARD

Example: REFVP4VTHJ1222~

REF Reference Identification

Level: Detail Position: 180 Loop: 2300 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

P4

Project Code

242

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 REF DEMONSTRATION PROJECT IDENTIFIER

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Demonstration
SYNTAX:

Project Identifier

R0203

2252 2252
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: EA0-43.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

243

004010X098 837 2300 K3 FILE INFORMATION

FILE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

K3

FILE INFORMATION 004010X098 837 2300 K3

IMPLEMENTATION

FILE INFORMATION
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 10

7 131

Notes:

1. At the time of publication K3 segments have no specific use. However, they have been included in this implementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirement by a state regulatory authority. This data element can only be required if the specific use is a result of a state law or a regulation issued by a state agency after the publication of this implementation guide, and only if the appropriate national body (X12N, HCPCS, NUBC, NUCC, etc) cannot offer an alternative solution within the current structure of the implementation guide. 2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislative requirement AND the administering state agency or other state organization has contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement, and X12N determines that there is no method to meet the requirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee.

7 280

8 279
STANDARD

Example: K3VSTATE DATA REQUIREMENT~

K3 File Information
Level: Detail Position: 185 Loop: 2300 Requirement: Optional Max Use: 10 Purpose: To transmit a fixed-format record or matrix contents
DIAGRAM

K301

449

K302

1333

K303

C001

K3 V

Fixed Form Information

M AN 1/80

Record V V Format Code

O ID 1/2

Composite Unit of Mea

O

244

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2300 K3 FILE INFORMATION

USAGE

NAME

ATTRIBUTES

REQUIRED

K301

449

Fixed Format Information

Data in fixed format agreed upon by sender and receiver

AN

1/80

2271 2271
NOT USED NOT USED K302 K303 1333 C001

NSF Reference: HA0-05.0 Record Format Code COMPOSITE UNIT OF MEASURE O O ID 1/2

MAY 2000

245

004010X098 837 2300 NTE CLAIM NOTE

NOTE/SPECIAL INSTRUCTION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NTE

CLAIM NOTE 004010X098 837 2300 NTE

IMPLEMENTATION

CLAIM NOTE
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

2 101

Notes:

1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who require narrative information with claims are encouraged to codify that information within the ASC X12 environment.

8 247

2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) in the opinion of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. Example: NTEVADDVSURGERY WAS UNUSUALLY LONG BECAUSE [FILL IN REASON]~

9 104
STANDARD

NTE Note/Special Instruction

Level: Detail Position: 190 Loop: 2300 Requirement: Optional Max Use: 20 Purpose: To transmit information in a free-form format, if necessary, for comment or special instruction
DIAGRAM

NTE01

363

NTE02

352

NTE

V
O

Note Ref Code

ID 3/3

V Description
M AN 1/80

246

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2300 NTE CLAIM NOTE

USAGE

NAME

ATTRIBUTES

REQUIRED

NTE01

363

Note Reference Code

CODE DEFINITION

ID

3/3

Code identifying the functional area or purpose for which the note applies

ADD CER DCP DGN PMT TPO REQUIRED NTE02 352 Description
INDUSTRY: Claim

Additional Information Certification Narrative Goals, Rehabilitation Potential, or Discharge Plans Diagnosis Description Payment Third Party Organization Notes M AN 1/80

A free-form description to clarify the related data elements and their content

Note Text

1503 1503

NSF Reference: HA0-05.0

MAY 2000

247

004010X098 837 2300 CR1 AMBULANCE TRANSPORT INFORMATION

AMBULANCE CERTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CR1

AMBULANCE 837 2300 INFORMATION 004010X098 TRANSPORTCR1

IMPLEMENTATION

AMBULANCE TRANSPORT INFORMATION

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

3 101 7 190 4 101

STANDARD

Notes:

1. The CR1 segment in Loop ID-2300 applies to the entire claim unless an exception is reported in the CR1 segment in Loop ID-2400. 2. Required on all claims involving ambulance services.

Example: CR1VLBV140VIVAVDHV12VVVVUNCONSCIOUS~

CR1 Ambulance Certification

Level: Detail Position: 195 Loop: 2300 Requirement: Optional Max Use: 1 Purpose: To supply information related to the ambulance service rendered to a patient Set Notes: 1. The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level. 1. P0102 If either CR101 or CR102 is present, then the other is required. 2. P0506 If either CR105 or CR106 is present, then the other is required.
DIAGRAM

Syntax:

CR101

355

CR102

81

CR103

1316

CR104

1317

CR105

355

CR106

380

CR1 V
V

Unit/Basis Meas Code

X ID 2/2

V
X

Weight
R 1/10

Ambulance Trans Code

O ID 1/1

V Ambulance V Reason Code

O ID 1/1

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

CR107

166

CR108

166

CR109

352

CR110

352

Address Information
O AN 1/55

Address Information
O AN 1/55

V Description V Description
O AN 1/80 O AN 1/80

248

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2300 CR1 AMBULANCE TRANSPORT INFORMATION

USAGE

NAME

ATTRIBUTES

SITUATIONAL

CR101

355

Unit or Basis for Measurement Code

ID

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0102

2220

Required if needed to justify extra ambulance services.

CODE DEFINITION

LB SITUATIONAL CR102 81 Weight

Pound X R 1/10

Numeric value of weight

INDUSTRY: Patient
SYNTAX:

Weight

P0102 CR102 is the weight of the patient at time of transport.

SEMANTIC:

1504 1504 2220

REQUIRED CR103 1316

NSF Reference: GA0-05.0 Required if needed to justify extra ambulance services. Ambulance Transport Code
Code indicating the type of ambulance transport
ALIAS: Ambulance

ID

1/1

Transport Code

1505 1505

NSF Reference: GA0-07.0

CODE DEFINITION

I R T X REQUIRED CR104 1317

Initial Trip Return Trip Transfer Trip Round Trip O ID 1/1

Ambulance Transport Reason Code

Code indicating the reason for ambulance transport
ALIAS: Ambulance

Transport Reason Code

1506 1506

NSF Reference: GA0-15.0

CODE DEFINITION

Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility.

2479
B

Patient was transported for the benefit of a preferred physician

MAY 2000

249

004010X098 837 2300 CR1 AMBULANCE TRANSPORT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Patient was transported for the nearness of family members Patient was transported for the care of a specialist or for availability of specialized equipment Patient Transferred to Rehabilitation Facility X ID 2/2

E REQUIRED CR105 355

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0506
DEFINITION

CODE

DH REQUIRED CR106 380 Quantity

Miles X R 1/15

Numeric value of quantity

INDUSTRY: Transport
SYNTAX:

Distance

P0506 CR106 is the distance traveled during transport.

SEMANTIC:

2480 2480 2481

NOT USED NOT USED SITUATIONAL CR107 CR108 CR109 166 166 352

NSF Reference: GA0-17.0, FA0-50.0 NSF crosswalk to FA0-50.0 is used only in Medicare payer-to-payer COB situations. Address Information Address Information Description
INDUSTRY: Round
SEMANTIC:

O O O

AN AN AN

1/55 1/55 1/80

A free-form description to clarify the related data elements and their content

Trip Purpose Description

CR109 is the purpose for the round trip ambulance service.

1508 1508 2221

SITUATIONAL CR110 352

NSF Reference: GA0-20.0 Required if CR103 (Ambulance Transport Code) = X - Round Trip; otherwise not used. Description
INDUSTRY: Stretcher
SEMANTIC:

AN

1/80

A free-form description to clarify the related data elements and their content

Purpose Description

CR110 is the purpose for the usage of a stretcher during ambulance

service.

1509 1509 2222

NSF Reference: GA0-21.0 Required if needed to justify usage of stretcher.

250

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CHIROPRACTIC CERTIFICATION

004010X098 837 2300 CR2 SPINAL MANIPULATION SERVICE INFORMATION

CR2

SPINAL MANIPULATION CR2 004010X098 837 2300SERVICE INFORMATION

IMPLEMENTATION

SPINAL MANIPULATION SERVICE INFORMATION

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

5 101 2 280

Notes:

1. The CR2 segment in Loop ID-2300 applies to the entire claim unless overridden by the presence of a CR2 segment in Loop ID-2400. 2. Required on all claims involving spinal manipulation. Such claims could originate with chiropractors, physical therapists, DOs, and many other types of health care providers.

6 101
STANDARD

Example: CR2V3V5VC4VC6VMOV2V2VMVYVVVY~

CR2 Chiropractic Certification

Level: Detail Position: 200 Loop: 2300 Requirement: Optional Max Use: 1 Purpose: To supply information related to the chiropractic service rendered to a patient Syntax: 1. P0102 If either CR201 or CR202 is present, then the other is required. 2. C0403 If CR204 is present, then CR203 is required. 3. P0506 If either CR205 or CR206 is present, then the other is required.
DIAGRAM

CR201

609

CR202

380

CR203

1367

CR204

1367

CR205

355

CR206

380

CR2 V
X

Count
N0 1/9

V
X

Quantity
R 1/15

V Subluxation V Subluxation V Level Code Level Code

X ID 2/3 O ID 2/3

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

CR207

380

CR208

1342

CR209

1073

CR210

352

CR211

352

CR212

1073

V
O

Quantity
R 1/15

Nature of Cond Code

O ID 1/1

V Yes/No Cond V Resp Code

O ID 1/1

Description
O AN 1/80

Description
O AN 1/80

V Yes/No Cond ~ Resp Code

O ID 1/1

MAY 2000

251

004010X098 837 2300 CR2 SPINAL MANIPULATION SERVICE INFORMATION ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

CR201

609

Count
Occurence counter
INDUSTRY: Treatment ALIAS: Treatment
SYNTAX:

N0

1/9

Series Number

Number. Spinal Manipulation

P0102 CR201 is the number this treatment is in the series.

SEMANTIC:

1510 1510
REQUIRED CR202 380

NSF Reference: GC0-07.0 Quantity

Numeric value of quantity
INDUSTRY: Treatment ALIAS: Treatment
SYNTAX:

1/15

Count

Series Total. Spinal Manipulation

P0102 CR202 is the total number of treatments in the series.

SEMANTIC:

1510 1510
SITUATIONAL CR203 1367

NSF Reference: GC0-07.0 Subluxation Level Code

Code identifying the specific level of subluxation
ALIAS: Subluxation
SYNTAX:

ID

2/3

Level Code

C0403

COMMENT: When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.

1511 1511 2253

NSF Reference: GC0-08.0 Required if subluxation is involved in the claim.

CODE DEFINITION

C1 C2 C3 C4 C5 C6 C7 CO IL L1

Cervical 1 Cervical 2 Cervical 3 Cervical 4 Cervical 5 Cervical 6 Cervical 7 Coccyx Ilium Lumbar 1

252

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CR2 SPINAL MANIPULATION SERVICE INFORMATION

L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9 SITUATIONAL CR204 1367

Lumbar 2 Lumbar 3 Lumbar 4 Lumbar 5 Occiput Sacrum Thoracic 1 Thoracic 10 Thoracic 11 Thoracic 12 Thoracic 2 Thoracic 3 Thoracic 4 Thoracic 5 Thoracic 6 Thoracic 7 Thoracic 8 Thoracic 9 O ID 2/3

Subluxation Level Code

Code identifying the specific level of subluxation
ALIAS: Subluxation
SYNTAX:

Level Code

C0403

1511 1511 2224

NSF Reference: GC0-08.0 Required if additional subluxation is involved in claim to indicate a range (i.e., subluxation from CR203 to CR204).
CODE DEFINITION

C1 C2 C3 C4 C5 C6 C7

Cervical 1 Cervical 2 Cervical 3 Cervical 4 Cervical 5 Cervical 6 Cervical 7

MAY 2000

253

004010X098 837 2300 CR2 SPINAL MANIPULATION SERVICE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CO IL L1 L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9 REQUIRED CR205 355

Coccyx Ilium Lumbar 1 Lumbar 2 Lumbar 3 Lumbar 4 Lumbar 5 Occiput Sacrum Thoracic 1 Thoracic 10 Thoracic 11 Thoracic 12 Thoracic 2 Thoracic 3 Thoracic 4 Thoracic 5 Thoracic 6 Thoracic 7 Thoracic 8 Thoracic 9 X ID 2/2

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0506
DEFINITION

CODE

DA MO WK YR

Days Months Week Years

254

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CR2 SPINAL MANIPULATION SERVICE INFORMATION

REQUIRED

CR206

380

Quantity
Numeric value of quantity
INDUSTRY: Treatment ALIAS: Treatment
SYNTAX:

1/15

Period Count

Series Period. Spinal Manipulation

P0506 CR206 is the time period involved in the treatment series.

SEMANTIC:

1512 1512
REQUIRED CR207 380

NSF Reference: GC0-09.0 Quantity

Numeric value of quantity
INDUSTRY: Monthly ALIAS: Treatment
SEMANTIC:

1/15

Treatment Count

Number in Month. Spinal Manipulation

CR207 is the number of treatments rendered in the month of service.

1513 1513
REQUIRED CR208 1342

NSF Reference: GC0-10.0 Nature of Condition Code

Code indicating the nature of a patients condition
INDUSTRY: Patient ALIAS: Nature

ID

1/1

Condition Code

of Condition Code. Spinal Manipulation

1514 1514

NSF Reference: GC0-11.0

CODE DEFINITION

A C D E F G M REQUIRED CR209 1073

Acute Condition Chronic Condition Non-acute Non-Life Threatening Routine Symptomatic Acute Manifestation of a Chronic Condition O ID 1/1

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Complication ALIAS: Complication
SEMANTIC:

Indicator

Indicator. Spinal Manipulation

CR209 is complication indicator. A Y value indicates a complicated condition; an N value indicates an uncomplicated condition.

1515 1515

NSF Reference: GC0-13.0

CODE DEFINITION

No

MAY 2000

255

004010X098 837 2300 CR2 SPINAL MANIPULATION SERVICE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Y SITUATIONAL CR210 352 Description

INDUSTRY: Patient ALIAS: Patient
SEMANTIC:

Yes O AN 1/80

A free-form description to clarify the related data elements and their content

Condition Description

Condition Description. Spinal Manipulation

CR210 is a description of the patients condition.

1516 1516 2225

SITUATIONAL CR211 352

NSF Reference: GC0-14.0 Used at discretion of submitter. Description

INDUSTRY: Patient ALIAS: Patient
SEMANTIC:

AN

1/80

A free-form description to clarify the related data elements and their content

Condition Description

Condition Description. Spinal Manipulation

CR211 is an additional description of the patients condition.

1516 1516 2225

REQUIRED CR212 1073

NSF Reference: GC0-14.0 Used at discretion of submitter. Yes/No Condition or Response Code
Code indicating a Yes or No condition or response
INDUSTRY: X-ray ALIAS: X-ray
SEMANTIC:

ID

1/1

Availability Indicator

Availability Indicator. Spinal Manipulation

CR212 is X-rays availability indicator. A Y value indicates X-rays are maintained and available for carrier review; an N value indicates X-rays are not maintained and available for carrier review.

1692 1692

NSF Reference: GC0-15.0

CODE DEFINITION

N Y

No Yes

256

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONDITIONS INDICATOR

004010X098 837 2300 CRC AMBULANCE CERTIFICATION

CRC

AMBULANCE 837 2300 CRC 004010X098 CERTIFICATION

IMPLEMENTATION

AMBULANCE CERTIFICATION
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 3

9 101

Notes:

1. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. 2. Required on ambulance claims/encounters, i.e. when CR1 segment is used.

2 248 0 102
STANDARD

Example: CRCV07VYV01~

CRC Conditions Indicator

Level: Detail Position: 220 Loop: 2300 Requirement: Optional Max Use: 100 Purpose: To supply information on conditions
DIAGRAM

CRC01

1136

CRC02

1073

CRC03

1321

CRC04

1321

CRC05

1321

CRC06

1321

CRC V
M

Code Category
ID 2/2

V Yes/No Cond V Resp Code

M ID 1/1

Certificate Cond Code

M ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

CRC07

1321

Certificate Cond Code

O ID 2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CRC01

1136

Code Category
Specifies the situation or category to which the code applies
SEMANTIC:

ID

2/2

CRC01 qualifies CRC03 through CRC07.

DEFINITION

CODE

07

Ambulance Certification

MAY 2000

257

004010X098 837 2300 CRC AMBULANCE CERTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

CRC02

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Certification ALIAS: Certification
SEMANTIC:

ID

1/1

Condition Indicator

Condition Code Applies Indicator

CRC02 is a Certification Condition Code applies indicator. A Y value indicates the condition codes in CRC03 through CRC07 apply; an N value indicates the condition codes in CRC03 through CRC07 do not apply.
CODE DEFINITION

N Y REQUIRED CRC03 1321

No Yes M ID 2/2

Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

Code

Indicator

1029

The codes for CRC03 also can be used for CRC04 through CRC07.
CODE DEFINITION

01

Patient was admitted to a hospital

NSF Reference:

1524 1524
02

GA0-06.0 Patient was bed confined before the ambulance service

NSF Reference:

1525 1525
03

GA0-08.0 Patient was bed confined after the ambulance service

NSF Reference:

1526 1526
04

GA0-09.0 Patient was moved by stretcher

NSF Reference:

1527 1527
05

GA0-10.0 Patient was unconscious or in shock

NSF Reference:

1528 1528
06

GA0-11.0 Patient was transported in an emergency situation

NSF Reference:

1529 1529
07

GA0-12.0 Patient had to be physically restrained

NSF Reference:

1530 1530
08

GA0-13.0 Patient had visible hemorrhaging

NSF Reference:

1531 1531

GA0-14.0

258

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CRC AMBULANCE CERTIFICATION

09

Ambulance service was medically necessary

NSF Reference:

1532 1532
60

GA0-16.0 Transportation Was To the Nearest Facility

NSF Reference:

1731 1731
SITUATIONAL CRC04 1321

GA0-24.0 Condition Indicator

Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850
SITUATIONAL CRC05 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850
SITUATIONAL CRC06 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850
SITUATIONAL CRC07 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850

Required if additional condition codes are needed. Use the codes listed in CRC03.

MAY 2000

259

004010X098 837 2300 CRC PATIENT CONDITION INFORMATION: VISION

CONDITIONS INDICATOR

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CRC

PATIENT CONDITION INFORMATION: VISION 004010X098 837 2300 CRC

IMPLEMENTATION

PATIENT CONDITION INFORMATION: VISION

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 3

7 248 6 248
STANDARD

Notes:

1. Required on vision claims/encounters involving replacement lenses or frames.

Example: CRCVE1VYVL1~

CRC Conditions Indicator

Level: Detail Position: 220 Loop: 2300 Requirement: Optional Max Use: 100 Purpose: To supply information on conditions
DIAGRAM

CRC01

1136

CRC02

1073

CRC03

1321

CRC04

1321

CRC05

1321

CRC06

1321

CRC V
M

Code Category
ID 2/2

V Yes/No Cond V Resp Code

M ID 1/1

Certificate Cond Code

M ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

CRC07

1321

Certificate Cond Code

O ID 2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CRC01

1136

Code Category
Specifies the situation or category to which the code applies
SEMANTIC:

ID

2/2

CRC01 qualifies CRC03 through CRC07.

DEFINITION

CODE

E1 E2 E3

Spectacle Lenses Contact Lenses Spectacle Frames

260

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 CRC PATIENT CONDITION INFORMATION: VISION

REQUIRED

CRC02

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Certification ALIAS: Certification
SEMANTIC:

ID

1/1

Condition Indicator

Condition Code Applies Indicator

CRC02 is a Certification Condition Code applies indicator. A Y value indicates the condition codes in CRC03 through CRC07 apply; an N value indicates the condition codes in CRC03 through CRC07 do not apply.
CODE DEFINITION

N Y REQUIRED CRC03 1321

No Yes M ID 2/2

Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition
CODE

Code

Indicator
DEFINITION

L1

General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met Replacement Due to Loss or Theft Replacement Due to Breakage or Damage Replacement Due to Patient Preference Replacement Due to Medical Reason O ID 2/2

L2 L3 L4 L5 SITUATIONAL CRC04 1321

Condition Indicator
Code indicating a condition
INDUSTRY: Condition

Code

2488 1782
SITUATIONAL CRC05 1321

Use codes listed in CRC03. Required if additional condition codes are needed. Condition Indicator
Code indicating a condition
INDUSTRY: Condition

ID

2/2

Code

2488 1782
SITUATIONAL CRC06 1321

Use codes listed in CRC03. Required if additional condition codes are needed. Condition Indicator
Code indicating a condition
INDUSTRY: Condition

ID

2/2

Code

2488 1782

Use codes listed in CRC03. Required if additional condition codes are needed.

MAY 2000

261

004010X098 837 2300 CRC PATIENT CONDITION INFORMATION: VISION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CRC07

1321

Condition Indicator
Code indicating a condition
INDUSTRY: Condition

ID

2/2

Code

2488 1782

Use codes listed in CRC03. Required if additional condition codes are needed.

262

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONDITIONS INDICATOR

004010X098 837 2300 CRC HOMEBOUND INDICATOR

CRC

HOMEBOUND INDICATOR 004010X098 837 2300 CRC

IMPLEMENTATION

HOMEBOUND INDICATOR
Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

4 248

Notes:

1. Required for Medicare claims/encounters when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.

1 123
STANDARD

Example: CRCV75VYVIH~

CRC Conditions Indicator

Level: Detail Position: 220 Loop: 2300 Requirement: Optional Max Use: 100 Purpose: To supply information on conditions
DIAGRAM

CRC01

1136

CRC02

1073

CRC03

1321

CRC04

1321

CRC05

1321

CRC06

1321

CRC V
M

Code Category
ID 2/2

V Yes/No Cond V Resp Code

M ID 1/1

Certificate Cond Code

M ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

CRC07

1321

Certificate Cond Code

O ID 2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CRC01

1136

Code Category
Specifies the situation or category to which the code applies
SEMANTIC:

ID

2/2

CRC01 qualifies CRC03 through CRC07.

DEFINITION

CODE

75

Functional Limitations

MAY 2000

263

004010X098 837 2300 CRC HOMEBOUND INDICATOR

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

CRC02

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Certification
SEMANTIC:

ID

1/1

Condition Indicator

CRC02 is a Certification Condition Code applies indicator. A Y value indicates the condition codes in CRC03 through CRC07 apply; an N value indicates the condition codes in CRC03 through CRC07 do not apply.
CODE DEFINITION

Y REQUIRED CRC03 1321

Yes M ID 2/2

Condition Indicator
Code indicating a condition
INDUSTRY: Homebound
CODE

Indicator

DEFINITION

IH

Independent at Home
NSF Reference:

1704 1704
NOT USED NOT USED NOT USED NOT USED CRC04 CRC05 CRC06 CRC07 1321 1321 1321 1321

EA0-50.0 Condition Indicator Condition Indicator Condition Indicator Condition Indicator O O O O ID ID ID ID 2/2 2/2 2/2 2/2

264

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HEALTH CARE INFORMATION CODES

004010X098 837 2300 HI HEALTH CARE DIAGNOSIS CODE

HI

HEALTH CARE DIAGNOSIS CODE 004010X098 837 2300 HI

IMPLEMENTATION

HEALTH CARE DIAGNOSIS CODE

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

5 112 9 248 1 132

STANDARD

Notes:

1. Required on all claims/encounters except claims for which there are no diagnoses (e.g., taxi claims). 2. Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

Example: HIVBK:8901VBF:87200VBF:5559~

HI Health Care Information Codes

Level: Detail Position: 231 Loop: 2300 Requirement: Optional Max Use: 25 Purpose: To supply information related to the delivery of health care
DIAGRAM

HI01

C022

HI02

C022

HI03

C022

HI04

C022

HI05

C022

HI06

C022

HI V
V

Health Care Code Info.

M

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

HI07

C022

HI08

C022

HI09

C022

HI10

C022

HI11

C022

HI12

C022

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

Health Care Code Info.

O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

HI01

C022

HEALTH CARE CODE INFORMATION

ALIAS: Principal

To send health care codes and their associated dates, amounts and quantities

1787 1126

Diagnosis

With a few exceptions, it is not recommended to put E codes in HI01. E codes may be put in any other HI element using BF as the qualifier. The diagnosis listed in this element is assumed to be the principal diagnosis.

1272

MAY 2000

265

004010X098 837 2300 HI HEALTH CARE DIAGNOSIS CODE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

HI01 - 1

1270

Code List Qualifier Code

Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BK

Principal Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI01 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code

2272 2272
NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL HI01 - 3 HI01 - 4 HI01 - 5 HI01 - 6 HI01 - 7 HI02 C022 1250 1251 782 380 799

NSF Reference: EA0-32.0, GX0-31.0, GU0-12.0 Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier X X O O O O ID AN R R AN 2/3 1/35 1/18 1/15 1/30

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

REQUIRED

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses. HI02 - 1 1270 Code List Qualifier Code
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI02 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code

2287 2287
NOT USED NOT USED NOT USED HI02 - 3 HI02 - 4 HI02 - 5 1250 1251 782

NSF Reference: EA0-33.0, GX0-32.0, GU0-13.0 Date Time Period Format Qualifier Date Time Period Monetary Amount X X O ID AN R 2/3 1/35 1/18

266

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 HI HEALTH CARE DIAGNOSIS CODE

NOT USED NOT USED SITUATIONAL

HI02 - 6 HI02 - 7 HI03 C022

380 799

Quantity Version Identifier

O O O

R AN

1/15 1/30

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

REQUIRED

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses. HI03 - 1 1270 Code List Qualifier Code
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI03 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code

2288 2288
NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL HI03 - 3 HI03 - 4 HI03 - 5 HI03 - 6 HI03 - 7 HI04 C022 1250 1251 782 380 799

NSF Reference: EA0-34.0, GX0-33.0, GU0-14.0 Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier X X O O O O ID AN R R AN 2/3 1/35 1/18 1/15 1/30

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses.

MAY 2000

267

004010X098 837 2300 HI HEALTH CARE DIAGNOSIS CODE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

HI04 - 1

1270

Code List Qualifier Code

Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI04 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code

2289 2289
NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL HI04 - 3 HI04 - 4 HI04 - 5 HI04 - 6 HI04 - 7 HI05 C022 1250 1251 782 380 799

NSF Reference: EA0-35.0, GX0-34.0, GU0-15.0 Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier X X O O O O ID AN R R AN 2/3 1/35 1/18 1/15 1/30

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

REQUIRED

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses. HI05 - 1 1270 Code List Qualifier Code
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI05 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code
X X O O O ID AN R R AN 2/3 1/35 1/18 1/15 1/30

NOT USED NOT USED NOT USED NOT USED NOT USED

HI05 - 3 HI05 - 4 HI05 - 5 HI05 - 6 HI05 - 7

1250 1251 782 380 799

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

268

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 HI HEALTH CARE DIAGNOSIS CODE

SITUATIONAL

HI06

C022

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

REQUIRED

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses. HI06 - 1 1270 Code List Qualifier Code
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI06 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code
X X O O O O ID AN R R AN 2/3 1/35 1/18 1/15 1/30

NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL

HI06 - 3 HI06 - 4 HI06 - 5 HI06 - 6 HI06 - 7 HI07 C022

1250 1251 782 380 799

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

REQUIRED

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses. HI07 - 1 1270 Code List Qualifier Code
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI07 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code

MAY 2000

269

004010X098 837 2300 HI HEALTH CARE DIAGNOSIS CODE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL

HI07 - 3 HI07 - 4 HI07 - 5 HI07 - 6 HI07 - 7 HI08 C022

1250 1251 782 380 799

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

X X O O O O

ID AN R R AN

2/3 1/35 1/18 1/15 1/30

HEALTH CARE CODE INFORMATION

ALIAS: Diagnosis

To send health care codes and their associated dates, amounts and quantities

1788 1143 2799

REQUIRED

Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C02203. Required if needed to report an additional diagnoses and if the preceeding HI data elements have been used to report other diagnoses. HI08 - 1 1270 Code List Qualifier Code
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE DEFINITION

ID

1/3

Type Code

BF

Diagnosis ICD-9 Codes

CODE SOURCE 131:

1836
REQUIRED HI08 - 2 1271

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Industry Code
INDUSTRY: Diagnosis

AN

1/30

Code indicating a code from a specific industry code list

Code
X X O O O O O O O ID AN R R AN 2/3 1/35 1/18 1/15 1/30

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

HI08 - 3 HI08 - 4 HI08 - 5 HI08 - 6 HI08 - 7 HI09 HI10 HI11 HI12 C022 C022 C022 C022

1250 1251 782 380 799

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION

270

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HEALTH CARE PRICING

004010X098 837 2300 HCP CLAIM PRICING/REPRICING INFORMATION

HCP

CLAIM PRICING/REPRICING INFORMATION 004010X098 837 2300 HCP

IMPLEMENTATION

CLAIM PRICING/REPRICING INFORMATION

Loop: 2300 CLAIM INFORMATION Usage: SITUATIONAL Repeat: 1

5 185 0 249

Notes:

1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. 2. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

5 109
STANDARD

Example: HCPV03V100V10VRPO12345~

HCP Health Care Pricing

Level: Detail Position: 241 Loop: 2300 Requirement: Optional Max Use: 1 Purpose: To specify pricing or repricing information about a health care claim or line item Syntax: 1. R0113 At least one of HCP01 or HCP13 is required. 2. P0910 If either HCP09 or HCP10 is present, then the other is required. 3. P1112 If either HCP11 or HCP12 is present, then the other is required.
DIAGRAM

HCP01

1473

HCP02

782

HCP03

782

HCP04

127

HCP05

118

HCP06

127

HCP

Pricing V V Methodology
X ID 2/2 O

Monetary Amount
R 1/18

V
O

Monetary Amount
R 1/18

Reference Ident
O AN 1/30

V
O

Rate
R 1/9

Reference Ident
O AN 1/30

HCP07

782

HCP08

234

HCP09

235

HCP10

234

HCP11

355

HCP12

380

V
O

Monetary Amount
R 1/18

Product/ Service ID
O AN 1/48

V
X

Prod/Serv ID Qual
ID 2/2

V
X

Product/ Service ID
AN 1/48

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

HCP13

901

HCP14

1526

HCP15

1527

Reject V Policy Comp V Reason Code Code

X ID 2/2 O ID 1/2

Exception Code
O ID 1/2

MAY 2000

271

004010X098 837 2300 HCP CLAIM PRICING/REPRICING INFORMATION ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

HCP01

1473

Pricing Methodology

ID

2/2

Code specifying pricing methodology at which the claim or line item has been priced or repriced
ALIAS: Pricing/repricing
SYNTAX:

methodology

R0113

1296

Trading partners need to agree on the codes to use in this element. There do not appear to be standard definitions for the code elements.
CODE DEFINITION

00 01 02 03 04 05 07 08 09 10 11 12 13 14 REQUIRED HCP02 782

Monetary amount

Zero Pricing (Not Covered Under Contract) Priced as Billed at 100% Priced at the Standard Fee Schedule Priced at a Contractual Percentage Bundled Pricing Peer Review Pricing Flat Rate Pricing Combination Pricing Maternity Pricing Other Pricing Lower of Cost Ratio of Cost Cost Reimbursed Adjustment Pricing O R 1/18

Monetary Amount
INDUSTRY: Repriced ALIAS: Allowed

Allowed Amount

amount, Pricing

SEMANTIC: HCP02 is the allowed amount.

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.

272

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 HCP CLAIM PRICING/REPRICING INFORMATION

SITUATIONAL

HCP03

782

Monetary Amount
Monetary amount
INDUSTRY: Repriced ALIAS: Savings
SEMANTIC:

1/18

Saving Amount

amount, Pricing

HCP03 is the savings amount.

1855
SITUATIONAL HCP04 127

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Repricing
SEMANTIC:

Organization Identifier

HCP04 is the repricing organization identification number.

1855
SITUATIONAL HCP05 118

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Rate
INDUSTRY: Repricing ALIAS: Pricing
SEMANTIC:

1/9

Rate expressed in the standard monetary denomination for the currency specified

Per Diem or Flat Rate Amount

rate

HCP05 is the pricing rate associated with per diem or flat rate repricing.

1855
SITUATIONAL HCP06 127

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Repriced ALIAS: Approved
SEMANTIC:

Approved Ambulatory Patient Group Code

APG code, Pricing

HCP06 is the approved DRG code.

COMMENT: HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.

1855
SITUATIONAL HCP07 782

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Monetary Amount
Monetary amount
INDUSTRY: Repriced ALIAS: Approved
SEMANTIC:

1/18

Approved Ambulatory Patient Group Amount

APG amount, Pricing

HCP07 is the approved DRG amount.

1855
NOT USED NOT USED NOT USED NOT USED NOT USED HCP08 HCP09 HCP10 HCP11 HCP12 234 235 234 355 380

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Product/Service ID Product/Service ID Qualifier Product/Service ID Unit or Basis for Measurement Code Quantity O X X X X AN ID AN ID R 1/48 2/2 1/48 2/2 1/15

MAY 2000

273

004010X098 837 2300 HCP CLAIM PRICING/REPRICING INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

HCP13

901

Reject Reason Code

Code assigned by issuer to identify reason for rejection
ALIAS: Reject
SYNTAX:

ID

2/2

reason code

R0113

SEMANTIC:

HCP13 is the rejection message returned from the third party organization.

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

T1

Cannot Identify Provider as TPO (Third Party Organization) Participant Cannot Identify Payer as TPO (Third Party Organization) Participant Cannot Identify Insured as TPO (Third Party Organization) Participant Payer Name or Identifier Missing Certification Information Missing Claim does not contain enough information for repricing O ID 1/2

T2

T3

T4 T5 T6 SITUATIONAL

HCP14

1526

Policy Compliance Code

Code specifying policy compliance
ALIAS: Policy

compliance code

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

1 2

Procedure Followed (Compliance) Not Followed - Call Not Made (Non-Compliance Call Not Made) Not Medically Necessary (Non-Compliance NonMedically Necessary) Not Followed Other (Non-Compliance Other) Emergency Admit to Non-Network Hospital

4 5

274

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2300 HCP CLAIM PRICING/REPRICING INFORMATION

SITUATIONAL

HCP15

1527

Exception Code

ID

1/2

Code specifying the exception reason for consideration of out-of-network health care services
ALIAS: Exception
SEMANTIC:

code

HCP15 is the exception reason generated by a third party organization.

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

Non-Network Professional Provider in Network Hospital Emergency Care Services or Specialist not in Network Out-of-Service Area State Mandates Other

2 3 4 5 6

MAY 2000

275

004010X098 837 2305 CR7 HOME HEALTH CARE PLAN INFORMATION

HOME HEALTH TREATMENT PLAN CERTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CR7

004010X098 837 2305 CR7 HOME HEALTH CARE PLAN INFORMATION

IMPLEMENTATION

HOME HEALTH CARE PLAN INFORMATION

Loop: 2305 HOME HEALTH CARE PLAN INFORMATION Repeat: 6 Usage: SITUATIONAL Repeat: 1

4 204 8 109
STANDARD

Notes:

1. Required on home health claims/encounters that involve billing/reporting home health visits.

Example: CR7VPTV4V12~

CR7 Home Health Treatment Plan Certification

Level: Detail Position: 242 Loop: 2305 Repeat: 6 Requirement: Optional Max Use: 1 Purpose: To supply information related to the home health care plan of treatment and services
DIAGRAM

CR701

921

CR702

1470

CR703

1470

CR7 V

Discipline Type Code

M ID 2/2

V
M

Number
N0 1/9

V
M

Number
N0 1/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CR701

921

Discipline Type Code

Code indicating disciplines ordered by a physician
ALIAS: Discipline
CODE

ID

2/2

type code
DEFINITION

AI MS OT PT SN ST

Home Health Aide Medical Social Worker Occupational Therapy Physical Therapy Skilled Nursing Speech Therapy

276

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2305 CR7 HOME HEALTH CARE PLAN INFORMATION

REQUIRED

CR702

1470

Number
A generic number
INDUSTRY: Total ALIAS: Total
SEMANTIC:

N0

1/9

Visits Rendered Count

visits rendered, home health

CR702 is the total visits on this bill rendered prior to the recertification

to date.

REQUIRED

CR703

1470

Number
A generic number
INDUSTRY: Certification ALIAS: Total

N0

1/9

Period Projected Visit Count

visits projected, home health

SEMANTIC: CR703 is the total visits projected during this certification period.

MAY 2000

277

004010X098 837 2305 HSD HEALTH CARE SERVICES DELIVERY

HEALTH CARE SERVICES DELIVERY

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HSD

HEALTH CARE SERVICES HSD 004010X098 837 2305 DELIVERY

IMPLEMENTATION

HEALTH CARE SERVICES DELIVERY

Loop: 2305 HOME HEALTH CARE PLAN INFORMATION Usage: SITUATIONAL Repeat: 3

0 275

Notes:

1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearly substantiate medical treatment. 2. The HSD segment is used to specify the delivery pattern of the health care services. This is how it is used: HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means one visit. Between HSD02 and HSD03 verbally insert a per every. HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means three days. Between HSD04 and HSD05 verbally insert a for. HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means 21 days. The total message reads: HSD*VS*1*DA*3*7*21~ = One visit per every three days for 21 days. Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days. An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means 1 visit on Wednesday and Thursday morning.

1 208

9 109 0 110
STANDARD

Example: HSDVVSV1VDAV1V7V10~ (This indicates 1 visit every (per) 1 day (daily) for 10 days) Example: HSDVVSV1VDAVVVVW~ (This indicates 1 visit per day whenever necessary)

HSD Health Care Services Delivery

Level: Detail Position: 243 Loop: 2305 Requirement: Optional Max Use: 12 Purpose: To specify the delivery pattern of health care services Syntax: 1. P0102 If either HSD01 or HSD02 is present, then the other is required.
MAY 2000

278

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2305 HSD HEALTH CARE SERVICES DELIVERY

2. C0605 If HSD06 is present, then HSD05 is required.

DIAGRAM

HSD01

673

HSD02

380

HSD03

355

HSD04

1167

HSD05

615

HSD06

616

HSD V
X

Quantity Qualifier
ID 2/2

V
X

Quantity
R 1/15

Unit/Basis Meas Code

O ID 2/2

Sample Sel Modulus

O R 1/6

V Time Period V Qualifier

X ID 1/2

Number of Periods
O N0 1/3

HSD07

678

HSD08

679

V Ship/Del or V Calend Code

O ID 1/2

Ship/Del Time Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

SITUATIONAL

HSD01

673

Quantity Qualifier
Code specifying the type of quantity
INDUSTRY: Visits
SYNTAX:

ID

2/2

P0102

2491

Required if the order/prescription for the service contains the data.

CODE DEFINITION

VS SITUATIONAL HSD02 380 Quantity

Visits X R 1/15

Numeric value of quantity

INDUSTRY: Number
SYNTAX:

of Visits

P0102

2491
SITUATIONAL HSD03 355

Required if the order/prescription for the service contains the data. Unit or Basis for Measurement Code O ID 2/2
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
INDUSTRY: Frequency ALIAS: Modulus,

Period

Unit

2491

Required if the order/prescription for the service contains the data.

CODE DEFINITION

DA MO

Days Months Month

1391
Q1 WK

Quarter (Time) Week

MAY 2000

279

004010X098 837 2305 HSD HEALTH CARE SERVICES DELIVERY

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

HSD04

1167

Sample Selection Modulus

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
INDUSTRY: Frequency ALIAS: Modulus,

Count

Amount

2491
SITUATIONAL HSD05 615

Required if the order/prescription for the service contains the data. Time Period Qualifier
Code defining periods
INDUSTRY: Duration
SYNTAX:

ID

1/2

of Visits Units

C0605

2491

Required if the order/prescription for the service contains the data.

CODE DEFINITION

7 35 SITUATIONAL HSD06 616

Day Week O N0 1/3

Number of Periods
Total number of periods
INDUSTRY: Duration
SYNTAX:

of Visits, Number of Units

C0605

2491
SITUATIONAL HSD07 678

Required if the order/prescription for the service contains the data. Ship/Delivery or Calendar Pattern Code
INDUSTRY: Ship, ALIAS: Pattern

ID

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

Delivery or Calendar Pattern Code

Code

2491

Required if the order/prescription for the service contains the data.

CODE DEFINITION

1 2 3 4 5 6 7 A B C D E

1st Week of the Month 2nd Week of the Month 3rd Week of the Month 4th Week of the Month 5th Week of the Month 1st & 3rd Weeks of the Month 2nd & 4th Weeks of the Month Monday through Friday Monday through Saturday Monday through Sunday Monday Tuesday

280

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2305 HSD HEALTH CARE SERVICES DELIVERY

F G H J K L N O S SA SB SC SD SG SL SP SX SY SZ W SITUATIONAL HSD08 679

Wednesday Thursday Friday Saturday Sunday Monday through Thursday As Directed Daily Mon. through Fri. Once Anytime Mon. through Fri. Sunday, Monday, Thursday, Friday, Saturday Tuesday through Saturday Sunday, Wednesday, Thursday, Friday, Saturday Monday, Wednesday, Thursday, Friday, Saturday Tuesday through Friday Monday, Tuesday and Thursday Monday, Tuesday and Friday Wednesday and Thursday Monday, Wednesday and Thursday Tuesday, Thursday and Friday Whenever Necessary O ID 1/1

Ship/Delivery Pattern Time Code

INDUSTRY: Delivery ALIAS: Time

Code which specifies the time for routine shipments or deliveries

Pattern Time Code

Code

2491

Required if the order/prescription for the service contains the data.

CODE DEFINITION

D E F

A.M. P.M. As Directed

MAY 2000

281

004010X098 837 2310A NM1 REFERRING PROVIDER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2310A NM1 REFERRING PROVIDER NAME

IMPLEMENTATION

REFERRING PROVIDER NAME

Loop: 2310A REFERRING PROVIDER NAME Repeat: 2 Usage: SITUATIONAL Repeat: 1

1 102

Notes:

1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. 2. When there is only one referral on the claim, use code DN - Referring Provider. When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code P3 - Primary Care Provider in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patients episode of care being billed/reported in this transaction. 3. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 4. Required if claim involved a referral. 5. When reporting the provider who ordered services such as diagnostic and lab utilize the 2310A loop at the claim level. For ordered services such as DMERC utilize the 2420E Loop at the line level.

3 249

7 221

2 249 5 010 100

3 123
STANDARD

Example: NM1VDNV1VWELBYVMARCUSVWVVJRV34V444332222~

NM1 Individual or Organizational Name

Level: Detail Position: 250 Loop: 2310 Repeat: 9 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Loop 2310 contains information about the rendering, referring, or attending provider. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

282

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2310A NM1 REFERRING PROVIDER NAME

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1059

The entity identifier in NM101 applies to all segments in this Loop ID-2310.
CODE DEFINITION

DN

Referring Provider Use on first iteration of this loop. Use if loop is used only once.

2494
P3

Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop.

2495
REQUIRED NM102 1065

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

ID

1/1

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Referring

Provider Last Name

1537 1537
SITUATIONAL NM104 1036

NSF Reference: EA0-24.0 Name First

Individual first name
INDUSTRY: Referring

AN

1/25

Provider First Name

2273 2273 1245

NSF Reference: EA0-25.0 Required if NM102=1 (person).

MAY 2000

283

004010X098 837 2310A NM1 REFERRING PROVIDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

NM105

1037

Name Middle
Individual middle name or initial
INDUSTRY: Referring

AN

1/25

Provider Middle Name

2290 2290 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: EA0-26.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Referring ALIAS: Referring

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058
SITUATIONAL NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2496

Required if Employers Identification/Social Security number (Tax ID) or National Provider Identifier is known.
CODE DEFINITION

24 34 XX

Employers Identification Number Social Security Number Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Referring ALIAS: Referring
SYNTAX:

Provider Identifier

Provider Primary Identifier

P0809

1538 1538 2496

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: EA0-20.0 Required if Employers Identification/Social Security number (Tax ID) or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

284

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PROVIDER INFORMATION

004010X098 837 2310A PRV REFERRING PROVIDER SPECIALTY INFORMATION

PRV

REFERRING PROVIDER SPECIALTY INFORMATION 004010X098 837 2310A PRV

IMPLEMENTATION

REFERRING PROVIDER SPECIALTY INFORMATION

Loop: 2310A REFERRING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

3 102

Notes:

1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. 2. Required if required under provider-payer contract. 3. PRV02 qualifies PRV03.

7 249 3 279 4 102

STANDARD

Example: PRVVRFVZZV363LP0200N~

PRV Provider Information

Level: Detail Position: 255 Loop: 2310 Requirement: Optional Max Use: 1 Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

PRV02

128

PRV03

127

PRV04

156

PRV05

C035

PRV06

1223

PRV

V
M

Provider Code
ID 1/3

Reference Ident Qual

M ID 2/3

Reference Ident
M AN 1/30

State or Prov Code

O ID 2/2

V
O

Provider Spec. Inf.

V
O

Provider Org Code

ID 3/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code
Code indentifying the type of provider
CODE DEFINITION

ID

1/3

RF

Referring

MAY 2000

285

004010X098 837 2310A PRV REFERRING PROVIDER SPECIALTY INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

PRV02

128

Reference Identification Qualifier

Code qualifying the Reference Identification

ID

2/3

2360

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

ZZ

Mutually Defined Health Care Provider Taxonomy Code list

2359
REQUIRED PRV03 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Provider ALIAS: Provider

Taxonomy Code

Specialty Code
O O O ID 3/3 ID 2/2

NOT USED NOT USED NOT USED

PRV04 PRV05 PRV06

156 C035 1223

State or Province Code PROVIDER SPECIALTY INFORMATION Provider Organization Code

286

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2310A N2 ADDITIONAL REFERRING PROVIDER NAME INFORMATION

N2

ADDITIONAL 837 2310A N2 004010X098 REFERRING PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL REFERRING PROVIDER NAME INFORMATION

Loop: 2310A REFERRING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 260 Loop: 2310 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Referring ALIAS: Referring

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

MAY 2000

287

004010X098 837 2310A REF REFERRING PROVIDER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

REFERRING PROVIDER SECONDARY IDENTIFICATION 004010X098 837 2310A REF

IMPLEMENTATION

REFERRING PROVIDER SECONDARY IDENTIFICATION

Loop: 2310A REFERRING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

8 249

Notes:

1. Required if NM108/09 in this loop is not used or if a secondary number is necessary to identify the provider. Until the NPI is mandated for use, this REF may be required if necessary to adjudicate the claim.

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 271 Loop: 2310 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1B 1C 1D 1G 1H

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number

288

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2310A REF REFERRING PROVIDER SECONDARY IDENTIFICATION

EI G2 LU N5 SY

Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Referring
SYNTAX:

Provider Secondary Identifier

R0203

1538 1538
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: EA0-20.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

289

004010X098 837 2310B NM1 RENDERING PROVIDER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 PROVIDER NAME RENDERING 837 2310B NM1

IMPLEMENTATION

RENDERING PROVIDER NAME

Loop: 2310B RENDERING PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

1 102

Notes:

1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. Required when the Rendering Provider NM1 information is different than that carried in either the Billing Provider NM1 or the Pay-to Provider NM1 in the 2010AA/AB loops respectively. 4. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a subsitute provider (locum tenans) was used, that person should be entered here.

7 221

9 249

0 250

2 102
STANDARD

Example: NM1V82V1VBEATTYVGARYVCVVSRVXXV12345678~

NM1 Individual or Organizational Name

Level: Detail Position: 250 Loop: 2310 Repeat: 9 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Loop 2310 contains information about the rendering, referring, or attending provider. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

290

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2310B NM1 RENDERING PROVIDER NAME

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1059

The entity identifier in NM101 applies to all segments in this Loop ID-2310.
CODE DEFINITION

82 REQUIRED NM102 1065

Rendering Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Rendering ALIAS: Rendering

Provider Last or Organization Name

Provider Last Name

1539 1539
SITUATIONAL NM104 1036

NSF Reference: FB1-14.0 Name First

Individual first name
INDUSTRY: Rendering

AN

1/25

Provider First Name

1540 1540 1245

NSF Reference: FB1-15.0 Required if NM102=1 (person).

MAY 2000

291

004010X098 837 2310B NM1 RENDERING PROVIDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

NM105

1037

Name Middle
Individual middle name or initial
INDUSTRY: Rendering

AN

1/25

Provider Middle Name

1541 1541 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: FB1-16.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Rendering ALIAS: Rendering

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058
REQUIRED NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2502 2502 2501

NSF Reference: FA0-57.0 FA0-57.0 crosswalk is only used in Medicare COB payer-to-payer claims.
CODE DEFINITION

24 34 XX

Employers Identification Number Social Security Number Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Rendering ALIAS: Rendering
SYNTAX:

Provider Identifier

Provider Primary Identifier

P0809

2504 2504 2503

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: FA0-23.0, FA0-58.0 FA0-58.0 crosswalk is only used in Medicare COB payer-to-payer claims. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

292

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PROVIDER INFORMATION

004010X098 837 2310B PRV RENDERING PROVIDER SPECIALTY INFORMATION

PRV

RENDERING 837 2310B PRV 004010X098 PROVIDER SPECIALTY INFORMATION

IMPLEMENTATION

RENDERING PROVIDER SPECIALTY INFORMATION

Loop: 2310B RENDERING PROVIDER NAME Usage: REQUIRED Repeat: 1

3 102

Notes:

1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. 2. PRV02 qualifies PRV03.

3 279 8 123
STANDARD

Example: PRVVPEVZZV203BA0200N~

PRV Provider Information

Level: Detail Position: 255 Loop: 2310 Requirement: Optional Max Use: 1 Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

PRV02

128

PRV03

127

PRV04

156

PRV05

C035

PRV06

1223

PRV V
M

Provider Code
ID 1/3

Reference Ident Qual

M ID 2/3

Reference Ident
M AN 1/30

State or Prov Code

O ID 2/2

V
O

Provider Spec. Inf.

V
O

Provider Org Code

ID 3/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code
Code indentifying the type of provider
CODE DEFINITION

ID

1/3

PE

Performing

MAY 2000

293

004010X098 837 2310B PRV RENDERING PROVIDER SPECIALTY INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

PRV02

128

Reference Identification Qualifier

Code qualifying the Reference Identification

ID

2/3

2360

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

ZZ

Mutually Defined Health Care Provider Taxonomy Code list

2359
REQUIRED PRV03 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Provider ALIAS: Provider

Taxonomy Code

Specialty Code

1009 1009
NOT USED NOT USED NOT USED PRV04 PRV05 PRV06 156 C035 1223

NSF Reference: FA0-37.0 State or Province Code PROVIDER SPECIALTY INFORMATION Provider Organization Code O O O ID 3/3 ID 2/2

294

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2310B N2 ADDITIONAL RENDERING PROVIDER NAME INFORMATION

N2

ADDITIONAL 837 2310B PROVIDER NAME INFORMATION 004010X098 RENDERING N2

IMPLEMENTATION

ADDITIONAL RENDERING PROVIDER NAME INFORMATION

Loop: 2310B RENDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 260 Loop: 2310 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Rendering ALIAS: Rendering

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

MAY 2000

295

004010X098 837 2310B REF RENDERING PROVIDER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

RENDERING 837 2310B REF 004010X098 PROVIDER SECONDARY IDENTIFICATION

IMPLEMENTATION

RENDERING PROVIDER SECONDARY IDENTIFICATION

Loop: 2310B RENDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 271 Loop: 2310 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification

ID

2/3

2502 2502

NSF Reference: FA0-57.0

CODE DEFINITION

0B 1B 1C 1D

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number

296

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2310B REF RENDERING PROVIDER SECONDARY IDENTIFICATION

1G 1H EI G2 LU N5 SY

Provider UPIN Number CHAMPUS Identification Number Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Rendering
SYNTAX:

Provider Secondary Identifier

R0203

2504 2504
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-58.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

297

004010X098 837 2310C NM1 PURCHASED SERVICE PROVIDER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 SERVICE PROVIDER NAME PURCHASED 837 2310C NM1

IMPLEMENTATION

PURCHASED SERVICE PROVIDER NAME

Loop: 2310C PURCHASED SERVICE PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

1 102

Notes:

1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. Required if purchased services are being billed/reported on this claim. Purchased services are situations where (for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination payer identified in the 2010BB loop.

7 221

5 250

6 123
STANDARD

Example: NM1VQBV2VVVVVVFIV111223333~

NM1 Individual or Organizational Name

Level: Detail Position: 250 Loop: 2310 Repeat: 9 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Loop 2310 contains information about the rendering, referring, or attending provider. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

298

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2310C NM1 PURCHASED SERVICE PROVIDER NAME

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

QB REQUIRED NM102 1065

Purchase Service Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL NM103 NM104 NM105 NM106 NM107 NM108 1035 1036 1037 1038 1039 66

Person Non-Person Entity O O O O O X AN AN AN AN AN ID 1/35 1/25 1/25 1/10 1/10 1/2

Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2506

Required if either Employers Identification/Social Security Number or National Provider Identifier is known.
CODE DEFINITION

24 34 XX

Employers Identification Number Social Security Number Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

MAY 2000

299

004010X098 837 2310C NM1 PURCHASED SERVICE PROVIDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Purchased ALIAS: Purchased
SYNTAX:

AN

2/80

Service Provider Identifier

Service Provider Primary Identifier

P0809

1543 1543 2506

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: FB0-11.0 Required if either Employers Identification/Social Security Number or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

300

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2310C REF PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION

REF

PURCHASED 837 2310C REF 004010X098 SERVICE PROVIDER SECONDARY IDENTIFICATION

IMPLEMENTATION

PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION

Loop: 2310C PURCHASED SERVICE PROVIDER NAME Usage: SITUATIONAL Repeat: 5

3 237

Notes:

1. Required when a secondary identification number is necessary to identify the entity. The primary identification number should be carried in NM108/9 in this loop.

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 271 Loop: 2310 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1A 1B 1C 1D 1G

State License Number Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number

MAY 2000

301

004010X098 837 2310C REF PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

1H EI G2 LU N5 SY

CHAMPUS Identification Number Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
U3 X5 REQUIRED REF02 127

Unique Supplier Identification Number (USIN) State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Purchased
SYNTAX:

Service Provider Secondary Identifier

R0203

1295 1295
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FB0-11.0 Description REFERENCE IDENTIFIER X O AN 1/80

302

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2310D NM1 SERVICE FACILITY LOCATION

NM1

004010X098 837 LOCATION SERVICE FACILITY 2310D NM1

IMPLEMENTATION

SERVICE FACILITY LOCATION

Loop: 2310D SERVICE FACILITY LOCATION Repeat: 1 Usage: SITUATIONAL Repeat: 1

1 102

Notes:

1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. This loop is required when the location of health care service is different than that carried in the 2010AA (Billing Provider) or 2010AB (Pay-to Provider) loops. 4. Required if the service was rendered in a Health Professional Shortage Area (QB or QU modifier billed) and the place of service is different than the HPSA billing address. 5. The purpose of this loop is to identify specifically where the service was rendered. In cases where it was rendered at the patients home, do not use this loop. In that case, the place of service code in CLM051 should indicate that the service occurred in the patients home.

7 221

8 250

9 250

0 251

7 123
STANDARD

Example: NM1VTLV2VA-OK MOBILE CLINICVVVVV24V11122333~

NM1 Individual or Organizational Name

Level: Detail Position: 250 Loop: 2310 Repeat: 9 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Loop 2310 contains information about the rendering, referring, or attending provider. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

MAY 2000

303

004010X098 837 2310D NM1 SERVICE FACILITY LOCATION DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

77

Service Location Use when other codes in this element do not apply.

2511
FA LI TL REQUIRED NM102 1065

Facility Independent Lab Testing Laboratory M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 SITUATIONAL NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Laboratory

or Facility Name Name

ALIAS: Laboratory/Facility

2274 2274 2512

NOT USED NOT USED NOT USED NOT USED NM104 NM105 NM106 NM107 1036 1037 1038 1039

NSF Reference: EA0-39.0 Required except when service was rendered in the patients home. Name First Name Middle Name Prefix Name Suffix O O O O AN AN AN AN 1/25 1/25 1/10 1/10

304

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2310D NM1 SERVICE FACILITY LOCATION

SITUATIONAL

NM108

66

Identification Code Qualifier

ID

1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2506

Required if either Employers Identification/Social Security Number or National Provider Identifier is known.
CODE DEFINITION

24 34 XX

Employers Identification Number Social Security Number Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Laboratory

or Facility Primary Identifier Primary Identifier

ALIAS: Laboratory/Facility
SYNTAX:

P0809

1693 1693 2506

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: EA1-04.0, EA0-53.0 Required if either Employers Identification/Social Security Number or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

305

004010X098 837 2310D N2 ADDITIONAL SERVICE FACILITY LOCATION NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2310D N2 004010X098 SERVICE FACILITY LOCATION NAME INFORMATION

IMPLEMENTATION

ADDITIONAL SERVICE FACILITY LOCATION NAME INFORMATION

Loop: 2310D SERVICE FACILITY LOCATION Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 260 Loop: 2310 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Laboratory

AN

1/60

or Facility Name Additional Text Additional Name Information

O AN 1/60

ALIAS: Laboratory/Facility

NOT USED

N202

93

Name

306

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDRESS INFORMATION

004010X098 837 2310D N3 SERVICE FACILITY LOCATION ADDRESS

N3

SERVICE FACILITY 2310D N3 004010X098 837 LOCATION ADDRESS

IMPLEMENTATION

SERVICE FACILITY LOCATION ADDRESS

Loop: 2310D SERVICE FACILITY LOCATION Usage: REQUIRED Repeat: 1

5 251

Notes:

1. If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (e.g., crossroad of State Road 34 and 45" or Exit near Mile marker 265 on Interstate 80".)

3 103
STANDARD

Example: N3V123 MAIN STREET~

N3 Address Information
Level: Detail Position: 265 Loop: 2310 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Laboratory

AN

1/55

or Facility Address Line Address 1

ALIAS: Laboratory/Facility

1544 1544
SITUATIONAL N302 166

NSF Reference: EA1-06.0 Address Information

Address information
INDUSTRY: Laboratory

AN

1/55

or Facility Address Line Address 2

ALIAS: Laboratory/Facility

1545 1545 2205

MAY 2000

NSF Reference: EA1-07.0 Required if a second address line exists.

307

004010X098 837 2310D N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP

GEOGRAPHIC LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N4

SERVICE FACILITY 2310D N4 004010X098 837 LOCATION CITY/STATE/ZIP

IMPLEMENTATION

SERVICE FACILITY LOCATION CITY/STATE/ZIP

Loop: 2310D SERVICE FACILITY LOCATION Usage: REQUIRED Repeat: 1

7 251

Notes:

1. If service facility location is in an area where there are no street addresses, enter the name of the nearest town, state and zip of where the service was rendered.

4 103
STANDARD

Example: N4VANY TOWNVTXV75123~

N4 Geographic Location
Level: Detail Position: 270 Loop: 2310 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Laboratory

AN

2/30

or Facility City Name City

ALIAS: Laboratory/Facility

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1546 1546

NSF Reference: EA1-08.0

308

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2310D N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP

REQUIRED

N402

156

State or Province Code

INDUSTRY: Laboratory

ID

2/2

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

or Facility State or Province Code State

ALIAS: Laboratory/Facility
COMMENT:

N402 is required only if city name (N401) is in the U.S. or Canada. States and Outlying Areas of the U.S.

CODE SOURCE 22:

1547 1547
REQUIRED N403 116

NSF Reference: EA1-09.0 Postal Code O ID 3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Laboratory

or Facility Postal Zone or ZIP Code Zip Code

ALIAS: Laboratory/Facility
CODE SOURCE 51:

ZIP Code

1548 1548
SITUATIONAL N404 26

NSF Reference: EA1-10.0 Country Code

Code identifying the country
ALIAS: Laboratory/Facility
CODE SOURCE 5:

ID

2/3

Country Code

Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

MAY 2000

309

004010X098 837 2310D REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

SERVICE FACILITY 2310D REF 004010X098 837 LOCATION SECONDARY IDENTIFICATION

IMPLEMENTATION

SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

Loop: 2310D SERVICE FACILITY LOCATION Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 271 Loop: 2310 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1A 1B 1C 1D 1G

State License Number Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number

310

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2310D REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

1H G2 LU N5 TJ X4

CHAMPUS Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Federal Taxpayers Identification Number Clinical Laboratory Improvement Amendment Number State Industrial Accident Provider Number X AN 1/30

X5 REQUIRED REF02 127

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Laboratory

or Facility Secondary Identifier Secondary Identification Number

ALIAS: Laboratory/Facility
SYNTAX:

R0203

1693 1693
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: EA1-04.0, EA0-53.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

311

004010X098 837 2310E NM1 SUPERVISING PROVIDER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2310E NAME SUPERVISING PROVIDER NM1

IMPLEMENTATION

SUPERVISING PROVIDER NAME

Loop: 2310E SUPERVISING PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

1 102

Notes:

1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. 2. Required when the rendering provider is supervised by a physician. 3. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules.

8 204 7 221

3 130
STANDARD

Example: NM1VDQV1VKILLIANVBARTVBVVIIV24V222334444~

NM1 Individual or Organizational Name

Level: Detail Position: 250 Loop: 2310 Repeat: 9 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Loop 2310 contains information about the rendering, referring, or attending provider. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

312

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2310E NM1 SUPERVISING PROVIDER NAME

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

DQ REQUIRED NM102 1065

Supervising Physician M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Supervising

Provider Last Name

1550 1550
REQUIRED NM104 1036

NSF Reference: EA1-18.0 Name First

Individual first name
INDUSTRY: Supervising

AN

1/25

Provider First Name

1551 1551
SITUATIONAL NM105 1037

NSF Reference: EA1-19.0 Name Middle

Individual middle name or initial
INDUSTRY: Supervising

AN

1/25

Provider Middle Name

1552 1552 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: EA1-20.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Supervising ALIAS: Supervising

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058

Required if known.

MAY 2000

313

004010X098 837 2310E NM1 SUPERVISING PROVIDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

NM108

66

Identification Code Qualifier

ID

1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2506

Required if either Employers Identification/Social Security Number or National Provider Identifier is known.
CODE DEFINITION

24 34

Employers Identification Number Social Security Number The social security number may not be used for Medicare.

2376
XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Supervising ALIAS: Supervising
SYNTAX: P0809

Provider Identifier

Provider Primary Identifier

1553 1553 2506

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: EA1-16.0 Required if either Employers Identification/Social Security Number or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

314

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2310E N2 ADDITIONAL SUPERVISING PROVIDER NAME INFORMATION

N2

ADDITIONAL 837 2310E N2 004010X098 SUPERVISING PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL SUPERVISING PROVIDER NAME INFORMATION

Loop: 2310E SUPERVISING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 260 Loop: 2310 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Supervising ALIAS: Supervising

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

MAY 2000

315

004010X098 837 2310E REF SUPERVISING PROVIDER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

SUPERVISING PROVIDER REF 004010X098 837 2310E SECONDARY IDENTIFICATION

IMPLEMENTATION

SUPERVISING PROVIDER SECONDARY IDENTIFICATION

Loop: 2310E SUPERVISING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

3 237

Notes:

1. Required when a secondary identification number is necessary to identify the entity. The primary identification number should be carried in NM108/9 in this loop.

5 280
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 271 Loop: 2310 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1B 1C 1D 1G 1H

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number

316

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2310E REF SUPERVISING PROVIDER SECONDARY IDENTIFICATION

EI G2 LU N5 SY

Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Supervising
SYNTAX:

Provider Secondary Identifier

R0203

1553 1553
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: EA1-16.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

317

004010X098 837 2320 SBR OTHER SUBSCRIBER INFORMATION

SUBSCRIBER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SBR

OTHER SUBSCRIBER INFORMATION 004010X098 837 2320 SBR

IMPLEMENTATION

OTHER SUBSCRIBER INFORMATION

Loop: 2320 OTHER SUBSCRIBER INFORMATION Repeat: 10 Usage: SITUATIONAL Repeat: 1

9 138 7 221

Notes:

1. Required if other payers are known to potentially be involved in paying on this claim. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. All information contained in the 2320 Loop applies only to the payer who is identified in the 2330B Loop of this iteration of the 2320 Loop. It is specific only to that payer. If information on additional payers is needed to be carried, run the 2320 Loop again with its respective 2330 Loops. See Section 1.4.4 for more information on handling COB.

9 251

0 280 9 123
STANDARD

4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837. Example: SBRVSV01VGR00786VVMCVVVVOF~

SBR Subscriber Information

Level: Detail Position: 290 Loop: 2320 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To record information specific to the primary insured and the insurance carrier for that insured Set Notes: 1. Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.

318

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2320 SBR OTHER SUBSCRIBER INFORMATION

SBR01

1138

SBR02

1069

SBR03

127

SBR04

93

SBR05

1336

SBR06

1143

SBR

Payer Resp V Seq No Code

M ID 1/1

Individual Relat Code

O ID 2/2

Reference Ident
O AN 1/30

V
O

Name
AN 1/60

Insurance Type Code

O ID 1/3

Benefits Coord Code

O ID 1/1

SBR07

1073

SBR08

584

SBR09

1032

V Yes/No Cond V Employment V

Resp Code
ID

Status Code
ID

Claim File Ind Code

O ID 1/2

1/1

2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

SBR01

1138

Payer Responsibility Sequence Number Code

ID

1/1

Code identifying the insurance carriers level of responsibility for a payment of a claim
ALIAS: Payer

responsibility sequence number code

1744 1744

NSF Reference: DA0-02.0, DA1-02.0, DA2-02.0

CODE DEFINITION

P S T REQUIRED SBR02 1069

Primary Secondary Tertiary O ID 2/2

Individual Relationship Code

ALIAS: Individual
SEMANTIC:

Code indicating the relationship between two individuals or entities

relationship code

SBR02 specifies the relationship to the person insured.

1555 1555

NSF Reference: DA0-17.0

CODE DEFINITION

01 04 05 07 10 15 17 18 19

Spouse Grandfather or Grandmother Grandson or Granddaughter Nephew or Niece Foster Child Ward Stepson or Stepdaughter Self Child

MAY 2000

319

004010X098 837 2320 SBR OTHER SUBSCRIBER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

20 21 22 23 24 29 32 33 36 39 40 41 43 53 G8 SITUATIONAL SBR03 127

Employee Unknown Handicapped Dependent Sponsored Dependent Dependent of a Minor Dependent Significant Other Mother Father Emancipated Minor Organ Donor Cadaver Donor Injured Plaintiff Child Where Insured Has No Financial Responsibility Life Partner Other Relationship O AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Insured ALIAS: Group
SEMANTIC:

Group or Policy Number

or Policy Number

SBR03 is policy or group number.

1556 1556 1096

NSF Reference: DA0-10.0 Required if the subscribers payer identification includes Group or Plan Number. This data element is intended to carry the subscribers Group Number, not the number that uniquely identifies the subscriber (Subscriber ID, Loop 2010BA-NM109). SBR04 93 Name
Free-form name
INDUSTRY: Other ALIAS: Group
SEMANTIC:

SITUATIONAL

AN

1/60

Insured Group Name

or Plan Name

SBR04 is plan name.

1557 1557 1240

NSF Reference: DA0-11.0 Required if the subscribers payer identification includes a Group or Plan Name.

320

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 SBR OTHER SUBSCRIBER INFORMATION

REQUIRED

SBR05

1336

Insurance Type Code

ALIAS: Insurance

ID

1/3

Code identifying the type of insurance policy within a specific insurance program

type code

1558 1558

NSF Reference: DA0-06.0

CODE DEFINITION

AP C1 CP GP HM IP LD LT MB MC MI MP OT PP SP NOT USED NOT USED NOT USED SITUATIONAL SBR06 SBR07 SBR08 SBR09 1143 1073 584 1032

Auto Insurance Policy Commercial Medicare Conditionally Primary Group Policy Health Maintenance Organization (HMO) Individual Policy Long Term Policy Litigation Medicare Part B Medicaid Medigap Part B Medicare Primary Other Personal Payment (Cash - No Insurance) Supplemental Policy O O O O ID ID ID ID 1/1 1/1 2/2 1/2

Coordination of Benefits Code Yes/No Condition or Response Code Employment Status Code Claim Filing Indicator Code
Code identifying type of claim
ALIAS: Claim

filing indicator code

1559 1559 2520

NSF Reference: DA0-05.0 Required prior to mandated used of PlanID. Not used after PlanID is mandated.
CODE DEFINITION

09 10

Self-pay Central Certification

NSF Reference:

1725 1725

CA0-23.0 (K), DA0-05.0 (K)

MAY 2000

321

004010X098 837 2320 SBR OTHER SUBSCRIBER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

11 12 13 14 15 16

Other Non-Federal Programs Preferred Provider Organization (PPO) Point of Service (POS) Exclusive Provider Organization (EPO) Indemnity Insurance Health Maintenance Organization (HMO) Medicare Risk Automobile Medical Blue Cross/Blue Shield Champus Commercial Insurance Co. Disability Health Maintenance Organization Liability Liability Medical Medicare Part B Medicaid Other Federal Program Title V Veteran Administration Plan Refers to Veterans Affairs Plan.

AM BL CH CI DS HM LI LM MB MC OF TV VA

1000106
WC ZZ

Workers Compensation Health Claim Mutually Defined Unknown

2521

322

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CLAIMS ADJUSTMENT

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

CAS

CLAIM LEVEL 837 2320 CAS 004010X098 ADJUSTMENTS

IMPLEMENTATION

CLAIM LEVEL ADJUSTMENTS

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 5

1 124

Notes:

1. Submitters should use this CAS segment to report prior payers claim level adjustments that cause the amount paid to differ from the amount originally charged. 2. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment again. 3. Codes and associated amounts should come from 835s (Remittance Advice) received on the claim. If no previous payments have been made, omit this segment. 4. Required if claim has been adjudicated by payer identified in this loop and has claim level adjustment information. 5. To locate the claim adjustment group codes (CAS01) and claim adjustment reason codes (CAS02, 05, 08, 11, 14, and 17) see the Washington Publishing Company web site: http://www.wpc-edi.com. Follow the buttons to Code Lists - Claim Adjustment Reason Codes.

5 135

0 139

9 204 2 252

MAY 2000

323

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

3 252

6. There several NSF fields which are not directly crosswalked from the 837 to NSF, particularly with respect to payer-to-payer COB situations. Below is a list of some of these NSF fields and some suggestions regarding how to handle them in the 837. Provider Adjustment Amt (DA3-25.0). This would equal the sum of all the adjustment amounts in CAS03, 06, 09, 12, 15, and 18 at both the claim and the line level. See the 835 for how to balance the CAS adjustments against the total billed amount. Beneficiary liability amount (FA0-53.0) This amount would equal the sum of all the adjustment amounts in CAS03, 06, 09, 12, 15, and 18 at both the claim and the line level when CAS01 = PR (patient responsibility). Amount paid to Provider (DA1-33.0). This would be calculated through the use of the CAS codes. Please see the detail on the codes and the discussion of how to use them in the 835 implementation guide. Balance bill limit charge (FA0-54.0). This would equal any CAS adjustment where CAS01=CO and one of the adjustment reason code elements equaled 45". Beneficiary Adjustment Amt (DA3-26.0) Amount paid to beneficiary (DA1-30.0)). The amount paid to the beneficiary is indicated by the use of CAS code 100 - Payment made to patient/insured/responsible party." Original Paid Amount (DA3-28.0): The original paid amount can be calculated from the original COB claim by subtracting all claim adjustments carried in the claim and line level CAS from the original billed amount.

1 110 2 110
STANDARD

Example: CASVPRV1V7.93~ Example: CASVOAV93V15.06~

CAS Claims Adjustment

Level: Detail Position: 295 Loop: 2320 Requirement: Optional Max Use: 99 Purpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Syntax: 1. L050607 If CAS05 is present, then at least one of CAS06 or CAS07 are required.

324

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

2. C0605 If CAS06 is present, then CAS05 is required. 3. C0705 If CAS07 is present, then CAS05 is required. 4. L080910 If CAS08 is present, then at least one of CAS09 or CAS10 are required. 5. C0908 If CAS09 is present, then CAS08 is required. 6. C1008 If CAS10 is present, then CAS08 is required. 7. L111213 If CAS11 is present, then at least one of CAS12 or CAS13 are required. 8. C1211 If CAS12 is present, then CAS11 is required. 9. C1311 If CAS13 is present, then CAS11 is required. 10. L141516 If CAS14 is present, then at least one of CAS15 or CAS16 are required. 11. C1514 If CAS15 is present, then CAS14 is required. 12. C1614 If CAS16 is present, then CAS14 is required. 13. L171819 If CAS17 is present, then at least one of CAS18 or CAS19 are required. 14. C1817 If CAS18 is present, then CAS17 is required. 15. C1917 If CAS19 is present, then CAS17 is required.

MAY 2000

325

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CAS01

1033

CAS02

1034

CAS03

782

CAS04

380

CAS05

1034

CAS06

782

CAS

Claim Adj V Claim Adj V Group Code Reason Code

M ID 1/2 M ID 1/5 M

Monetary Amount
R 1/18

V
O

Quantity
R 1/15

Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

CAS07

380

CAS08

1034

CAS09

782

CAS10

380

CAS11

1034

CAS12

782

V
X

Quantity
R 1/15

Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

V
X

Quantity
R 1/15

Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

CAS13

380

CAS14

1034

CAS15

782

CAS16

380

CAS17

1034

CAS18

782

V
X

Quantity
R 1/15

V Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

V
X

Quantity
R 1/15

V Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

CAS19

380

V
X

Quantity
R 1/15

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CAS01

1033

Claim Adjustment Group Code

Code identifying the general category of payment adjustment
ALIAS: Claim
CODE

ID

1/2

Adjustment Group Code

DEFINITION

CO CR OA PI PR REQUIRED CAS02 1034

Contractual Obligations Correction and Reversals Other adjustments Payor Initiated Reductions Patient Responsibility M ID 1/5

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
CODE SOURCE 139:

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Claim Level

Claim Adjustment Reason Code

2732 2732

NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0, DA316.0, DA1-16.0, DA1-30.0

326

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

REQUIRED

CAS03

782

Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SEMANTIC:

1/18

Amount

Amount - Claim Level

CAS03 is the amount of adjustment.

COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero.

2743 2743
SITUATIONAL

NSF Reference: DA1-09.0, DA1-10.0, DA1-11.0, DA1-12.0, DA1-13.0, DA3-05.0, DA307.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0 CAS04 380 Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SEMANTIC:

1/15

Quantity

Units - Claim Level

CAS04 is the units of service being adjusted.

2050
SITUATIONAL CAS05 1034

Use as needed to show payer adjustment. Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Claim Level

L050607, C0605, C0705 Claim Adjustment Reason Code

CODE SOURCE 139:

2732 2732 2050

SITUATIONAL CAS06 782

NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0, DA316.0, DA1-17.0, DA1-30.0 Use as needed to show payer adjustment. Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Claim Level

L050607, C0605 CAS06 is the amount of the adjustment.

SEMANTIC:

2743 2743 2050

NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA317.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0 Use as needed to show payer adjustment.

MAY 2000

327

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CAS07

380

Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Claim Level

L050607, C0705 CAS07 is the units of service being adjusted.

SEMANTIC:

2050
SITUATIONAL CAS08 1034

Use as needed to show payer adjustment. Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Claim Level

L080910, C0908, C1008 Claim Adjustment Reason Code

CODE SOURCE 139:

1000092 1000092 2050

SITUATIONAL CAS09 782

NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0, DA316.0, DA1-30.0, DA1-18.0 Use as needed to show payer adjustment. Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Claim Level

L080910, C0908 CAS09 is the amount of the adjustment.

SEMANTIC:

2743 2743 2050

SITUATIONAL CAS10 380

NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA317.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0 Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted

1/15

Quantity

Units - Claim Level

SYNTAX: L080910, C1008 SEMANTIC:

CAS10 is the units of service being adjusted.

2050

Use as needed to show payer adjustment.

328

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

SITUATIONAL

CAS11

1034

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Claim Level

L111213, C1211, C1311 Claim Adjustment Reason Code

CODE SOURCE 139:

2732 2732 2050

SITUATIONAL CAS12 782

NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0, DA316.0, DA1-30.0 Use as needed to show payer adjustment. Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Claim Level

L111213, C1211 CAS12 is the amount of the adjustment.

SEMANTIC:

2743 2743 2050

SITUATIONAL CAS13 380

NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA317.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0 Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Claim Level

L111213, C1311 CAS13 is the units of service being adjusted.

SEMANTIC:

2050
SITUATIONAL CAS14 1034

Use as needed to show payer adjustment. Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Claim Level

SYNTAX: L141516, C1514, C1614 CODE SOURCE 139:

Claim Adjustment Reason Code

2732 2732 2050

NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0, DA316.0, DA1-30.0 Use as needed to show payer adjustment.

MAY 2000

329

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CAS15

782

Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Claim Level

L141516, C1514 CAS15 is the amount of the adjustment.

SEMANTIC:

2743 2743 2050

SITUATIONAL CAS16 380

NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA317.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0 Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Claim Level

L141516, C1614 CAS16 is the units of service being adjusted.

SEMANTIC:

2050
SITUATIONAL CAS17 1034

Use as needed to show payer adjustment. Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Claim Level

L171819, C1817, C1917 Claim Adjustment Reason Code

CODE SOURCE 139:

2732 2732 2050

SITUATIONAL CAS18 782

NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0, DA316.0, DA1-30.0 Use as needed to show payer adjustment. Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted

1/18

Amount

Amount - Claim Level

SYNTAX: L171819, C1817 SEMANTIC:

CAS18 is the amount of the adjustment.

2743 2743 2050

NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA317.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0 Use as needed to show payer adjustment.

330

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 CAS CLAIM LEVEL ADJUSTMENTS

SITUATIONAL

CAS19

380

Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Claim Level

L171819, C1917 CAS19 is the units of service being adjusted.

SEMANTIC:

2050

Use as needed to show payer adjustment.

MAY 2000

331

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT
MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) PAYER PAID AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

1 205 8 107
STANDARD

Notes:

1. Required if claim has been adjudicated by payer identified in this loop. It is acceptable to show 0" amount paid.

Example: AMTVDV411~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

D REQUIRED AMT02 782

Monetary amount
INDUSTRY: Payer

Payor Amount Paid M R 1/18

Monetary Amount

Paid Amount

1717
NOT USED AMT03 478

This is a crosswalk from CLP04 in 835 when doing COB. Credit/Debit Flag Code O ID 1/1

332

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) APPROVED AMOUNT

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) APPROVED AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) APPROVED AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

9 253

Notes:

1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer. Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the information is available. 2. The approved amount equals the amount for the total claim that was approved by the payer sending this 837 to another payer.

2 254 7 275
STANDARD

Example: AMTVAAEV500.35~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

AAE REQUIRED AMT02 782

Monetary amount

Approved Amount M R 1/18

Monetary Amount
INDUSTRY: Approved

Amount

2744 2744
NOT USED
MAY 2000

NSF Reference: DA1-37.0 AMT03 478 Credit/Debit Flag Code O ID 1/1

333

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) ALLOWED AMOUNT

MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) ALLOWED AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) ALLOWED AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

9 253

Notes:

1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer. Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the information is available. 2. The allowed amount equals the amount for the total claim that was allowed by the payer sending this 837 to another payer.

5 254 8 275
STANDARD

Example: AMTVB6V519.21~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

B6 REQUIRED AMT02 782

Monetary amount

Allowed - Actual M R 1/18

Monetary Amount
INDUSTRY: Allowed

Amount
O ID 1/1

NOT USED

AMT03

478

Credit/Debit Flag Code

334

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) PATIENT RESPONSIBILITY AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

6 254

Notes:

1. Required if patient is responsible for payment according to another payers adjudication. This is the amount of money which is the responsibility of the patient according to the payer identified in this loop (2330B NM1).

3 135
STANDARD

Example: AMTVF2V15~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V
Code
ID M 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

F2 REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Patient Responsibility - Actual M R 1/18

Monetary Amount

Payer Patient Responsibility Amount

1718
NOT USED AMT03 478

This is a crosswalk from CLP05 in 835 when doing COB. Credit/Debit Flag Code O ID 1/1

MAY 2000

335

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) COVERED AMOUNT

MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) COVERED AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) COVERED AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

9 253

Notes:

1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer. Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the information is available. 2. The covered amount equals the amount for the total claim that was covered by the payer sending this 837 to another payer.

0 254 4 273
STANDARD

Example: AMTVAUV50~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

AU REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Coverage Amount M R 1/18

Monetary Amount

Payer Covered Amount

1719
NOT USED AMT03 478

This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = AU. Credit/Debit Flag Code O ID 1/1

336

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) DISCOUNT AMOUNT

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) DISCOUNT AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) DISCOUNT AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

4 205

Notes:

1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included in the remittance advice reporting those adjudication results.

3 152
STANDARD

Example: AMTVD8V35~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

D8 REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Discount Amount M R 1/18

Monetary Amount

Payer Discount Amount

1720
NOT USED AMT03 478

This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = D8. Credit/Debit Flag Code O ID 1/1

MAY 2000

337

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) PER DAY LIMIT AMOUNT
MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) PER DAY LIMIT AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) PER DAY LIMIT AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

4 205

Notes:

1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included in the remittance advice reporting those adjudication results.

2 168
STANDARD

Example: AMTVDYV46~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

DY REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Per Day Limit M R 1/18

Monetary Amount

Payer Per Day Limit Amount

1721
NOT USED AMT03 478

This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = DY. Credit/Debit Flag Code O ID 1/1

338

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) PATIENT PAID AMOUNT

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) PATIENT PAID AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) PATIENT PAID AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

4 205

Notes:

1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included in the remittance advice reporting those adjudication results. 2. The amount carried in this segment is the total amount of money paid by the payer to the patient (rather than to the provider) on this claim.

7 254 5 126
STANDARD

Example: AMTVF5V152.45~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

F5 REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Patient Amount Paid M R 1/18

Monetary Amount

Payer Patient Paid Amount

1722
NOT USED AMT03 478

This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = F5. Credit/Debit Flag Code O ID 1/1

MAY 2000

339

004010X098 837 2320 AMT COORDINATION OF BENEFITS (COB) TAX AMOUNT

MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) TAX AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) TAX AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

4 205

Notes:

1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included in the remittance advice reporting those adjudication results.

2 171
STANDARD

Example: AMTVTV45~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

T REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Tax M R 1/18

Monetary Amount

Payer Tax Amount

1723
NOT USED AMT03 478

This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = T. Credit/Debit Flag Code O ID 1/1

340

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE 004010X098 837 2320 AMT IMPLEMENTATION GUIDE COORDINATION OF BENEFITS (COB) TOTAL CLAIM BEFORE TAXES AMOUNT
MONETARY AMOUNT

AMT

COORDINATION OF BENEFITS 004010X098 837 2320 AMT(COB) TOTAL CLAIM BEFORE TAXES AMOUNT

IMPLEMENTATION

COORDINATION OF BENEFITS (COB) TOTAL CLAIM BEFORE TAXES AMOUNT

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

4 205

Notes:

1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included in the remittance advice reporting those adjudication results.

3 171
STANDARD

Example: AMTVT2V456~

AMT Monetary Amount

Level: Detail Position: 300 Loop: 2320 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

T2 REQUIRED AMT02 782

Monetary amount
INDUSTRY: Other

Total Claim Before Taxes M R 1/18

Monetary Amount

Payer Pre-Tax Claim Total Amount

1724
NOT USED AMT03 478

This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = T2. Credit/Debit Flag Code O ID 1/1

MAY 2000

341

004010X098 837 2320 DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

DEMOGRAPHIC INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DMG

SUBSCRIBER DEMOGRAPHIC INFORMATION 004010X098 837 2320 DMG

IMPLEMENTATION

SUBSCRIBER DEMOGRAPHIC INFORMATION

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

8 254 0 280 6 107

STANDARD

Notes:

1. Required when 2330A NM102 = 1 (person). 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: DMGVD8V19671105VF~

DMG Demographic Information

Level: Detail Position: 305 Loop: 2320 Requirement: Optional Max Use: 1 Purpose: To supply demographic information Syntax:
DIAGRAM

1. P0102 If either DMG01 or DMG02 is present, then the other is required.

DMG01

1250

DMG02

1251

DMG03

1068

DMG04

1067

DMG05

1109

DMG06

1066

DMG V
V

Date Time format Qual

X ID 2/3

V
X

Date Time Period

AN 1/35

V
O

Gender Code
ID 1/1

Marital Race or V V V Citizenship Status Code Ethnic Code Status Code

O ID 1/1 O ID 1/1 O ID 1/2

DMG07

26

DMG08

659

DMG09

380

Country Code
O ID 2/3

Basis of Verif Code

O ID 1/2

V
O

Quantity
R 1/15

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

SYNTAX:

ID

2/3

Code indicating the date format, time format, or date and time format P0102
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

342

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

REQUIRED

DMG02

1251

Date Time Period

INDUSTRY: Other ALIAS: Date
SYNTAX:

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Insured Birth Date

of Birth - Subscriber

P0102 DMG02 is the date of birth.

SEMANTIC:

1354 1354
REQUIRED DMG03 1068

NSF Reference: DA0-24.0 Gender Code

Code indicating the sex of the individual
INDUSTRY: Other ALIAS: Gender

ID

1/1

Insured Gender Code

- Subscriber

1738 1738

NSF Reference: DA0-23.0

CODE DEFINITION

F M U NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 1067 1109 1066 26 659 380

Female Male Unknown O O O O O O ID ID ID ID ID R 1/1 1/1 1/2 2/3 1/2 1/15

Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity

MAY 2000

343

004010X098 837 2320 OI OTHER INSURANCE COVERAGE INFORMATION

OTHER HEALTH INSURANCE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

OI

OTHER INSURANCE COVERAGE INFORMATION 004010X098 837 2320 OI

IMPLEMENTATION

OTHER INSURANCE COVERAGE INFORMATION

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: REQUIRED Repeat: 1

9 254

Notes:

1. All information contained in the OI segment applies only to the payer who is identified in the 2330B loop of this iteration of the 2320 loop. It is specific only to that payer. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

0 280 3 108
STANDARD

Example: OIVVVYVBVVY~

OI Other Health Insurance Information

Level: Detail Position: 310 Loop: 2320 Requirement: Optional Max Use: 1 Purpose: To specify information associated with other health insurance coverage
DIAGRAM

OI01

1032

OI02

1383

OI03

1073

OI04

1351

OI05

1360

OI06

1363

OI V
O

Claim File Ind Code

ID 1/2

V Claim Submt V Yes/No Cond V Patient Sig V Reason Code Resp Code Source Code
O ID 2/2 O ID 1/1 O ID 1/1

Provider Agree Code

O ID 1/1

Release of Info Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

NOT USED NOT USED

OI01 OI02

1032 1383

Claim Filing Indicator Code Claim Submission Reason Code

O O

ID ID

1/2 2/2

344

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 OI OTHER INSURANCE COVERAGE INFORMATION

REQUIRED

OI03

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Benefits

ID

1/1

Assignment Certification Indicator of Benefits Indicator

ALIAS: Assignment
SEMANTIC:

OI03 is the assignment of benefits indicator. A Y value indicates insured or authorized person authorizes benefits to be assigned to the provider; an N value indicates benefits have not been assigned to the provider.

1560 1560 1714

NSF Reference: DA0-15.0 This is a crosswalk from CLM08 when doing COB.
CODE DEFINITION

N Y SITUATIONAL OI04 1351

No Yes O ID 1/1

Patient Signature Source Code

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

Signature Source Code

1561 1561 1710 1715

NSF Reference: DA0-16.0 Required except in cases where N is used in OI06. This is a crosswalk from CLM10 when doing COB.
CODE DEFINITION

Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file Signed HCFA-1500 Claim Form on file Signed signature authorization form for HCFA-1500 Claim Form block 13 on file Signature generated by provider because the patient was not physically present for services Signed signature authorization form for HCFA-1500 Claim Form block 12 on file O O ID ID 1/1 1/1

C M

S NOT USED REQUIRED

OI05 OI06

1360 1363

Provider Agreement Code Release of Information Code

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

of Information Code

1716

This is a crosswalk from CLM09 when doing COB.

CODE DEFINITION

Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization

MAY 2000

345

004010X098 837 2320 OI OTHER INSURANCE COVERAGE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes The Provider has Limited or Restricted Ability to Release Data Related to a Claim No, Provider is Not Allowed to Release Data On file at Payor or at Plan Sponsor Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

N O Y

346

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MEDICARE OUTPATIENT ADJUDICATION

004010X098 837 2320 MOA MEDICARE OUTPATIENT ADJUDICATION INFORMATION

MOA

004010X098OUTPATIENT MOA MEDICARE 837 2320 ADJUDICATION INFORMATION

IMPLEMENTATION

MEDICARE OUTPATIENT ADJUDICATION INFORMATION

Loop: 2320 OTHER SUBSCRIBER INFORMATION Usage: SITUATIONAL Repeat: 1

5 178 3 110
STANDARD

Notes:

1. Required if returned in the electronic remittance advice (835).

Example: MOAVVVA4~

MOA Medicare Outpatient Adjudication

Level: Detail Position: 320 Loop: 2320 Requirement: Optional Max Use: 1 Purpose: To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
DIAGRAM

MOA01

954

MOA02

782

MOA03

127

MOA04

127

MOA05

127

MOA06

127

MOA V
O

Percent
R 1/10

V
O

Monetary Amount
R 1/18

Reference Ident
O AN 1/30

Reference Ident
O AN 1/30

Reference Ident
O AN 1/30

Reference Ident
O AN 1/30

MOA07

127

MOA08

782

MOA09

782

Reference Ident
O AN 1/30

V
O

Monetary Amount
R 1/18

V
O

Monetary Amount
R 1/18

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

SITUATIONAL

MOA01

954

Percent
Percentage expressed as a decimal
INDUSTRY: Reimbursement ALIAS: Outpatient

1/10

Rate

Reimbursement Rate

SEMANTIC: MOA01 is the reimbursement rate.

1785

Required if returned in the electronic remittance advice (835).

MAY 2000

347

004010X098 837 2320 MOA MEDICARE OUTPATIENT ADJUDICATION INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

MOA02

782

Monetary Amount
Monetary amount
INDUSTRY: HCPCS
SEMANTIC:

1/18

Payable Amount

MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.

1785
SITUATIONAL MOA03 127

Required if returned in the electronic remittance advice (835). Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Remark ALIAS: Remarks
SEMANTIC:

Code

Code

MOA03 is the Remittance Remark Code. See Code Source 411.

2554 2554 1785

SITUATIONAL MOA04 127

NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0 Required if returned in the electronic remittance advice (835). Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Remark ALIAS: Remarks
SEMANTIC:

Code

Code

MOA04 is the Remittance Remark Code. See Code Source 411.

2554 2554 1785

SITUATIONAL MOA05 127

NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0 Required if returned in the electronic remittance advice (835). Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Remark ALIAS: Remarks
SEMANTIC:

Code

Code

MOA05 is the Remittance Remark Code. See Code Source 411.

2554 2554 1785

SITUATIONAL MOA06 127

NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0 Required if returned in the electronic remittance advice (835). Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Remark ALIAS: Remarks
SEMANTIC:

Code

Code

MOA06 is the Remittance Remark Code. See Code Source 411.

2554 2554 1785

NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0 Required if returned in the electronic remittance advice (835).

348

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2320 MOA MEDICARE OUTPATIENT ADJUDICATION INFORMATION

SITUATIONAL

MOA07

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Remark ALIAS: Remarks
SEMANTIC:

Code

Code

MOA07 is the Remittance Remark Code. See Code Source 411.

2554 2554 1785

SITUATIONAL MOA08 782

NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0 Required if returned in the electronic remittance advice (835). Monetary Amount
Monetary amount
INDUSTRY: End ALIAS: ESRD
SEMANTIC:

1/18

Stage Renal Disease Payment Amount

Paid Amount

MOA08 is the End Stage Renal Disease (ESRD) payment amount.

1785
SITUATIONAL MOA09 782

Required if returned in the electronic remittance advice (835). Monetary Amount

Monetary amount
INDUSTRY: Non-Payable ALIAS: Professional
SEMANTIC:

1/18

Professional Component Billed Amount

Component

MOA09 is the professional component amount billed but not payable.

1785

Required if returned in the electronic remittance advice (835).

MAY 2000

349

004010X098 837 2330A NM1 OTHER SUBSCRIBER NAME

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330A NM1 OTHER SUBSCRIBER NAME

IMPLEMENTATION

OTHER SUBSCRIBER NAME

Loop: 2330A OTHER SUBSCRIBER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

7 135 5 255 0 280 1 116

STANDARD

Notes:

1. Submitters are required to send information on all known other subscribers in Loop ID-2330. 2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is not used. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: NM1VILV1VDOEVJOHNVTVVJRVMIV123456~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

350

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330A NM1 OTHER SUBSCRIBER NAME

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

IL REQUIRED NM102 1065

Insured or Subscriber M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Other

Insured Last Name Last Name

ALIAS: Subscriber

1562 1562
SITUATIONAL NM104 1036

NSF Reference: DA0-19.0 Name First

Individual first name
INDUSTRY: Other

AN

1/25

Insured First Name First Name

ALIAS: Subscriber

1563 1563 1245

SITUATIONAL NM105 1037

NSF Reference: DA0-20.0 Required if NM102=1 (person). Name Middle

Individual middle name or initial
INDUSTRY: Other

AN

1/25

Insured Middle Name Middle Name

ALIAS: Subscriber

1564 1564 1848

NOT USED NM106 1038

NSF Reference: DA0-21.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix O AN 1/10

MAY 2000

351

004010X098 837 2330A NM1 OTHER SUBSCRIBER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

NM107

1039

Name Suffix
Suffix to individual name
INDUSTRY: Other

AN

1/10

Insured Name Suffix Generation

ALIAS: Subscriber

1745 1745 1058 1166

REQUIRED NM108 66

NSF Reference: DA0-22.0 Required if known. Examples: I, II, III, IV, Jr, Sr Identification Code Qualifier X ID 1/2
Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

MI

Member Identification Number The code MI is intended to be the subscribers identification number as assigned by the payer. Payers use different terminology to convey the same number. Therefore the 837 Professional Workgroup recommends using MI - Member Identification Number to convey the following terms: Insureds ID, Subscribers ID, Health Insurance Claim Number (HIC), etc.

1000102

ZZ

Mutually Defined The value ZZ, when used in this data element shall be defined as HIPAA Individual Identifier once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of the Department of Health and Human Services must adopt a standard individual identifier for use in this transaction.

2219

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Other ALIAS: Other
SYNTAX:

AN

2/80

Insured Identifier

Subscriber Primary Identifier

P0809

1739 1739
NOT USED NOT USED NM110 NM111 706 98

NSF Reference: DA0-18.0 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

352

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2330A N2 ADDITIONAL OTHER SUBSCRIBER NAME INFORMATION

N2

ADDITIONAL 837 2330A N2 004010X098 OTHER SUBSCRIBER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL OTHER SUBSCRIBER NAME INFORMATION

Loop: 2330A OTHER SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

0 280 4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 330 Loop: 2330 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Other

AN

1/60

Insured Additional Name Additional Name Information

O AN 1/60

ALIAS: Subscriber

NOT USED

N202

93

Name

MAY 2000

353

004010X098 837 2330A N3 OTHER SUBSCRIBER ADDRESS

ADDRESS INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N3

OTHER SUBSCRIBER ADDRESS 004010X098 837 2330A N3

IMPLEMENTATION

OTHER SUBSCRIBER ADDRESS

Loop: 2330A OTHER SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

6 255 0 280 4 108

STANDARD

Notes:

1. Required when information is available. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: N3V4320 WASHINGTON STVSUITE 100~

N3 Address Information
Level: Detail Position: 332 Loop: 2330 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Other

AN

1/55

Insured Address Line Address 1

ALIAS: Subscriber

1565 1565
SITUATIONAL N302 166

NSF Reference: DA2-04.0 Address Information

Address information
INDUSTRY: Other

AN

1/55

Insured Address Line Address 2

ALIAS: Subscriber

1566 1566 2205

NSF Reference: DA2-05.0 Required if a second address line exists.

354

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GEOGRAPHIC LOCATION

004010X098 837 2330A N4 OTHER SUBSCRIBER CITY/STATE/ZIP CODE

N4

OTHER SUBSCRIBER CITY/STATE/ZIP CODE 004010X098 837 2330A N4

IMPLEMENTATION

OTHER SUBSCRIBER CITY/STATE/ZIP CODE

Loop: 2330A OTHER SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 1

6 255 0 280 5 108

STANDARD

Notes:

1. Required when information is available. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: N4VPALISADESVORV23119~

N4 Geographic Location
Level: Detail Position: 340 Loop: 2330 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

SITUATIONAL

N401

19

City Name
Free-form text for city name
INDUSTRY: Other

AN

2/30

Insured City Name City Name

ALIAS: Subscriber
COMMENT:

A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1567 1567 2556

NSF Reference: DA2-06.0 Required when information is available.

MAY 2000

355

004010X098 837 2330A N4 OTHER SUBSCRIBER CITY/STATE/ZIP CODE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

N402

156

State or Province Code

INDUSTRY: Other

ID

2/2

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

Insured State Code State Code

ALIAS: Subscriber
COMMENT:

N402 is required only if city name (N401) is in the U.S. or Canada. States and Outlying Areas of the U.S.

CODE SOURCE 22:

1568 1568 2556

SITUATIONAL N403 116

NSF Reference: DA2-07.0 Required when information is available. Postal Code O ID 3/15
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Other

Insured Postal Zone or ZIP Code Zip Code

ALIAS: Subscriber
CODE SOURCE 51:

ZIP Code

1569 1569 2556

SITUATIONAL N404 26

NSF Reference: DA2-08.0 Required when information is available. Country Code

Code identifying the country
ALIAS: Subscriber
CODE SOURCE 5:

ID

2/3

Country Code

Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

356

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2330A REF OTHER SUBSCRIBER SECONDARY IDENTIFICATION

REF

OTHER SUBSCRIBER SECONDARY IDENTIFICATION 004010X098 837 2330A REF

IMPLEMENTATION

OTHER SUBSCRIBER SECONDARY IDENTIFICATION

Loop: 2330A OTHER SUBSCRIBER NAME Usage: SITUATIONAL Repeat: 3

9 170 0 280 9 106

STANDARD

Notes:

1. Required if additional identification numbers are necessary to adjudicate the claim/encounter. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: REFVSYV528446666~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1W 23

Member Identification Number Client Number This code is intended to be used only in claims submitted to the Indian Health Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose of reporting the Health Record Number.

1000103

MAY 2000

357

004010X098 837 2330A REF OTHER SUBSCRIBER SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

IG SY

Insurance Policy Number Social Security Number The social security number may not be used for Medicare.

2376
REQUIRED REF02 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other ALIAS: Other
SYNTAX:

Insured Additional Identifier

Subscriber Secondary Identification

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

358

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2330B NM1 OTHER PAYER NAME

NM1

004010X098 837 2330B NM1 OTHER PAYER NAME

IMPLEMENTATION

OTHER PAYER NAME

Loop: 2330B OTHER PAYER NAME Repeat: 1 Usage: REQUIRED Repeat: 1

8 135 5 255 0 280 5 107

STANDARD

Notes:

1. Submitters are required to send all known information on other payers in this Loop ID-2330. 2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is not used. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: NM1VPRV2VUNION MUTUAL OF OREGONVVVVVPIV11122333~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

359

004010X098 837 2330B NM1 OTHER PAYER NAME ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

PR REQUIRED NM102 1065

Payer M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 REQUIRED NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Other ALIAS: Payer

Payer Last or Organization Name

Name

1570 1570
NOT USED NOT USED NOT USED NOT USED REQUIRED NM104 NM105 NM106 NM107 NM108 1036 1037 1038 1039 66

NSF Reference: DA0-09.0 Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier O O O O X AN AN AN AN ID 1/25 1/25 1/10 1/10 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

PI XV

Payor Identification Health Care Financing Administration National PlanID Required if the National PlanID is mandated for use. Otherwise, one of the other listed codes may be used.
CODE SOURCE 540:

Health Care Financing Administration

National PlanID

360

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330B NM1 OTHER PAYER NAME

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Other ALIAS: Other
SYNTAX:

AN

2/80

Payer Primary Identifier

Payer Primary Identification Number

P0809

1694 1694 1305

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: DA0-07.0 This number must be identical to SVD01 (Loop ID-2430) for COB. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

361

004010X098 837 2330B N2 ADDITIONAL OTHER PAYER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2330B NAME INFORMATION 004010X098 OTHER PAYERN2

IMPLEMENTATION

ADDITIONAL OTHER PAYER NAME INFORMATION

Loop: 2330B OTHER PAYER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

0 280 4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 330 Loop: 2330 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Other ALIAS: Payer

AN

1/60

Payer Additional Name Text

Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

362

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADMINISTRATIVE COMMUNICATIONS CONTACT

004010X098 837 2330B PER OTHER PAYER CONTACT INFORMATION

PER

OTHER PAYER CONTACT PER 004010X098 837 2330B INFORMATION

IMPLEMENTATION

OTHER PAYER CONTACT INFORMATION

Loop: 2330B OTHER PAYER NAME Usage: SITUATIONAL Repeat: 2

2 257

Notes:

1. This segment is used only in payer-to-payer COB situations. This segment may be completed by a payer who has adjudicated the claim and is passing it on to a secondary payer. It is not completed by submitting providers. 2. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g., (534) 224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number. 3. There are 2 repetitions of the PER segment to allow for six possible combination of communication numbers including extensions.

3 100

9 009 100 1 257

STANDARD

Example: PERVICVSHELLYVTEV5552340000~

PER Administrative Communications Contact

Level: Detail Position: 345 Loop: 2330 Requirement: Optional Max Use: 2 Purpose: To identify a person or office to whom administrative communications should be directed Syntax: 1. P0304 If either PER03 or PER04 is present, then the other is required. 2. P0506 If either PER05 or PER06 is present, then the other is required. 3. P0708 If either PER07 or PER08 is present, then the other is required.

MAY 2000

363

004010X098 837 2330B PER OTHER PAYER CONTACT INFORMATION DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PER01

366

PER02

93

PER03

365

PER04

364

PER05

365

PER06

364

PER

Contact Funct Code

M ID 2/2

V
O

Name
AN 1/60

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

PER07

365

PER08

364

PER09

443

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

V Contact Inq
Reference
O AN 1/20

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PER01

366

Contact Function Code

CODE DEFINITION

ID

2/2

Code identifying the major duty or responsibility of the person or group named

IC REQUIRED PER02 93 Name

Free-form name
INDUSTRY: Other

Information Contact O AN 1/60

Payer Contact Name

X ID 2/2

REQUIRED

PER03

365

Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

P0304
DEFINITION

CODE

ED EM FX TE REQUIRED PER04 364

Electronic Data Interchange Access Number Electronic Mail Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0304

SITUATIONAL

PER05

365

Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0506

2204

Used at the discretion of the submitter.

CODE DEFINITION

ED EM EX FX

Electronic Data Interchange Access Number Electronic Mail Telephone Extension Facsimile

364

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330B PER OTHER PAYER CONTACT INFORMATION

TE SITUATIONAL PER06 364

Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0506

2204
SITUATIONAL PER07 365

Used at the discretion of the submitter. Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0708

2204

Used at the discretion of the submitter.

CODE DEFINITION

ED EM EX FX TE SITUATIONAL PER08 364

Electronic Data Interchange Access Number Electronic Mail Telephone Extension Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0708

2204
NOT USED PER09 443

Used at the discretion of the submitter. Contact Inquiry Reference O AN 1/20

MAY 2000

365

004010X098 837 2330B DTP CLAIM ADJUDICATION DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

CLAIM ADJUDICATION DATE 004010X098 837 2330B DTP

IMPLEMENTATION

CLAIM ADJUDICATION DATE

Loop: 2330B OTHER PAYER NAME Usage: SITUATIONAL Repeat: 1

9 256

Notes:

1. This segment is required when the payer identified in this iteration of the 2330 loop has previously adjudicated the claim and Loop-ID 2430 (Line Adjudication Information) is not used.

9 234
STANDARD

Example: DTPV573VD8V19980314~

DTP Date or Time or Period

Level: Detail Position: 345 Loop: 2330 Requirement: Optional Max Use: 2 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

573 REQUIRED DTP02 1250

Date Claim Paid M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

366

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330B DTP CLAIM ADJUDICATION DATE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Adjudication

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

or Payment Date

2543 2543

NSF Reference: DA1-27.0

MAY 2000

367

004010X098 837 2330B REF OTHER PAYER SECONDARY IDENTIFIER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER SECONDARY IDENTIFIER 004010X098 837 2330B REF

IMPLEMENTATION

OTHER PAYER SECONDARY IDENTIFIER

Loop: 2330B OTHER PAYER NAME Usage: SITUATIONAL Repeat: 2

6 220

Notes:

1. Required when a secondary identification number is necessary to identify the entity. The primary identification number should be carried in NM109 in this loop. 2. Used when it is necessary to identify the other payers claim number in a payer-to-payer COB situation (use code F8). Code F8 is not used by providers. 3. There can only be a maximum of three REF segments in any one iteration of the 2330 loop. 4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

3 257

7 257 0 280 5 115

STANDARD

Example: REFVFYV435261708~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

2U

Payer Identification Number

368

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330B REF OTHER PAYER SECONDARY IDENTIFIER

F8

Original Reference Number Use to indicate the payers claim number for this claim for the payer identified in this iteration of the 2330B loop.

2574

FY NF

Claim Office Number National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE 245:

National Association of Insurance Commissioners (NAIC) Code

TJ REQUIRED REF02 127

Federal Taxpayers Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:

Payer Secondary Identifier

R0203

2575 2575 2576

NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: DA3-29.0 The DA3-29.0 crosswalk is only used in payer-to-payer COB situations. Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

369

004010X098 837 2330B REF OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER
REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER 004010X098 837 2330B REF

IMPLEMENTATION

OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

Loop: 2330B OTHER PAYER NAME Usage: SITUATIONAL Repeat: 2

5 268

Notes:

1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. This element is primarily used in payer-to-payer COB situations. 2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

7 257 0 280 4 264

STANDARD

Example: REFVG1VAB333-Y5~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9F G1

Referral Number Prior Authorization Number

370

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330B REF OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:

Payer Prior Authorization or Referral Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

371

004010X098 837 2330B REF OTHER PAYER CLAIM ADJUSTMENT INDICATOR

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER CLAIM ADJUSTMENT INDICATOR 004010X098 837 2330B REF

IMPLEMENTATION

OTHER PAYER CLAIM ADJUSTMENT INDICATOR

Loop: 2330B OTHER PAYER NAME Usage: SITUATIONAL Repeat: 2

8 268

Notes:

1. Used only in payer-to-payer COB. In that situation, the destination payer is secondary to the payer identified in this loop. Providers/other submitters do not use this segment. 2. Required when the payer identified in this loop has previously paid this claim and has indicated so to the destination payer. In this case the payer identified in this loop has readjudicated the claim and is sending the adjusted payment information to the destination payer. This REF segment is used to indicate that this claim is an adjustment of a previously adjudicated claim. If the claim has not been previously adjudicated this REF is not used. 3. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.

9 268

7 257 7 268
STANDARD

Example: REFVT4VY~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

372

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330B REF OTHER PAYER CLAIM ADJUSTMENT INDICATOR

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

T4 REQUIRED REF02 127

Signal Code X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:

Payer Claim Adjustment Indicator

R0203

2691 2691 2690

NSF Reference: DA3-24.0 Allowable values are Y indicating that the payer in this loop has previously adjudicated this claim and sent a record of that adjudication to the destination payer identified in the 2010BB loop. The claim being transmitted in this iteration of the 2300 loop is a readjudicated version of that claim. REF03 REF04 352 C040 Description REFERENCE IDENTIFIER X O AN 1/80

NOT USED NOT USED

MAY 2000

373

004010X098 837 2330C NM1 OTHER PAYER PATIENT INFORMATION

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330C NM1 OTHER PAYER PATIENT INFORMATION

IMPLEMENTATION

OTHER PAYER PATIENT INFORMATION

Loop: 2330C OTHER PAYER PATIENT INFORMATION Repeat: 1 Usage: SITUATIONAL Repeat: 1

0 256

Notes:

1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identification numbers. The patient identification number(s) carried in this iteration of the 2330 loop are those patient IDs which belong to non-destination (COB) payers. The patient ID(s) forr the destination payer are carried in the 2010CA loop NM1 and REF segments. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling non-destination payer patient identifiers and other COB elements. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules.

7 221

9 255
STANDARD

Example: NM1VQCV1VVVVVVMIV6677U801~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

374

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330C NM1 OTHER PAYER PATIENT INFORMATION

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

QC REQUIRED NM102 1065

Patient M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Patient

Last Name
O O O O X AN AN AN AN ID 1/25 1/25 1/10 1/10 1/2

NOT USED NOT USED NOT USED NOT USED REQUIRED

NM104 NM105 NM106 NM107 NM108

1036 1037 1038 1039 66

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

MI

Member Identification Number The code MI is intended to be the subscribers identification number as assigned by the payer. Payers use different terminology to convey the same number. Therefore the 837 Professional Workgroup recommends using MI - Member Identification Number to convey the following terms: Insureds ID, Subscribers ID, Health Insurance Claim Number (HIC), etc.

1000102

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Other ALIAS: Patients
SYNTAX:

AN

2/80

Payer Patient Primary Identifier Other Payer Primary Identification Number

P0809

NOT USED NOT USED

NM110 NM111

706 98

Entity Relationship Code Entity Identifier Code

X O

ID ID

2/2 2/3

MAY 2000

375

004010X098 837 2330C REF OTHER PAYER PATIENT IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER PATIENT IDENTIFICATION 004010X098 837 2330C REF

IMPLEMENTATION

OTHER PAYER PATIENT IDENTIFICATION

Loop: 2330C OTHER PAYER PATIENT INFORMATION Usage: SITUATIONAL Repeat: 3

3 256

Notes:

1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers for this claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop. 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

0 280 6 279
STANDARD

Example: REFVAZVB333-Y5~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1W

Member Identification Number If NM108 = M1 do not use this code.

1000100
23

Client Number This code is intended to be used only in claims submitted to the Indian Health Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose of reporting the Health Record Number.

1000103

376

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330C REF OTHER PAYER PATIENT IDENTIFICATION

IG SY

Insurance Policy Number Social Security Number Do not use for Medicare.

1000107
REQUIRED REF02 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other ALIAS: Patients
SYNTAX:

Payer Patient Secondary Identifier Other Payer Secondary Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

377

004010X098 837 2330D NM1 OTHER PAYER REFERRING PROVIDER

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330D NM1 OTHER PAYER REFERRING PROVIDER

IMPLEMENTATION

OTHER PAYER REFERRING PROVIDER

Loop: 2330D OTHER PAYER REFERRING PROVIDER Repeat: 2 Usage: SITUATIONAL Repeat: 1

3 276 7 221

Notes:

1. Used when it is necessary to send an additional payer-specific provider identification number for non-destination (COB) payers. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

0 280 2 276
STANDARD

Example: NM1VDNV1~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

378

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330D NM1 OTHER PAYER REFERRING PROVIDER

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

DN

Referring Provider Use on first iteration of this loop. Use if loop is used only once.

2764
P3

Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop.

2765
REQUIRED NM102 1065

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

ID

1/1

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Referring

Provider Last Name

O O O O X X X O AN AN AN AN ID AN ID ID 1/25 1/25 1/10 1/10 1/2 2/80 2/2 2/3

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

1036 1037 1038 1039 66 67 706 98

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code

MAY 2000

379

004010X098 837 2330D REF OTHER PAYER REFERRING PROVIDER IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER REFERRING PROVIDER IDENTIFICATION 004010X098 837 2330D REF

IMPLEMENTATION

OTHER PAYER REFERRING PROVIDER IDENTIFICATION

Loop: 2330D OTHER PAYER REFERRING PROVIDER Usage: REQUIRED Repeat: 3

7 278 0 280 7 276

STANDARD

Notes:

1. Non-destination (COB) payers provider identification number(s). 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: REFVN5VRF446~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1B 1C 1D EI G2

Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Employers Identification Number Provider Commercial Number

380

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330D REF OTHER PAYER REFERRING PROVIDER IDENTIFICATION

LU N5 REQUIRED REF02 127

Location Number Provider Plan Network Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other ALIAS: Other
SYNTAX:

Payer Referring Provider Identifier

Payer Referring Provider Identification

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

381

004010X098 837 2330E NM1 OTHER PAYER RENDERING PROVIDER

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330E NM1 OTHER PAYER RENDERING PROVIDER

IMPLEMENTATION

OTHER PAYER RENDERING PROVIDER

Loop: 2330E OTHER PAYER RENDERING PROVIDER Repeat: 1 Usage: SITUATIONAL Repeat: 1

3 276 7 221

Notes:

1. Used when it is necessary to send an additional payer-specific provider identification number for non-destination (COB) payers. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

0 280 8 276
STANDARD

Example: NM1V82V1~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

382

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330E NM1 OTHER PAYER RENDERING PROVIDER

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

82 REQUIRED NM102 1065

Rendering Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Rendering

Provider Last or Organization Name

O O O O X X X O AN AN AN AN ID AN ID ID 1/25 1/25 1/10 1/10 1/2 2/80 2/2 2/3

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

1036 1037 1038 1039 66 67 706 98

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code

MAY 2000

383

004010X098 837 2330E REF OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION
REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION 004010X098 837 2330E REF

IMPLEMENTATION

OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION

Loop: 2330E OTHER PAYER RENDERING PROVIDER Usage: REQUIRED Repeat: 3

7 278 0 280 0 277

STANDARD

Notes:

1. Non-destination (COB) payers provider identification number(s). 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: REFVLUVSLC987~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1B 1C 1D EI G2

Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Employers Identification Number Provider Commercial Number

384

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330E REF OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION

LU N5 REQUIRED REF02 127

Location Number Provider Plan Network Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:

Payer Rendering Provider Secondary Identifier

R0203

2769
NOT USED NOT USED REF03 REF04 352 C040

Other Payer Rendering Provider Secondary Identification Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

385

004010X098 837 2330F NM1 OTHER PAYER PURCHASED SERVICE PROVIDER

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330F NM1 OTHER PAYER PURCHASED SERVICE PROVIDER

IMPLEMENTATION

OTHER PAYER PURCHASED SERVICE PROVIDER

Loop: 2330F OTHER PAYER PURCHASED SERVICE PROVIDER Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Used when it is necessary to send an additional payer-specific provider identification number for non-destination (COB) payers. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

3 276 0 280 2 277

STANDARD

Example: NM1VQBV2~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

386

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330F NM1 OTHER PAYER PURCHASED SERVICE PROVIDER

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

QB REQUIRED NM102 1065

Purchase Service Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Purchased

Service Provider Name

O O O O X X X O AN AN AN AN ID AN ID ID 1/25 1/25 1/10 1/10 1/2 2/80 2/2 2/3

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

1036 1037 1038 1039 66 67 706 98

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code

MAY 2000

387

004010X098 837 2330F REF OTHER PAYER PURCHASED SERVICE PROVIDER IDENTIFICATION
REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER PURCHASED SERVICE PROVIDER IDENTIFICATION 004010X098 837 2330F REF

IMPLEMENTATION

OTHER PAYER PURCHASED SERVICE PROVIDER IDENTIFICATION

Loop: 2330F OTHER PAYER PURCHASED SERVICE PROVIDER Usage: REQUIRED Repeat: 3

7 278 0 280 4 277

STANDARD

Notes:

1. Non-destination (COB) payers provider identification number(s). 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: REFVG2V8893U21~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1A 1B 1C 1D EI

Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Employers Identification Number

388

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330F REF OTHER PAYER PURCHASED SERVICE PROVIDER IDENTIFICATION

G2 LU N5 REQUIRED REF02 127

Provider Commercial Number Location Number Provider Plan Network Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:

Payer Purchased Service Provider Identifier

R0203

2773
NOT USED NOT USED REF03 REF04 352 C040

Other Payer Purchased Service Provider Identification Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

389

004010X098 837 2330G NM1 OTHER PAYER SERVICE FACILITY LOCATION

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330G NM1 LOCATION OTHER PAYER SERVICE FACILITY

IMPLEMENTATION

OTHER PAYER SERVICE FACILITY LOCATION

Loop: 2330G OTHER PAYER SERVICE FACILITY LOCATION Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Used when it is necessary to send an additional payer-specific provider identification number for non-destination (COB) payers. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

3 276 0 280 6 277

STANDARD

Example: NM1VTLV2~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

390

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330G NM1 OTHER PAYER SERVICE FACILITY LOCATION

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

77

Service Location Use when other codes in this element do not apply.

2777
FA LI TL REQUIRED NM102 1065

Facility Independent Lab Testing Laboratory M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 REQUIRED NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Service

Facility Name
O O O O X X X O AN AN AN AN ID AN ID ID 1/25 1/25 1/10 1/10 1/2 2/80 2/2 2/3

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

1036 1037 1038 1039 66 67 706 98

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code

MAY 2000

391

004010X098 837 2330G REF OTHER PAYER SERVICE FACILITY LOCATION IDENTIFICATION
REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER SERVICE FACILITY 004010X098 837 2330G REF LOCATION IDENTIFICATION

IMPLEMENTATION

OTHER PAYER SERVICE FACILITY LOCATION IDENTIFICATION

Loop: 2330G OTHER PAYER SERVICE FACILITY LOCATION Usage: REQUIRED Repeat: 3

7 278 0 280 9 277

STANDARD

Notes:

1. Non-destination (COB) payers provider identification number(s). 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: REFVG2VLAB1234~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1A 1B 1C 1D G2

Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider Commercial Number

392

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330G REF OTHER PAYER SERVICE FACILITY LOCATION IDENTIFICATION

LU N5 REQUIRED REF02 127

Location Number Provider Plan Network Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other ALIAS: Other
SYNTAX:

Payer Service Facility Location Identifier

Payer Service Facility Location Identification

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

393

004010X098 837 2330H NM1 OTHER PAYER SUPERVISING PROVIDER

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 2330H NM1 OTHER PAYER SUPERVISING PROVIDER

IMPLEMENTATION

OTHER PAYER SUPERVISING PROVIDER

Loop: 2330H OTHER PAYER SUPERVISING PROVIDER Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Used when it is necessary to send an additional payer-specific provider identification number for non-destination (COB) payers. 3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

3 276 0 280 1 278

STANDARD

Example: NM1VDQV1~

NM1 Individual or Organizational Name

Level: Detail Position: 325 Loop: 2330 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: Syntax: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

394

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2330H NM1 OTHER PAYER SUPERVISING PROVIDER

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

DQ REQUIRED NM102 1065

Supervising Physician M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Supervising

Provider Last Name

O O O O X X X O AN AN AN AN ID AN ID ID 1/25 1/25 1/10 1/10 1/2 2/80 2/2 2/3

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

1036 1037 1038 1039 66 67 706 98

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code

MAY 2000

395

004010X098 837 2330H REF OTHER PAYER SUPERVISING PROVIDER IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER SUPERVISING PROVIDER IDENTIFICATION 004010X098 837 2330H REF

IMPLEMENTATION

OTHER PAYER SUPERVISING PROVIDER IDENTIFICATION

Loop: 2330H OTHER PAYER SUPERVISING PROVIDER Usage: REQUIRED Repeat: 3

7 278 0 280 6 280

STANDARD

Notes:

1. Non-destination (COB) payers provider identification number(s). 2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.

Example: REFVG2V53334~

REF Reference Identification

Level: Detail Position: 355 Loop: 2330 Requirement: Optional Max Use: 3 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1B 1C 1D EI G2

Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Employers Identification Number Provider Commercial Number

396

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2330H REF OTHER PAYER SUPERVISING PROVIDER IDENTIFICATION

N5 REQUIRED REF02 127

Provider Plan Network Identification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other ALIAS: Other
SYNTAX:

Payer Supervising Provider Identifier

Payer Supervising Provider Identification

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

397

004010X098 837 2400 LX SERVICE LINE

ASSIGNED NUMBER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

LX

SERVICE LINE 004010X098 837 2400 LX

IMPLEMENTATION

SERVICE LINE
Loop: 2400 SERVICE LINE Repeat: 50 Usage: REQUIRED Repeat: 1

4 127

Notes:

1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a claim. The LX functions as a line counter. 2. The datum in the LX is not usually returned in the 835 (Remittance Advice) transaction. LX01 may be used as a line item control number by the payer in the 835 if a line item control number has not been submitted on the service line. See that REF for more information. LX01 is used to indicate bundling/unbundling in SVC06. See Section 1.4.3 for more information on bundling and unbundling.

3 183

6 221 6 102
STANDARD

3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules. Example: LXV1~

LX Assigned Number
Level: Detail Position: 365 Loop: 2400 Repeat: >1 Requirement: Optional Max Use: 1 Purpose: To reference a line number in a transaction set Set Notes:
DIAGRAM

1. Loop 2400 contains Service Line information.

LX01

554

LX V
M

Assigned Number
N0 1/6

398

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 LX SERVICE LINE

USAGE

NAME

ATTRIBUTES

REQUIRED

LX01

554

Assigned Number
Number assigned for differentiation within a transaction set
ALIAS: Line

N0

1/6

Counter

2281 2281 1025

NSF Reference: FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX202.0, HA0-02.0, FB2-02.0, GU0-02.0 The service line number incremented by 1 for each service line.

MAY 2000

399

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

PROFESSIONAL SERVICE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SV1

PROFESSIONAL SERVICE 004010X098 837 2400 SV1

IMPLEMENTATION

PROFESSIONAL SERVICE
Loop: 2400 SERVICE LINE Usage: REQUIRED Repeat: 1

7 102
STANDARD

Example: SV1VHC:99211:25V12.25VUNV1V11VV1:2:3VVN~

SV1 Professional Service

Level: Detail Position: 370 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To specify the claim service detail for a Health Care professional Syntax:
DIAGRAM

1. P0304 If either SV103 or SV104 is present, then the other is required.

SV101

C003

SV102

782

SV103

355

SV104

380

SV105

1331

SV106

1365

SV1 V

Comp. Med. Proced. ID

M

V
O

Monetary Amount
R 1/18

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

V
O

Facility Code
AN 1/2

Service Type Code

O ID 1/2

SV107

C004

SV108

782

SV109

1073

SV110

1340

SV111

1073

SV112

1073

V Comp. Diag. V Code Point.

O O

Monetary Amount
R 1/18

V Yes/No Cond V Resp Code

O ID 1/1

Multiple Proc Code

O ID 1/2

V Yes/No Cond V Yes/No Cond Resp Code Resp Code

O ID 1/1 O ID 1/1

SV113

1364

SV114

1341

SV115

1327

SV116

1334

SV117

127

SV118

116

V
O

Review Code
ID 1/2

Natl/Local Rev Value

O AN 1/2

Copay V Status Code

O ID 1/1

Healthcare Short Code

O ID 1/1

Reference Ident
O AN 1/30

V
O

Postal Code
ID 3/15

SV119

782

SV120

1337

SV121

1360

V
O

Monetary Amount
R 1/18

Level of Care Code

O ID 1/1

Provider Agree Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

SV101

C003

COMPOSITE MEDICAL PROCEDURE IDENTIFIER

To identify a medical procedure by its standardized codes and applicable modifiers

1801

ALIAS: Procedure

identifier
MAY 2000

400

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

REQUIRED

SV101 - 1

235

Product/Service ID Qualifier

ID

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)
INDUSTRY: Product
CODE DEFINITION

or Service ID Qualifier

HC

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMAs CPT codes are also level 1 HCPCS codes, they are reported under HC.
CODE SOURCE 130:

1297

Health Care Financing Administration Common Procedural Coding System

IV

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513:

Home Infusion EDI Coalition (HIEC) Product/Service Code List

N1 N2 N3 N4 ZZ

National Drug Code in 4-4-2 Format

CODE SOURCE 240:

National Drug Code by Format

National Drug Code in 5-3-2 Format

CODE SOURCE 240:

National Drug Code by Format

National Drug Code in 5-4-1 Format

CODE SOURCE 240:

National Drug Code by Format

National Drug Code in 5-4-2 Format

CODE SOURCE 240:

National Drug Code by Format

Mutually Defined Jurisdictionally Defined Procedure and Supply Codes. (Used for Workers Compensation claims). Contact your local (State) Jurisdiction for a list of these codes.

1843

REQUIRED

SV101 - 2

234

Product/Service ID
Identifying number for a product or service
INDUSTRY: Procedure

AN

1/48

Code

2257 2257
SITUATIONAL SV101 - 3 1339

NSF Reference: FA0-09.0, FB0-15.0, GU0-07.0 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 1

2258 2258 1091 2578

NSF Reference: FA0-10.0, GU0-08.0 Use this modifier for the first procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code.

MAY 2000

401

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

SV101 - 4

1339

Procedure Modifier

AN

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 2

1574 1574 1092 2578

SITUATIONAL SV101 - 5 1339

NSF Reference: FA0-11.0 Use this modifier for the second procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 3

1575 1575 1093 2578

SITUATIONAL SV101 - 6 1339

NSF Reference: FA0-12.0 Use this modifier for the third procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 4

1576 1576 1094 2578

NOT USED REQUIRED SV101 - 7 SV102 782 352

NSF Reference: FA0-36.0 Use this modifier for the fourth procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Description O O AN R 1/80 1/18

Monetary Amount
Monetary amount
INDUSTRY: Line

Item Charge Amount charge amount

ALIAS: Submitted
SEMANTIC:

SV102 is the submitted charge amount.

1577 1577 1844

NSF Reference: FA0-13.0 For encounter transmissions, zero (0) may be a valid amount.

402

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

REQUIRED

SV103

355

Unit or Basis for Measurement Code

ID

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0304

2480 2480 2579

NSF Reference: FA0-50.0 FA0-50.0 is only used in Medicare COB payer-to-payer situations.
CODE DEFINITION

F2

International Unit International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

2708

MJ UN REQUIRED SV104 380 Quantity

Minutes Unit X R 1/15

Numeric value of quantity

INDUSTRY: Service ALIAS: Units
SYNTAX:

Unit Count

or Minutes

P0304

1000087 1000087 1061

NSF Reference: FA0-18.0, FA0-19.0, FB0-16.0 Note: If a decimal is needed to report units, include it in this element, e.g., 15.6".

MAY 2000

403

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

SV105

1331

Facility Code Value

AN

1/2

Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format
INDUSTRY: Place ALIAS: Place
SEMANTIC:

of Service Code

of Service Code

SV105 is the place of service.

2283 2283 1097 2581

NSF Reference: FA0-07.0, GU0-05.0 Required if value is different than value carried in CLM05-1 in Loop ID-2300. Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here. 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance - Land 42 Ambulance - Air or Water 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation 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 Laboratory 99 Other Unlisted Facility SV106 1365 Service Type Code O ID 1/2

NOT USED

404

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

SITUATIONAL

SV107

C004

COMPOSITE DIAGNOSIS CODE POINTER

To identify one or more diagnosis code pointers
ALIAS: Diagnosis

1276 1937
REQUIRED SV107 - 1

Code Pointer

Required if HI segment in Loop ID-2300 is used. 1328 Diagnosis Code Pointer M N0 1/2
A pointer to the claim diagnosis code in the order of importance to this service

1580 1580 1087

NSF Reference: FA0-14.0 Use this pointer for the first diagnosis code pointer (primary diagnosis for this service line). Use remaining diagnosis pointers in declining level of importance to service line. Acceptable values are 1 through 8, inclusive. SV107 - 2 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the claim diagnosis code in the order of importance to this service

SITUATIONAL

1581 1581 1088 2582

SITUATIONAL

NSF Reference: FA0-15.0 Use this pointer for the second diagnosis code pointer. Required if the service relates to that specific diagnosis and is needed to substantiate the medical treatment. Acceptable values are 1 through 8, inclusive. SV107 - 3 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the claim diagnosis code in the order of importance to this service

1582 1582 1089 2582

SITUATIONAL

NSF Reference: FA0-16.0 Use this pointer for the third diagnosis code pointer. Required if the service relates to that specific diagnosis and is needed to substantiate the medical treatment. Acceptable values are 1 through 8, inclusive. SV107 - 4 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the claim diagnosis code in the order of importance to this service

1583 1583 1090 2582

NOT USED

NSF Reference: FA0-17.0 Use this pointer for the fourth diagnosis code pointer. Required if the service relates to that specific diagnosis and is needed to substantiate the medical treatment. Acceptable values are 1 through 8, inclusive. SV108 782 Monetary Amount O R 1/18

MAY 2000

405

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

SV109

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Emergency
SEMANTIC:

ID

1/1

Indicator

SV109 is the emergency-related indicator; a Y value indicates service provided was emergency related; an N value indicates service provided was not emergency related.

1584 1584

NSF Reference: FA0-20.0

CODE DEFINITION

N Y NOT USED SITUATIONAL SV110 SV111 1340 1073

No Yes O O ID ID 1/2 1/1

Multiple Procedure Code Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: EPSDT

Indicator

SEMANTIC: SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a Y value indicates EPSDT involvement; an N value indicates no EPSDT involvement.

1585 1585 2583

NSF Reference: FB0-22.0 Required if Medicaid services are the result of a screening referral.
CODE DEFINITION

Y SITUATIONAL SV112 1073

Yes O ID 1/1

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Family
SEMANTIC:

Planning Indicator

SV112 is the family planning involvement indicator. A Y value indicates family planning services involvement; an N value indicates no family planning services involvement.

1294 1294 2584

NSF Reference: FB0-23.0 Required if applicable for Medicaid claims.

CODE DEFINITION

Y NOT USED NOT USED SV113 SV114 1364 1341 Review Code

Yes O O ID AN 1/2 1/2

National or Local Assigned Review Value

406

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 SV1 PROFESSIONAL SERVICE

SITUATIONAL

SV115

1327

Copay Status Code

ID

1/1

Code indicating whether or not co-payment requirements were met on a line by line basis
INDUSTRY: Co-Pay ALIAS: Co-Pay

Status Code

Waiver

2045 2045 2055

NSF Reference: FB0-21.0 Required if patient was exempt from co-pay.

CODE DEFINITION

0 NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED SV116 SV117 SV118 SV119 SV120 SV121 1334 127 116 782 1337 1360

Copay exempt O O O O O O ID AN ID R ID ID 1/1 1/30 3/15 1/18 1/1 1/1

Health Care Professional Shortage Area Code Reference Identification Postal Code Monetary Amount Level of Care Code Provider Agreement Code

MAY 2000

407

004010X098 837 2400 SV4 PRESCRIPTION NUMBER

DRUG SERVICE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SV4

PRESCRIPTION NUMBER 004010X098 837 2400 SV4

IMPLEMENTATION

PRESCRIPTION NUMBER
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

7 258 8 258

Notes:

1. Required if dispense of the drug has been done with an assigned Rx number. 2. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.

6 258
STANDARD

Example: SV4V4466777TJ~

SV4 Drug Service

Level: Detail Position: 385 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To specify the claim service detail for prescription drugs
DIAGRAM

SV401

127

SV402

C003

SV403

127

SV404

1073

SV405

1329

SV406

1338

SV4 V

Reference Ident
M AN 1/30

Comp. Med. Proced. ID

O

Reference Ident
O AN 1/30

V Yes/No Cond V Resp Code

O ID 1/1 O

DAW Code
ID 1/1

Level of Serv Code

O ID 1/3

SV407

1356

SV408

352

SV409

1073

SV410

1073

SV411

1370

SV412

1319

Prescript V V Origin Code

O ID 1/1

Description
O AN 1/80

V Yes/No Cond V Yes/No Cond V Resp Code Resp Code

O ID 1/1 O ID 1/1 O

Unit Dose Code

ID 1/1

V Basis Cost Determ Code

O ID 1/2

SV413

1320

SV414

1330

SV415

1327

SV416

1384

SV417

1337

SV418

1357

Copay V Basis Days V Dosage Form V V Supply Code Code Status Code
O ID 1/1 O ID 2/2 O ID 1/1

Patient Loc Code

O ID 1/1

Level of Care Code

O ID 1/1

Prior Auth Type Code

O ID 1/1

408

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 SV4 PRESCRIPTION NUMBER

USAGE

NAME

ATTRIBUTES

REQUIRED

SV401

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Prescription
SEMANTIC:

Number

SV401 is a prescription number.

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

SV402 SV403 SV404 SV405 SV406 SV407 SV408 SV409 SV410 SV411 SV412 SV413 SV414 SV415 SV416 SV417 SV418

C003 127 1073 1329 1338 1356 352 1073 1073 1370 1319 1320 1330 1327 1384 1337 1357

COMPOSITE MEDICAL PROCEDURE IDENTIFIER Reference Identification Yes/No Condition or Response Code Dispense as Written Code Level of Service Code Prescription Origin Code Description Yes/No Condition or Response Code Yes/No Condition or Response Code Unit Dose Code Basis of Cost Determination Code Basis of Days Supply Determination Code Dosage Form Code Copay Status Code Patient Location Code Level of Care Code Prior Authorization Type Code

O O O O O O O O O O O O O O O O O AN ID ID ID ID AN ID ID ID ID ID ID ID ID ID ID 1/30 1/1 1/1 1/3 1/1 1/80 1/1 1/1 1/1 1/2 1/1 2/2 1/1 1/1 1/1 1/1

MAY 2000

409

004010X098 837 2400 PWK DMERC CMN INDICATOR

PAPERWORK

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PWK

DMERC CMN 837 2400 004010X098 INDICATOR PWK

IMPLEMENTATION

DMERC CMN INDICATOR

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

9 205 8 205
STANDARD

Notes:

1. Required on Medicare claims when DMERC CMN is included in this claim.

Example: PWKVCTVAB~

PWK Paperwork
Level: Detail Position: 420 Loop: 2400 Requirement: Optional Max Use: 10 Purpose: To identify the type or transmission or both of paperwork or supporting information Syntax:
DIAGRAM

1. P0506 If either PWK05 or PWK06 is present, then the other is required.

PWK01

755

PWK02

756

PWK03

757

PWK04

98

PWK05

66

PWK06

67

PWK

Report Report V Report Type V V V Copies Need Code Transm Code

M ID 2/2 O ID 1/2 O N0 1/2 O

Entity ID Code
ID 2/3

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

PWK07

352

PWK08

C002

PWK09

1525

Description
O AN 1/80

V
O

Actions Indicated

Request Categ Code

O ID 1/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PWK01

755

Report Type Code

INDUSTRY: Attachment ALIAS: DMERC
CODE

ID

2/2

Code indicating the title or contents of a document, report or supporting item

Report Type Code

Report Type Code

DEFINITION

CT

Certification

410

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 PWK DMERC CMN INDICATOR

REQUIRED

PWK02

756

Report Transmission Code

ID

1/2

Code defining timing, transmission method or format by which reports are to be sent
INDUSTRY: Attachment

Transmission Code

1499 1499

NSF Reference: EA0-40.0

CODE DEFINITION

AB AD AF AG NS

Previously Submitted to Payer Certification Included in this Claim Narrative Segment Included in this Claim No Documentation is Required Not Specified NS = Paperwork is available on request at the providers site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

1824

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

PWK03 PWK04 PWK05 PWK06 PWK07 PWK08 PWK09

757 98 66 67 352 C002 1525

Report Copies Needed Entity Identifier Code Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code

O O X X O O O

N0 ID ID AN AN

1/2 2/3 1/2 2/80 1/80

ID

1/2

MAY 2000

411

004010X098 837 2400 CR1 AMBULANCE TRANSPORT INFORMATION

AMBULANCE CERTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CR1

AMBULANCE 837 2400 INFORMATION 004010X098 TRANSPORTCR1

IMPLEMENTATION

AMBULANCE TRANSPORT INFORMATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

1 206 4 101
STANDARD

Notes:

1. Required on all ambulance claims if the information is different than in the CR1 at the claim level (Loop ID-2300).

Example: CR1VLBV140VIVAVDHV12VVVVUNCONSCIOUS~

CR1 Ambulance Certification

Level: Detail Position: 425 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To supply information related to the ambulance service rendered to a patient Set Notes: 1. The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level. 1. P0102 If either CR101 or CR102 is present, then the other is required. 2. P0506 If either CR105 or CR106 is present, then the other is required.
DIAGRAM

Syntax:

CR101

355

CR102

81

CR103

1316

CR104

1317

CR105

355

CR106

380

CR1 V
V

Unit/Basis Meas Code

X ID 2/2

V
X

Weight
R 1/10

Ambulance Trans Code

O ID 1/1

V Ambulance V Reason Code

O ID 1/1

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

CR107

166

CR108

166

CR109

352

CR110

352

Address Information
O AN 1/55

Address Information
O AN 1/55

Description
O AN 1/80

Description
O AN 1/80

412

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 CR1 AMBULANCE TRANSPORT INFORMATION

USAGE

NAME

ATTRIBUTES

SITUATIONAL

CR101

355

Unit or Basis for Measurement Code

ID

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0102

2589

Required if CR102 is present.

CODE DEFINITION

LB SITUATIONAL CR102 81 Weight

Pound X R 1/10

Numeric value of weight

INDUSTRY: Patient
SYNTAX:

Weight

P0102 CR102 is the weight of the patient at time of transport.

SEMANTIC:

1588 1588 2590

REQUIRED CR103 1316

NSF Reference: GA0-05.0 Required if it is necessary to justify the medical necessity of the level of ambulance services. Ambulance Transport Code
Code indicating the type of ambulance transport
ALIAS: Ambulance

ID

1/1

transport code

1589 1589

NSF Reference: GA0-07.0

CODE DEFINITION

I R T X REQUIRED CR104 1317

Initial Trip Return Trip Transfer Trip Round Trip O ID 1/1

Ambulance Transport Reason Code

Code indicating the reason for ambulance transport
ALIAS: Ambulance

Transport Reason Code

1590 1590

NSF Reference: GA0-15.0

CODE DEFINITION

Patient was transported to nearest facility for care of symptoms, complaints, or both Patient was transported for the benefit of a preferred physician Patient was transported for the nearness of family members

MAY 2000

413

004010X098 837 2400 CR1 AMBULANCE TRANSPORT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Patient was transported for the care of a specialist or for availability of specialized equipment Patient Transferred to Rehabilitation Facility X ID 2/2

E REQUIRED CR105 355

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0506
DEFINITION

CODE

DH REQUIRED CR106 380 Quantity

Miles X R 1/15

Numeric value of quantity

INDUSTRY: Transport
SYNTAX:

Distance

P0506 CR106 is the distance traveled during transport.

SEMANTIC:

2480 2480 2481

NOT USED NOT USED SITUATIONAL CR107 CR108 CR109 166 166 352

NSF Reference: GA0-17.0, FA0-50.0 NSF crosswalk to FA0-50.0 is used only in Medicare payer-to-payer COB situations. Address Information Address Information Description
INDUSTRY: Round ALIAS: Transport

O O O

AN AN AN

1/55 1/55 1/80

A free-form description to clarify the related data elements and their content

Trip Purpose Description purpose description

SEMANTIC: CR109 is the purpose for the round trip ambulance service.

1592 1592 2221

SITUATIONAL CR110 352

NSF Reference: GA0-20.0 Required if CR103 (Ambulance Transport Code) = X - Round Trip; otherwise not used. Description
INDUSTRY: Stretcher
SEMANTIC:

AN

1/80

A free-form description to clarify the related data elements and their content

Purpose Description

CR110 is the purpose for the usage of a stretcher during ambulance

service.

1593 1593 2222

NSF Reference: GA0-21.0 Required if needed to justify usage of stretcher.

414

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CHIROPRACTIC CERTIFICATION

004010X098 837 2400 CR2 SPINAL MANIPULATION SERVICE INFORMATION

CR2

SPINAL MANIPULATION CR2 004010X098 837 2400SERVICE INFORMATION

IMPLEMENTATION

SPINAL MANIPULATION SERVICE INFORMATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 5

3 222

Notes:

1. Required on all claims involving spinal manipulation if information is different from Loop-ID 2300 CR2 information. Such claims could originate with chiropractors, physical therapists, DOs, and many other types of health care providers.

6 101
STANDARD

Example: CR2V3V5VC4VC6VMOV2V2VMVYVVVY~

CR2 Chiropractic Certification

Level: Detail Position: 430 Loop: 2400 Requirement: Optional Max Use: 5 Purpose: To supply information related to the chiropractic service rendered to a patient Syntax: 1. P0102 If either CR201 or CR202 is present, then the other is required. 2. C0403 If CR204 is present, then CR203 is required. 3. P0506 If either CR205 or CR206 is present, then the other is required.
DIAGRAM

CR201

609

CR202

380

CR203

1367

CR204

1367

CR205

355

CR206

380

CR2 V
X

Count
N0 1/9

V
X

Quantity
R 1/15

V Subluxation V Subluxation V Level Code Level Code

X ID 2/3 O ID 2/3

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

CR207

380

CR208

1342

CR209

1073

CR210

352

CR211

352

CR212

1073

V
O

Quantity
R 1/15

Nature of Cond Code

O ID 1/1

V Yes/No Cond V Resp Code

O ID 1/1

Description
O AN 1/80

Description
O AN 1/80

V Yes/No Cond ~ Resp Code

O ID 1/1

MAY 2000

415

004010X098 837 2400 CR2 SPINAL MANIPULATION SERVICE INFORMATION ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

CR201

609

Count
Occurence counter
INDUSTRY: Treatment ALIAS: Treatment
SYNTAX:

N0

1/9

Series Number

Number. Spinal Manipulation

P0102 CR201 is the number this treatment is in the series.

SEMANTIC:

1594 1594
REQUIRED CR202 380

NSF Reference: GC0-07.0 Quantity

Numeric value of quantity
INDUSTRY: Treatment ALIAS: Treatment
SYNTAX:

1/15

Count

Series Total. Spinal Manipulation

P0102 CR202 is the total number of treatments in the series.

SEMANTIC:

1594 1594
SITUATIONAL CR203 1367

NSF Reference: GC0-07.0 Subluxation Level Code

Code identifying the specific level of subluxation
ALIAS: Subluxation
SYNTAX:

ID

2/3

Level Code

C0403

COMMENT: When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.

1595 1595 2263

NSF Reference: GC0-08.0 Required if subluxation is involved in claim.

CODE DEFINITION

C1 C2 C3 C4 C5 C6 C7 CO IL L1

Cervical 1 Cervical 2 Cervical 3 Cervical 4 Cervical 5 Cervical 6 Cervical 7 Coccyx Ilium Lumbar 1

416

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 CR2 SPINAL MANIPULATION SERVICE INFORMATION

L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9 SITUATIONAL CR204 1367

Lumbar 2 Lumbar 3 Lumbar 4 Lumbar 5 Occiput Sacrum Thoracic 1 Thoracic 10 Thoracic 11 Thoracic 12 Thoracic 2 Thoracic 3 Thoracic 4 Thoracic 5 Thoracic 6 Thoracic 7 Thoracic 8 Thoracic 9 O ID 2/3

Subluxation Level Code

Code identifying the specific level of subluxation
ALIAS: Subluxation
SYNTAX:

Level Code

C0403

1596 1596 2224

NSF Reference: GC0-08.0 Required if additional subluxation is involved in claim to indicate a range (i.e., subluxation from CR203 to CR204).
CODE DEFINITION

C1 C2 C3 C4 C5 C6 C7

Cervical 1 Cervical 2 Cervical 3 Cervical 4 Cervical 5 Cervical 6 Cervical 7

MAY 2000

417

004010X098 837 2400 CR2 SPINAL MANIPULATION SERVICE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CO IL L1 L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9 REQUIRED CR205 355

Coccyx Ilium Lumbar 1 Lumbar 2 Lumbar 3 Lumbar 4 Lumbar 5 Occiput Sacrum Thoracic 1 Thoracic 10 Thoracic 11 Thoracic 12 Thoracic 2 Thoracic 3 Thoracic 4 Thoracic 5 Thoracic 6 Thoracic 7 Thoracic 8 Thoracic 9 X ID 2/2

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0506
DEFINITION

CODE

DA MO WK YR

Days Months Week Years

418

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 CR2 SPINAL MANIPULATION SERVICE INFORMATION

REQUIRED

CR206

380

Quantity
Numeric value of quantity
INDUSTRY: Treatment ALIAS: Treatment
SYNTAX:

1/15

Period Count

Series Period. Spinal Manipulation

P0506 CR206 is the time period involved in the treatment series.

SEMANTIC:

1597 1597
REQUIRED CR207 380

NSF Reference: GC0-09.0 Quantity

Numeric value of quantity
INDUSTRY: Monthly ALIAS: Treatment
SEMANTIC:

1/15

Treatment Count

Number in Month. Spinal Manipulation

CR207 is the number of treatments rendered in the month of service.

1598 1598
REQUIRED CR208 1342

NSF Reference: GC0-10.0 Nature of Condition Code

Code indicating the nature of a patients condition
INDUSTRY: Patient ALIAS: Nature

ID

1/1

Condition Code

of Condition Code. Spinal Manipulation

1599 1599

NSF Reference: GC0-11.0

CODE DEFINITION

A C D E F G M REQUIRED CR209 1073

Acute Condition Chronic Condition Non-acute Non-Life Threatening Routine Symptomatic Acute Manifestation of a Chronic Condition O ID 1/1

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Complication ALIAS: Complication
SEMANTIC:

Indicator

Indicator. Spinal Manipulation

CR209 is complication indicator. A Y value indicates a complicated condition; an N value indicates an uncomplicated condition.

1600 1600

NSF Reference: GC0-13.0

CODE DEFINITION

No

MAY 2000

419

004010X098 837 2400 CR2 SPINAL MANIPULATION SERVICE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Y SITUATIONAL CR210 352 Description

INDUSTRY: Patient ALIAS: Patient
SEMANTIC:

Yes O AN 1/80

A free-form description to clarify the related data elements and their content

Condition Description

Condition Description, Chiropractic

CR210 is a description of the patients condition.

1601 1601 2225

SITUATIONAL CR211 352

NSF Reference: GC0-14.0 Used at discretion of submitter. Description

INDUSTRY: Patient ALIAS: Patient
SEMANTIC:

AN

1/80

A free-form description to clarify the related data elements and their content

Condition Description

Condition Description, Chiropractic

CR211 is an additional description of the patients condition.

1602 1602 2225

REQUIRED CR212 1073

NSF Reference: GC0-14.0 Used at discretion of submitter. Yes/No Condition or Response Code
Code indicating a Yes or No condition or response
INDUSTRY: X-ray ALIAS: X-ray
SEMANTIC:

ID

1/1

Availability Indicator

Availability Indicator, Chiropractic

CR212 is X-rays availability indicator. A Y value indicates X-rays are maintained and available for carrier review; an N value indicates X-rays are not maintained and available for carrier review.

1692 1692

NSF Reference: GC0-15.0

CODE DEFINITION

N Y

No Yes

420

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DURABLE MEDICAL EQUIPMENT CERTIFICATION

004010X098 837 2400 CR3 DURABLE MEDICAL EQUIPMENT CERTIFICATION

CR3

004010X098 837 2400 CR3 CERTIFICATION DURABLE MEDICAL EQUIPMENT

IMPLEMENTATION

DURABLE MEDICAL EQUIPMENT CERTIFICATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 227

Notes:

1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician.

5 226
STANDARD

Example: CR3VIVMOV6~

CR3 Durable Medical Equipment Certification

Level: Detail Position: 435 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To supply information regarding a physicians certification for durable medical equipment Syntax:
DIAGRAM

1. P0203 If either CR302 or CR303 is present, then the other is required.

CR301

1322

CR302

355

CR303

380

CR304

1335

CR305

352

CR3 V

Certificate Type Code

O ID 1/1

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

Insulin V V Depend Code

O ID 1/1

Description
O AN 1/80

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CR301

1322

Certification Type Code

Code indicating the type of certification

ID

1/1

2268 2268

NSF Reference: GU0-04.0

CODE DEFINITION

I R S

Initial Renewal Revised

MAY 2000

421

004010X098 837 2400 CR3 DURABLE MEDICAL EQUIPMENT CERTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

CR302

355

Unit or Basis for Measurement Code

ID

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P0203 CR302 and CR303 specify the time period covered by this certification.
DEFINITION

SEMANTIC:

CODE

MO REQUIRED CR303 380 Quantity

Months X R 1/15

Numeric value of quantity

INDUSTRY: Durable ALIAS: DME
SYNTAX:

Medical Equipment Duration

Duration

P0203

2269 2269 2267

NOT USED NOT USED CR304 CR305 1335 352

NSF Reference: GU0-21.0 Length of time DME equipment is needed. Insulin Dependent Code Description O O ID AN 1/1 1/80

422

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

OXYGEN THERAPY CERTIFICATION

004010X098 837 2400 CR5 HOME OXYGEN THERAPY INFORMATION

CR5

HOME OXYGEN THERAPY INFORMATION 004010X098 837 2400 CR5

IMPLEMENTATION

HOME OXYGEN THERAPY INFORMATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

2 206 8 101
STANDARD

Notes:

1. Required on all initial, renewal, and revision home oxygen therapy claims.

Example: CR5VIV6VVVVVVVV56VVRV1~

CR5 Oxygen Therapy Certification

Level: Detail Position: 445 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To supply information regarding certification of medical necessity for home oxygen therapy
DIAGRAM

CR501

1322

CR502

380

CR503

1348

CR504

1348

CR505

352

CR506

380

CR5 V
V

Certificate Type Code

O ID 1/1

V
O

Quantity
R 1/15

Oxygen Equip Code

O ID 1/1

Oxygen Equip Code

O ID 1/1

Description
O AN 1/80

V
O

Quantity
R 1/15

CR507

380

CR508

380

CR509

352

CR510

380

CR511

380

CR512

1349

Quantity
O R 1/15

V
O

Quantity
R 1/15

V Description V
O AN 1/80 O

Quantity
R 1/15

V
O

Quantity
R 1/15

V Oxygen Test
Cond Code
ID O 1/1

CR513

1350

CR514

1350

CR515

1350

CR516

380

CR517

1382

CR518

1348

V Oxygen Test V Oxygen Test V Oxygen Test V Find Code Find Code Find Code
O ID 1/1 O ID 1/1 O ID 1/1 O

Quantity
R 1/15

Oxygen Del Sys Code

O ID 1/1

Oxygen Equip Code

O ID 1/1

MAY 2000

423

004010X098 837 2400 CR5 HOME OXYGEN THERAPY INFORMATION ELEMENT SUMMARY
REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

CR501

1322

Certification Type Code

Code indicating the type of certification
ALIAS: Certification

ID

1/1

Type Code. Oxygen Therapy

1518 1518

NSF Reference: GX0-04.0

CODE DEFINITION

I R S REQUIRED CR502 380 Quantity

Initial Renewal Revised O R 1/15

Numeric value of quantity

INDUSTRY: Treatment ALIAS: Certification
SEMANTIC:

Period Count

Period, Home Oxygen Therapy

CR502 is the number of months covered by this certification.

1275 1275
NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL CR503 CR504 CR505 CR506 CR507 CR508 CR509 CR510 1348 1348 352 380 380 380 352 380

NSF Reference: GX0-06.0 Oxygen Equipment Type Code Oxygen Equipment Type Code Description Quantity Quantity Quantity Description Quantity
Numeric value of quantity
INDUSTRY: Arterial ALIAS: Arterial
SEMANTIC:

O O O O O O O O

ID ID AN R R R AN R

1/1 1/1 1/80 1/15 1/15 1/15 1/80 1/15

Blood Gas Quantity

Blood Gas

CR510 is the arterial blood gas.

1519 1519 2037 2591

NSF Reference: GX0-22.0 Either CR510 or CR511 is required. Required on claims which report arterial blood gas.

424

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 CR5 HOME OXYGEN THERAPY INFORMATION

SITUATIONAL

CR511

380

Quantity
Numeric value of quantity
INDUSTRY: Oxygen ALIAS: Oxygen
SEMANTIC:

1/15

Saturation Quantity

Saturation

CR511 is the oxygen saturation.

1520 1520 2037 2592

REQUIRED CR512 1349

NSF Reference: GX0-23.0 Either CR510 or CR511 is required. Required on claims which report oxygen saturation quantity. Oxygen Test Condition Code
ALIAS: Oxygen

ID

1/1

Code indicating the conditions under which a patient was tested

test condition code

1521 1521

NSF Reference: GX0-26.0

CODE DEFINITION

E R S SITUATIONAL CR513 1350

Exercising At rest on room air Sleeping O ID 1/1

Oxygen Test Findings Code

ALIAS: Oxygen

Code indicating the findings of oxygen tests performed on a patient

test finding code

1522 1522 1124

NSF Reference: GX0-27.0 Required if patients arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CODE DEFINITION

1 SITUATIONAL

Dependent edema suggesting congestive heart failure O ID 1/1

CR514

1350

Oxygen Test Findings Code

ALIAS: Oxygen

Code indicating the findings of oxygen tests performed on a patient

test finding code

1522 1522 1124

NSF Reference: GX0-27.0 Required if patients arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CODE DEFINITION

P Pulmonale on Electrocardiogram (EKG)

MAY 2000

425

004010X098 837 2400 CR5 HOME OXYGEN THERAPY INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CR515

1350

Oxygen Test Findings Code

ALIAS: Oxygen

ID

1/1

Code indicating the findings of oxygen tests performed on a patient

test finding code

1522 1522 1124

NSF Reference: GX0-27.0 Required if patients arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CODE DEFINITION

3 NOT USED NOT USED NOT USED

Erythrocythemia with a hematocrit greater than 56 percent O O O R ID ID 1/15 1/1 1/1

CR516 CR517 CR518

380 1382 1348

Quantity Oxygen Delivery System Code Oxygen Equipment Type Code

426

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONDITIONS INDICATOR

004010X098 837 2400 CRC AMBULANCE CERTIFICATION

CRC

AMBULANCE 837 2400 CRC 004010X098 CERTIFICATION

IMPLEMENTATION

AMBULANCE CERTIFICATION
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 3

3 206

Notes:

1. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed. 2. Required on all service lines which bill/report ambulance services if the information is different when CRC01=07 in Loop ID-2300.

4 206 6 208
STANDARD

Example: CRCV07VYV08~

CRC Conditions Indicator

Level: Detail Position: 450 Loop: 2400 Requirement: Optional Max Use: 3 Purpose: To supply information on conditions
DIAGRAM

CRC01

1136

CRC02

1073

CRC03

1321

CRC04

1321

CRC05

1321

CRC06

1321

CRC V
M

Code Category
ID 2/2

V Yes/No Cond V Resp Code

M ID 1/1

Certificate Cond Code

M ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

CRC07

1321

Certificate Cond Code

O ID 2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CRC01

1136

Code Category
Specifies the situation or category to which the code applies
SEMANTIC:

ID

2/2

CRC01 qualifies CRC03 through CRC07.

DEFINITION

CODE

07

Ambulance Certification

MAY 2000

427

004010X098 837 2400 CRC AMBULANCE CERTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

CRC02

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Certification ALIAS: Certification
SEMANTIC:

ID

1/1

Condition Indicator

Condition Code, Ambulance Certification

CRC02 is a Certification Condition Code applies indicator. A Y value indicates the condition codes in CRC03 through CRC07 apply; an N value indicates the condition codes in CRC03 through CRC07 do not apply.
CODE DEFINITION

N Y REQUIRED CRC03 1321

No Yes M ID 2/2

Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

Code

Indicator

1029

The codes for CRC03 also can be used for CRC04 through CRC07.
CODE DEFINITION

01

Patient was admitted to a hospital

NSF Reference:

1524 1524
02

GA0-06.0 Patient was bed confined before the ambulance service

NSF Reference:

1525 1525
03

GA0-08.0 Patient was bed confined after the ambulance service

NSF Reference:

1526 1526
04

GA0-09.0 Patient was moved by stretcher

NSF Reference:

1527 1527
05

GA0-10.0 Patient was unconscious or in shock

NSF Reference:

1528 1528
06

GA0-11.0 Patient was transported in an emergency situation

NSF Reference:

1529 1529
07

GA0-12.0 Patient had to be physically restrained

NSF Reference:

1530 1530
08

GA0-13.0 Patient had visible hemorrhaging

NSF Reference:

1531 1531

GA0-14.0

428

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 CRC AMBULANCE CERTIFICATION

09

Ambulance service was medically necessary

NSF Reference:

1532 1532
60

GA0-16.0 Transportation Was To the Nearest Facility

NSF Reference:

1768 1768
SITUATIONAL CRC04 1321

GA0-24.0 Condition Indicator

Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850
SITUATIONAL CRC05 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850
SITUATIONAL CRC06 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850
SITUATIONAL CRC07 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
INDUSTRY: Condition ALIAS: Condition

ID

2/2

Code

Indicator

1782 1850

Required if additional condition codes are needed. Use the codes listed in CRC03.

MAY 2000

429

004010X098 837 2400 CRC HOSPICE EMPLOYEE INDICATOR

CONDITIONS INDICATOR

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CRC

HOSPICE EMPLOYEE INDICATOR 004010X098 837 2400 CRC

IMPLEMENTATION

HOSPICE EMPLOYEE INDICATOR

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

9 131 3 206

Notes:

1. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. 2. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed. 3. Required on all Medicare claims involving physician services to hospice patients.

3 259 8 131
STANDARD

Example: CRCV70VYV65~

CRC Conditions Indicator

Level: Detail Position: 450 Loop: 2400 Requirement: Optional Max Use: 3 Purpose: To supply information on conditions
DIAGRAM

CRC01

1136

CRC02

1073

CRC03

1321

CRC04

1321

CRC05

1321

CRC06

1321

CRC V
M

Code Category
ID 2/2

V Yes/No Cond V Resp Code

M ID 1/1

Certificate Cond Code

M ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

CRC07

1321

Certificate Cond Code

O ID 2/2

430

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 CRC HOSPICE EMPLOYEE INDICATOR

USAGE

NAME

ATTRIBUTES

REQUIRED

CRC01

1136

Code Category
Specifies the situation or category to which the code applies
SEMANTIC:

ID

2/2

CRC01 qualifies CRC03 through CRC07.

DEFINITION

CODE

70 REQUIRED CRC02 1073

Hospice M ID 1/1

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Hospice ALIAS: Hospice
SEMANTIC:

Employed Provider Indicator

Employee Indicator

CRC02 is a Certification Condition Code applies indicator. A Y value indicates the condition codes in CRC03 through CRC07 apply; an N value indicates the condition codes in CRC03 through CRC07 do not apply.

1802 1802 1320

NSF Reference: FA0-40.0 A Y value indicates the provider is employed by the hospice. A N value indicates the provider is not employed by the hospice.
CODE DEFINITION

N Y REQUIRED CRC03 1321

No Yes M ID 2/2

Condition Indicator
Code indicating a condition
CODE DEFINITION

65

Open Use this code as a place holder (element is mandatory) when reporting whether the provider is a hospice employee.

1695
NOT USED NOT USED NOT USED NOT USED

CRC04 CRC05 CRC06 CRC07

1321 1321 1321 1321

Condition Indicator Condition Indicator Condition Indicator Condition Indicator

O O O O

ID ID ID ID

2/2 2/2 2/2 2/2

MAY 2000

431

004010X098 837 2400 CRC DMERC CONDITION INDICATOR

CONDITIONS INDICATOR

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CRC

DMERC CONDITION INDICATOR 004010X098 837 2400 CRC

IMPLEMENTATION

DMERC CONDITION INDICATOR

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 2

2 174 3 206

Notes:

1. Required on all oxygen therapy and DME claims that require a certificate of medical necessity (CMN). 2. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed. 3. The first example shows a case where an item billed was not a replacement item.

3 278 0 198 9 225

STANDARD

Example: CRCV09VNVZV~ Example: CRCV11VYV37V38VP1~

CRC Conditions Indicator

Level: Detail Position: 450 Loop: 2400 Requirement: Optional Max Use: 3 Purpose: To supply information on conditions
DIAGRAM

CRC01

1136

CRC02

1073

CRC03

1321

CRC04

1321

CRC05

1321

CRC06

1321

CRC V
M

Code Category
ID 2/2

V Yes/No Cond V Resp Code

M ID 1/1

Certificate Cond Code

M ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

Certificate Cond Code

O ID 2/2

CRC07

1321

Certificate Cond Code

O ID 2/2

432

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 CRC DMERC CONDITION INDICATOR

USAGE

NAME

ATTRIBUTES

REQUIRED

CRC01

1136

Code Category
Specifies the situation or category to which the code applies
SEMANTIC:

ID

2/2

CRC01 qualifies CRC03 through CRC07.

DEFINITION

CODE

09 11 REQUIRED CRC02 1073

Durable Medical Equipment Certification Oxygen Therapy Certification M ID 1/1

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Certification ALIAS: Certification
SEMANTIC:

Condition Indicator

Condition Code Applies Indicator

CRC02 is a Certification Condition Code applies indicator. A Y value indicates the condition codes in CRC03 through CRC07 apply; an N value indicates the condition codes in CRC03 through CRC07 do not apply.
CODE DEFINITION

N Y REQUIRED CRC03 1321

No Yes M ID 2/2

Condition Indicator
Code indicating a condition
ALIAS: Condition

Indicator

2194

Use P1" (GX0-20.0) to answer the Medicare Oxygen CMN question: The test was performed either with the patient in a chronic stable state as an outpatient or within two days prior to discharge from an inpatient facility to home." Code ZV was approved by ASC X12 in the version 004011 Data Dictionary but is included in this guide to provide standard way to report DMERC claims within the HIPAA implementation time frame. It is recommended that entities who have a need to submit or receive DMERC claims customize their 004010 translator map to allow this exception code.
CODE DEFINITION

2594

37

Oxygen delivery equipment is stationary

NSF Reference:

1732 1732
38

GX0-05.0 Certification signed by the physician is on file at the suppliers office

NSF Reference:

2745 2745
AL

GX0-35.0 GU0-24.0 Ambulation Limitations

NSF Reference:

2189 2189
MAY 2000

GX0-05.0

433

004010X098 837 2400 CRC DMERC CONDITION INDICATOR

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

P1

Patient was Discharged from the First Facility

NSF Reference:

2286 2286
ZV

GX0-20.0 Replacement Item

NSF Reference:

1135 1135
SITUATIONAL CRC04 1321

GU0-06.0 Condition Indicator

Code indicating a condition
ALIAS: Condition

ID

2/2

Indicator

1782 1850
SITUATIONAL CRC05 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
ALIAS: Condition

ID

2/2

Indicator

1782 1850
SITUATIONAL CRC06 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
ALIAS: Condition

ID

2/2

Indicator

1782 1850
SITUATIONAL CRC07 1321

Required if additional condition codes are needed. Use the codes listed in CRC03. Condition Indicator
Code indicating a condition
ALIAS: Condition

ID

2/2

Indicator

1782 1850

Required if additional condition codes are needed. Use the codes listed in CRC03.

434

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - SERVICE DATE

DTP

DATE - SERVICE 2400 004010X098 837DATE DTP

IMPLEMENTATION

DATE - SERVICE DATE

Loop: 2400 SERVICE LINE Usage: REQUIRED Repeat: 1

5 259 8 010 100

Notes:

1. The total number of DTP segments in the 2400 loop cannot exceed 15. 2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate the range of dates through which the drug will be used by the patient. Use RD8 for this purpose. 3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written).

9 010 100

1 128
STANDARD

Example: DTPV472VRD8V19970607-19970608~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

472

Service Use RD8 in DTP02 to indicate begin/end or from/to dates.

2161

MAY 2000

435

004010X098 837 2400 DTP DATE - SERVICE DATE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

SEMANTIC:

ID

2/3

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 RD8

Date Expressed in Format CCYYMMDD Range of Dates Expressed in Format CCYYMMDDCCYYMMDD Use RD8 if it is necessary to indicate begin/end dates. Date range indicates drug duration for which the supply of drug be will used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (e.g., every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.

1000110

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Service

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Date

1605 1605

NSF Reference: FA0-05.0, FA0-06.0

436

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - CERTIFICATION REVISION DATE

DTP

DATE - CERTIFICATION DTP 004010X098 837 2400REVISION DATE

IMPLEMENTATION

DATE - CERTIFICATION REVISION DATE

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 260 5 259 1 260

STANDARD

Notes:

1. Required if CR301 (DMERC Certification) = R or S. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV607VD8V19970519~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

607 REQUIRED DTP02 1250

Certification Revision M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

MAY 2000

437

004010X098 837 2400 DTP DATE - CERTIFICATION REVISION DATE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Certification

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Revision Date

2603 2603

NSF Reference: GU0-20.0, GX0-11.0

438

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - REFERRAL DATE

DTP

DATE - REFERRAL 2400 004010X098 837 DATE DTP

IMPLEMENTATION

DATE - REFERRAL DATE

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

4 260 5 259 1 245

STANDARD

Notes:

1. Required when service line includes a referral. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV330VD8V19970617~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

330 REQUIRED DTP02 1250

Referral Date M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Referral

Expression of a date, a time, or range of dates, times or dates and times

Date

MAY 2000

439

004010X098 837 2400 DTP DATE - BEGIN THERAPY DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - BEGIN THERAPY DATE 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - BEGIN THERAPY DATE

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 227

Notes:

1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

5 259 6 260
STANDARD

Example: DTPV463VD8V19970519~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

463 REQUIRED DTP02 1250

Begin Therapy M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

440

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - BEGIN THERAPY DATE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Begin

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Therapy Date

1000097 1000097

NSF Reference: GU0-19.0, GX0-10.0

MAY 2000

441

004010X098 837 2400 DTP DATE - LAST CERTIFICATION DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - LAST 837 2400 DTP 004010X098 CERTIFICATION DATE

IMPLEMENTATION

DATE - LAST CERTIFICATION DATE

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

1 275

Notes:

1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician. 2. Required on oxygen therapy certificates of medical necessity (CMN). This is the date the ordering physician signed the CMN. 3. The total number of DTP segments in the 2400 loop cannot exceed 15.

2 275 5 259 8 260

STANDARD

Example: DTPV461VD8V19970519~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

461

Last Certification

442

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - LAST CERTIFICATION DATE

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

SEMANTIC:

ID

2/3

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Last

Expression of a date, a time, or range of dates, times or dates and times

Certification Date

2609 2609

NSF Reference: GX0-11.0, GU0-22.0

MAY 2000

443

004010X098 837 2400 DTP DATE - ORDER DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ORDER DATE 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - ORDER DATE

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

1 261 5 259 8 244

STANDARD

Notes:

1. Required when service line includes an order for services or supplies. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV938VD8V19970617~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

938 REQUIRED DTP02 1250

Order M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Order

Expression of a date, a time, or range of dates, times or dates and times

Date

444

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - DATE LAST SEEN

DTP

DATE - DATE 837 2400 004010X098 LAST SEEN DTP

IMPLEMENTATION

DATE - DATE LAST SEEN

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

6 113

Notes:

1. Required when claim is from an independent physical therapist, occupational therapist, or physician providing routine footcare if the date last seen by an attending or supervising physician is different from that listed at the claim level (Loop ID-2300). 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

5 259 2 128
STANDARD

Example: DTPV304VD8V19970813~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

304 REQUIRED DTP02 1250

Latest Visit or Consultation M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

MAY 2000

445

004010X098 837 2400 DTP DATE - DATE LAST SEEN

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Last

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Seen Date

1484 1484

NSF Reference: EA0-48.0

446

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - TEST

DTP

DATE - TEST 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - TEST
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 2

6 203 5 259 2 261

STANDARD

Notes:

1. Required on initial EPO claims service lines where test results are being billed/reported. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV738VD8V19970615~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

738 739 REQUIRED DTP02 1250

Most Recent Hemoglobin or Hematocrit or Both Most Recent Serum Creatine M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

MAY 2000

447

004010X098 837 2400 DTP DATE - TEST

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Test

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Performed Date

1606 1606

NSF Reference: FA0-41.0, FA0-46.0

448

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - OXYGEN SATURATION/ARTERIAL BLOOD GAS TEST

DTP

DATE - OXYGEN SATURATION/ARTERIAL BLOOD GAS TEST 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - OXYGEN SATURATION/ARTERIAL BLOOD GAS TEST

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 3

3 128 5 259 4 128

STANDARD

Notes:

1. Required on initial oxygen therapy service line(s) involving certificate of medical necessity (CMN). 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV480VD8V19970615~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

119

Test Performed Use for any 4 liter/minute test date. Results for this test date are reported in MEA03 using either the GRA or ZO qualifiers in MEA02.

2192

480

Arterial Blood Gas Test Do not use to report any 4 liter/minute test date. Results for the arterial blood gas test are reported in CR510.

2188

MAY 2000

449

004010X098 837 2400 DTP DATE - OXYGEN SATURATION/ARTERIAL BLOOD GAS TEST

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

481

Oxygen Saturation Test Do not use to report any 4 liter/minute test date. Results for the oxygen saturation test are reported in CR511.

2183
REQUIRED

DTP02

1250

Date Time Period Format Qualifier

SEMANTIC:

ID

2/3

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Oxygen

Expression of a date, a time, or range of dates, times or dates and times

Saturation Test Date

1491 1491

NSF Reference: GX0-19.0, GX0-24.0

450

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DATE OR TIME OR PERIOD

004010X098 837 2400 DTP DATE - SHIPPED

DTP

DATE - SHIPPED 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - SHIPPED
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

7 222 5 259 5 128

STANDARD

Notes:

1. Required when billing/reporting shipped products. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV011VD8V19970526~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

011 REQUIRED DTP02 1250

Shipped M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Shipped

Expression of a date, a time, or range of dates, times or dates and times

Date

MAY 2000

451

004010X098 837 2400 DTP DATE - ONSET OF CURRENT SYMPTOM/ILLNESS

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ONSET OF CURRENT SYMPTOM/ILLNESS 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - ONSET OF CURRENT SYMPTOM/ILLNESS

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 224 3 261 5 259 6 128

STANDARD

Notes:

1. Required if different from that entered at claim level (Loop ID-2300). 2. Required on claims involving services to a patient experiencing symptoms similar or identical to previously reported symptoms. 3. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV431VD8V19971112~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

431 REQUIRED DTP02 1250

Onset of Current Symptoms or Illness M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

452

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - ONSET OF CURRENT SYMPTOM/ILLNESS

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Onset

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Date

1608 1608

NSF Reference: EA0-07.0, EA0-16.0

MAY 2000

453

004010X098 837 2400 DTP DATE - LAST X-RAY

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - LAST 837 004010X098 X-RAY 2400 DTP

IMPLEMENTATION

DATE - LAST X-RAY

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 222 5 259 7 128

STANDARD

Notes:

1. Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300). 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV455VD8V19970220~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

455 REQUIRED DTP02 1250

Last X-Ray M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

454

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - LAST X-RAY

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Last

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

X-Ray Date

1609 1609

NSF Reference: GC0-06.0

MAY 2000

455

004010X098 837 2400 DTP DATE - ACUTE MANIFESTATION

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - ACUTE MANIFESTATION 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - ACUTE MANIFESTATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 222 5 259 3 139

STANDARD

Notes:

1. Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300). 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV453VD8V19961230~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

453 REQUIRED DTP02 1250

Acute Manifestation of a Chronic Condition M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

456

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - ACUTE MANIFESTATION

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Acute

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Manifestation Date

1486 1486

NSF Reference: GC0-12.0

MAY 2000

457

004010X098 837 2400 DTP DATE - INITIAL TREATMENT

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - INITIAL TREATMENT 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - INITIAL TREATMENT

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 222 5 259 4 139

STANDARD

Notes:

1. Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300). 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTPV454VD8V19970112~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

454 REQUIRED DTP02 1250

Initial Treatment M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

458

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - INITIAL TREATMENT

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Initial

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Treatment Date

1603 1603

NSF Reference: GC0-05.0

MAY 2000

459

004010X098 837 2400 DTP DATE - SIMILAR ILLNESS/SYMPTOM ONSET

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

DATE - SIMILAR ILLNESS/SYMPTOM ONSET 004010X098 837 2400 DTP

IMPLEMENTATION

DATE - SIMILAR ILLNESS/SYMPTOM ONSET

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

9 270

Notes:

1. Required if line value is different than value given at claim level (Loop ID-2300) and claim involves services to a patient experiencing symptoms similar or identical to previously reported symptoms. 2. The total number of DTP segments in the 2400 loop cannot exceed 15.

5 259 3 125
STANDARD

Example: DTPV438VD8V19970115~

DTP Date or Time or Period

Level: Detail Position: 455 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

438 REQUIRED DTP02 1250

Onset of Similar Symptoms or Illness M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8

Date Expressed in Format CCYYMMDD

460

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 DTP DATE - SIMILAR ILLNESS/SYMPTOM ONSET

REQUIRED

DTP03

1251

Date Time Period

INDUSTRY: Similar

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times

Illness or Symptom Date

MAY 2000

461

004010X098 837 2400 QTY ANESTHESIA MODIFYING UNITS

QUANTITY

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

QTY

ANESTHESIA 837 2400 QTY 004010X098 MODIFYING UNITS

IMPLEMENTATION

ANESTHESIA MODIFYING UNITS

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 5

2 223 1 223
STANDARD

Notes:

1. Required on anesthesia service lines if one or more of the extenuating circumstances coded in QTY01 was present at the time of service.

Example: QTYVBFV4~

QTY Quantity
Level: Detail Position: 460 Loop: 2400 Requirement: Optional Max Use: 5 Purpose: To specify quantity information Syntax: 1. R0204 At least one of QTY02 or QTY04 is required. 2. E0204 Only one of QTY02 or QTY04 may be present.
DIAGRAM

QTY01

673

QTY02

380

QTY03

C001

QTY04

61

QTY V
M

Quantity Qualifier
ID 2/2

V
X

Quantity
R 1/15

Composite Unit of Mea

O

V
X

Free-Form Message
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

QTY01

673

Quantity Qualifier
Code specifying the type of quantity
CODE DEFINITION

ID

2/2

BF EC EM HM HO HP

Age Modifying Units Use of Extracorporeal Circulation Emergency Modifying Units Use of Hypothermia Use of Hypotension Use of Hyperbaric Pressurization

462

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 QTY ANESTHESIA MODIFYING UNITS

P3 P4 P5 SG REQUIRED QTY02 380 Quantity

Physical Status III Physical Status IV Physical Status V Swan-Ganz X R 1/15

Numeric value of quantity

INDUSTRY: Anesthesia
SYNTAX:

Modifying Units

R0204, E0204

NOT USED NOT USED

QTY03 QTY04

C001 61

COMPOSITE UNIT OF MEASURE Free-Form Message

O X AN 1/30

MAY 2000

463

004010X098 837 2400 MEA TEST RESULT

MEASUREMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MEA

TEST RESULT 004010X098 837 2400 MEA

IMPLEMENTATION

TEST RESULT
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 20

5 261

Notes:

1. Required on service lines which bill/report the following: Concentration, Hemoglobin, Hematocrit, Epoetin Starting Dosage, Creatin, and Oxygen.

1 114
STANDARD

Example: MEAVTRVR1V113.4~

MEA Measurements
Level: Detail Position: 462 Loop: 2400 Requirement: Optional Max Use: 20 Purpose: To specify physical measurements or counts, including dimensions, tolerances, variances, and weights Syntax: 1. R03050608 At least one of MEA03, MEA05, MEA06 or MEA08 is required. 2. C0504 If MEA05 is present, then MEA04 is required. 3. C0604 If MEA06 is present, then MEA04 is required. 4. L07030506 If MEA07 is present, then at least one of MEA03, MEA05 or MEA06 are required. 5. E0803 Only one of MEA08 or MEA03 may be present.
DIAGRAM

MEA01

737

MEA02

738

MEA03

739

MEA04

C001

MEA05

740

MEA06

741

MEA

V Measurement V Measurement V Measurement V

Ref ID Code
ID

Qualifier
ID

Value
R

Composite Unit of Mea

X

V
X

Range Minimum
R 1/20

V
X

Range Maximum
R 1/20

2/2

1/3

1/20

MEA07

935

MEA08

936

MEA09

752

MEA10

1373

V Measurement V Measurement V Sig Code Attrib Code

O ID 2/2 X ID 2/2

Layer/Posit Code
O ID 2/2

V Measurement ~ Method
O ID 2/4

464

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 MEA TEST RESULT

USAGE

NAME

ATTRIBUTES

REQUIRED

MEA01

737

Measurement Reference ID Code

INDUSTRY: Measurement ALIAS: Measurement
CODE

ID

2/2

Code identifying the broad category to which a measurement applies

Reference Identification Code

identifier

DEFINITION

OG

Original Starting dosage

1705
TR REQUIRED MEA02 738

Test Results O ID 1/3

Measurement Qualifier

Code identifying a specific product or process characteristic to which a measurement applies

CODE DEFINITION

CON GRA HT R1 R2 R3 R4 ZO REQUIRED MEA03 739

Concentration Gas Test Rate Height Hemoglobin Hematocrit Epoetin Starting Dosage Creatin Oxygen X R 1/20

Measurement Value
The value of the measurement
INDUSTRY: Test
SYNTAX:

Results

R03050608, L07030506, E0803

2616 2616

NSF Reference: FA0-42.0 - Hemoglobin, FA0-43.0 - Hematocrit, FA0-45.0 - Epoetin Starting Dosage, FA0-47.0 - Creatin, GX0-17.0 - Arterial Blood Gas on 4 liters/minute, GX0-18.0 - Oxygen Saturation on 4 liters/minute, GU0-16.0 - Patient Height MEA04 MEA05 MEA06 MEA07 MEA08 MEA09 MEA10 C001 740 741 935 936 752 1373 COMPOSITE UNIT OF MEASURE Range Minimum Range Maximum Measurement Significance Code Measurement Attribute Code Surface/Layer/Position Code Measurement Method or Device X X X O X O O R R ID ID ID ID 1/20 1/20 2/2 2/2 2/2 2/4

NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED NOT USED

MAY 2000

465

004010X098 837 2400 CN1 CONTRACT INFORMATION

CONTRACT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CN1

CONTRACT 837 2400 004010X098 INFORMATIONCN1

IMPLEMENTATION

CONTRACT INFORMATION
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

5 136 4 107
STANDARD

Notes:

1. Information contained at this level overwrites CN1 information at the claim level for this specific service line.

Example: CN1V04V410.5~

CN1 Contract Information

Level: Detail Position: 465 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To specify basic data about the contract or contract line item
DIAGRAM

CN101

1166

CN102

782

CN103

332

CN104

127

CN105

338

CN106

799

CN1 V

Contract Type Code

M ID 2/2

V
O

Monetary Amount
R 1/18

Allow/Chrg Percent
O R 1/6

Reference Ident
O AN 1/30

Terms Disc Percent

O R 1/6

V
O

Version ID
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

CN101

1166

Contract Type Code

Code identifying a contract type
ALIAS: Contract

ID

2/2

type code

1107

The developers of this implementation guide recommend always providing CN101 for capitated encounters.
CODE DEFINITION

01 02 03 04 05 06 09

Diagnosis Related Group (DRG) Per Diem Variable Per Diem Flat Capitated Percent Other

466

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 CN1 CONTRACT INFORMATION

SITUATIONAL

CN102

782

Monetary Amount
Monetary amount
INDUSTRY: Contract
SEMANTIC:

1/18

Amount

CN102 is the contract amount.

2233
SITUATIONAL CN103 332

Required if information is different than that given at claim level (Loop ID-2300). Percent
Percent expressed as a percent
INDUSTRY: Contract ALIAS: Contract

1/6

Percentage

Allowance or Charge Percent

SEMANTIC: CN103 is the allowance or charge percent.

2233
SITUATIONAL CN104 127

Required if information is different than that given at claim level (Loop ID-2300). Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Contract
SEMANTIC:

Code

CN104 is the contract code.

2233
SITUATIONAL CN105 338

Required if information is different than that given at claim level (Loop ID-2300). Terms Discount Percent O R 1/6
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
INDUSTRY: Terms ALIAS: Terms

Discount Percentage

discount percent

2233
SITUATIONAL CN106 799

Required if information is different than that given at claim level (Loop ID-2300). Version Identifier
INDUSTRY: Contract ALIAS: Contract
SEMANTIC:

AN

1/30

Revision level of a particular format, program, technique or algorithm

Version Identifier

Version

CN106 is an additional identifying number for the contract.

2233

Required if information is different than that given at claim level (Loop ID-2300).

MAY 2000

467

004010X098 837 2400 REF REPRICED LINE ITEM REFERENCE NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

REPRICED 837 2400 REF 004010X098LINE ITEM REFERENCE NUMBER

IMPLEMENTATION

REPRICED LINE ITEM REFERENCE NUMBER

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

5 183

Notes:

1. This segment is intended to be used exclusively by repricing (pricing) organizations who have a need to identify a certain line in their claim submission transmission to their payer organization.

0 129
STANDARD

Example: REFV9BV444444~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9B REQUIRED REF02 127

Repriced Line Item Reference Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Repriced
SYNTAX:

Line Item Reference Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

468

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2400 REF ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER

REF

ADJUSTED 837 2400 REF 004010X098REPRICED LINE ITEM REFERENCE NUMBER

IMPLEMENTATION

ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

5 183

Notes:

1. This segment is intended to be used exclusively by repricing (pricing) organizations who have a need to identify a certain line in their claim submission transmission to their payer organization.

1 129
STANDARD

Example: REFV9DV444444~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9D REQUIRED REF02 127

Adjusted Repriced Line Item Reference Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Adjusted
SYNTAX:

Repriced Line Item Reference Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

469

004010X098 837 2400 REF PRIOR AUTHORIZATION OR REFERRAL NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

PRIOR AUTHORIZATION REF 004010X098 837 2400 OR REFERRAL NUMBER

IMPLEMENTATION

PRIOR AUTHORIZATION OR REFERRAL NUMBER

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 2

7 261

Notes:

1. Required if service line involved a prior authorization number or referral number that is different than the number reported at the claim level (Loop-ID 2300).

2 129
STANDARD

Example: REFV9FV12345678~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9F G1 REQUIRED REF02 127

Referral Number Prior Authorization Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Prior
SYNTAX:

Authorization or Referral Number

R0203

NOT USED

REF03

352

Description

AN

1/80
MAY 2000

470

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 REF PRIOR AUTHORIZATION OR REFERRAL NUMBER

NOT USED

REF04

C040

REFERENCE IDENTIFIER

MAY 2000

471

004010X098 837 2400 REF LINE ITEM CONTROL NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

LINE ITEM CONTROL NUMBER 004010X098 837 2400 REF

IMPLEMENTATION

LINE ITEM CONTROL NUMBER

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 261

Notes:

1. Required if it is necessary to send a line control or inventory number. Providers are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the provider automatically posts their remittance advice. Submitting a unique line item control number gives providers the capability to automatically post by service line. The line item control number should be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the providers sends it to them in the 837.

3 129
STANDARD

Example: REFV6RV54321~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

6R

Provider Control Number

472

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 REF LINE ITEM CONTROL NUMBER

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Line
SYNTAX:

Item Control Number

R0203

1702 1702
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-04.0, FB0-04.0, FB1-04.0, FB2-04.0, FD0-04.0, FE0-04.0, HA004.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

473

004010X098 837 2400 REF MAMMOGRAPHY CERTIFICATION NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

MAMMOGRAPHY 2400 REF 004010X098 837CERTIFICATION NUMBER

IMPLEMENTATION

MAMMOGRAPHY CERTIFICATION NUMBER

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

9 261 8 136
STANDARD

Notes:

1. Required for Medicare claims for all mammography services.

Example: REFVEWVT554~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

EW REQUIRED REF02 127

Mammography Certification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Mammography
SYNTAX:

Certification Number

R0203

1614 1614
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-31.0 Description REFERENCE IDENTIFIER X O AN 1/80

474

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE 004010X098 837 2400 REF IMPLEMENTATION GUIDE CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) IDENTIFICATION
REFERENCE IDENTIFICATION

REF

CLINICAL LABORATORY REF 004010X098 837 2400 IMPROVEMENT AMENDMENT (CLIA) IDENTIFICATION

IMPLEMENTATION

CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) IDENTIFICATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 262

Notes:

1. Required for all CLIA certified facilities performing CLIA covered laboratory services and if number is different than CLIA number reported at claim level (Loop ID-2300).

9 126
STANDARD

Example: REFVX4V12D4567890~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

X4

Clinical Laboratory Improvement Amendment Number

MAY 2000

475

004010X098 837 2400 REF ASC X12N INSURANCE SUBCOMMITTEE CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) IDENTIFICATION IMPLEMENTATION GUIDE

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Clinical
SYNTAX:

Laboratory Improvement Amendment Number

R0203

1854 1854
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-34.0 Description REFERENCE IDENTIFIER X O AN 1/80

476

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE 004010X098 837 2400 REF IMPLEMENTATION GUIDE REFERRING CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) FACILITY ID
REFERENCE IDENTIFICATION

REF

REFERRING CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) FACILITY IDENTIFICATION 004010X098 837 2400 REF

IMPLEMENTATION

REFERRING CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) FACILITY IDENTIFICATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

3 262 2 262
STANDARD

Notes:

1. Required for Medicare claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line.

Example: REFVF4V34D1234567~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

F4 REQUIRED REF02 127

Facility Certification Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Referring
SYNTAX:

CLIA Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

477

004010X098 837 2400 REF IMMUNIZATION BATCH NUMBER

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

IMMUNIZATION BATCH NUMBER 004010X098 837 2400 REF

IMPLEMENTATION

IMMUNIZATION BATCH NUMBER

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 223 7 223
STANDARD

Notes:

1. Use when required by state law for health data reporting.

Example: REFVBTVDTP22333444~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

BT REQUIRED REF02 127

Batch Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Immunization
SYNTAX:

Batch Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

478

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2400 REF AMBULATORY PATIENT GROUP (APG)

REF

AMBULATORY PATIENT REF 004010X098 837 2400 GROUP (APG)

IMPLEMENTATION

AMBULATORY PATIENT GROUP (APG)

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 4

5 222 7 215
STANDARD

Notes:

1. Used at discretion of submitter.

Example: REFV1SVXXXXX~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

1S REQUIRED REF02 127

Ambulatory Patient Group (APG) Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Ambulatory
SYNTAX:

Patient Group Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

479

004010X098 837 2400 REF OXYGEN FLOW RATE

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OXYGEN FLOW RATE 004010X098 837 2400 REF

IMPLEMENTATION

OXYGEN FLOW RATE

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

6 222 7 219
STANDARD

Notes:

1. Required on oxygen therapy certificate of medical necessity (CMN) claim where service line reports oxygen flow rate.

Example: REFVTPV002~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

TP

Test Specification Number Oxygen Flow Rate

2195

480

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 REF OXYGEN FLOW RATE

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Oxygen
SYNTAX:

Flow Rate

R0203

1841 1841 2624

NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: GX0-14.0 Valid values are 1 - 999 liters per minute and X for less than 1 liter per minute. Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

481

004010X098 837 2400 REF UNIVERSAL PRODUCT NUMBER (UPN)

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

UNIVERSAL PRODUCT NUMBER 004010X098 837 2400 REF (UPN)

IMPLEMENTATION

UNIVERSAL PRODUCT NUMBER (UPN)

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 271

Notes:

1. X12N has been informed by HCFA that this information will be required on Medicare claims in the near future. It may also be required by some state Medicaids. This segment has been added to the 4010 implementation guide to allow providers to meet the Medicare/Medicaid requirements when they are implemented. When implemented by Medicare/Medicaid, the UPN is required on claim/encounters when an item/supply is being billed/reported that has an associated UPN included in the Health Care Uniform Code Council system or the Health Industry Business Communications Council system. See Appendix C for Code Source 41 and 522.

6 262
STANDARD

Example: REFVOZV5737904086~

REF Reference Identification

Level: Detail Position: 470 Loop: 2400 Requirement: Optional Max Use: 30 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

482

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2400 REF UNIVERSAL PRODUCT NUMBER (UPN)

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

OZ

Product Number Code Source 41 Use to indicate Health Care Uniform Code Council System. See Appendix C, code source 41.

2627

VP

Vendor Product Number Code Source 522 Use to indicate Health Industry Business Communications Council system. See Appendix C, code source 522.

2628

REQUIRED

REF02

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Universal
SYNTAX:

Product Number

R0203

2629 2629
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FA0-62.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

483

004010X098 837 2400 AMT SALES TAX AMOUNT

MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

SALES TAX 837 2400 AMT 004010X098 AMOUNT

IMPLEMENTATION

SALES TAX AMOUNT

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

0 263 2 171
STANDARD

Notes:

1. Required if sales tax applies to service line and submitter is required to report that information to the receiver.

Example: AMTVTV45~

AMT Monetary Amount

Level: Detail Position: 475 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

T REQUIRED AMT02 782

Monetary amount
INDUSTRY: Sales

Tax M R 1/18

Monetary Amount

Tax Amount
O ID 1/1

NOT USED

AMT03

478

Credit/Debit Flag Code

484

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

MONETARY AMOUNT

004010X098 837 2400 AMT APPROVED AMOUNT

AMT

APPROVED 837 2400 AMT 004010X098 AMOUNT

IMPLEMENTATION

APPROVED AMOUNT
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

9 253

Notes:

1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer. Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the information is available. 2. The allowed amount equals the amount for the service line that was approved by the payer sending this 837 to another payer.

1 263 7 279
STANDARD

Example: AMTVAAEV125~

AMT Monetary Amount

Level: Detail Position: 475 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

AAE REQUIRED AMT02 782

Monetary amount

Approved Amount M R 1/18

Monetary Amount
INDUSTRY: Approved

Amount

2544 2544
NOT USED AMT03 478

NSF Reference: FA0-51.0 Credit/Debit Flag Code O ID 1/1

MAY 2000

485

004010X098 837 2400 AMT POSTAGE CLAIMED AMOUNT

MONETARY AMOUNT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AMT

POSTAGE CLAIMED AMOUNT 004010X098 837 2400 AMT

IMPLEMENTATION

POSTAGE CLAIMED AMOUNT

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

2 263 6 136
STANDARD

Notes:

1. Required if service line charge (SV102) includes postage amount claimed in this service line.

Example: AMTVF4V56.78~

AMT Monetary Amount

Level: Detail Position: 475 Loop: 2400 Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

522

AMT02

782

AMT03

478

AMT

V Amount Qual V Code

M ID 1/3 M

Monetary Amount
R 1/18

Cred/Debit Flag Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

Code to qualify amount
CODE DEFINITION

ID

1/3

F4 REQUIRED AMT02 782

Monetary amount

Postage Claimed M R 1/18

Monetary Amount
INDUSTRY: Postage

Claimed Amount
O ID 1/1

NOT USED

AMT03

478

Credit/Debit Flag Code

486

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

FILE INFORMATION

004010X098 837 2400 K3 FILE INFORMATION

K3

FILE INFORMATION 004010X098 837 2400 K3

IMPLEMENTATION

FILE INFORMATION
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 10

7 280

Notes:

1. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislative requirement AND the administering state agency or other state organization has contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement, and X12N determines that there is no method to meet the requirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee.

3 263
STANDARD

Example: K3VSTATE DATA REQUIREMENT~

K3 File Information
Level: Detail Position: 480 Loop: 2400 Requirement: Optional Max Use: 10 Purpose: To transmit a fixed-format record or matrix contents
DIAGRAM

K301

449

K302

1333

K303

C001

K3 V

Fixed Form Information

M AN 1/80

Record V V Format Code

O ID 1/2

Composite Unit of Mea

O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

K301

449

Fixed Format Information

Data in fixed format agreed upon by sender and receiver

AN

1/80

1503 1503
NOT USED NOT USED K302 K303 1333 C001

NSF Reference: HA0-05.0 Record Format Code COMPOSITE UNIT OF MEASURE O O ID 1/2

MAY 2000

487

004010X098 837 2400 NTE LINE NOTE

NOTE/SPECIAL INSTRUCTION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NTE

LINE NOTE 004010X098 837 2400 NTE

IMPLEMENTATION

LINE NOTE
Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 199

Notes:

1. Required if submitter used a"not otherwise classified" (NOC) procedure code on this service line (use ADD in NTE01). Otherwise, use at providers discretion.

5 161
STANDARD

Example: NTEVDCPVPATIENT GOAL TO BE OFF OXYGEN BY END OF MONTH~

NTE Note/Special Instruction

Level: Detail Position: 485 Loop: 2400 Requirement: Optional Max Use: 10 Purpose: To transmit information in a free-form format, if necessary, for comment or special instruction
DIAGRAM

NTE01

363

NTE02

352

NTE

V
O

Note Ref Code

ID 3/3

V Description
M AN 1/80

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NTE01

363

Note Reference Code

CODE DEFINITION

ID

3/3

Code identifying the functional area or purpose for which the note applies

ADD DCP PMT TPO REQUIRED NTE02 352 Description

INDUSTRY: Line

Additional Information Goals, Rehabilitation Potential, or Discharge Plans Payment Third Party Organization Notes M AN 1/80

A free-form description to clarify the related data elements and their content

Note Text

1503 1503

NSF Reference: HA0-05.0

488

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PURCHASE SERVICE

004010X098 837 2400 PS1 PURCHASED SERVICE INFORMATION

PS1

PURCHASED 837 2400 PS1 004010X098 SERVICE INFORMATION

IMPLEMENTATION

PURCHASED SERVICE INFORMATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

8 110 4 263

Notes:

1. Using the PS1 segment indicates that services were purchased from another source. 2. Required on service lines involving purchased services/tests if different than the information given at the claim level (Loop ID = 2310C).

4 105
STANDARD

Example: PS1VPN222222V110~

PS1 Purchase Service

Level: Detail Position: 488 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To specify the information about services that are purchased
DIAGRAM

PS101

127

PS102

782

PS103

156

PS1 V

Reference Ident
M AN 1/30

V
M

Monetary Amount
R 1/18

State or Prov Code

O ID 2/2

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PS101

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Purchased
SEMANTIC:

Service Provider Identifier

PS101 is provider identification number.

1295 1295

NSF Reference: FB0-11.0

MAY 2000

489

004010X098 837 2400 PS1 PURCHASED SERVICE INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

PS102

782

Monetary Amount
Monetary amount
INDUSTRY: Purchased
SEMANTIC:

1/18

Service Charge Amount

PS102 is cost of the purchased service.

1616 1616
NOT USED PS103 156

NSF Reference: FB0-05.0 State or Province Code O ID 2/2

490

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HEALTH CARE SERVICES DELIVERY

004010X098 837 2400 HSD HEALTH CARE SERVICES DELIVERY

HSD

HEALTH CARE SERVICES HSD 004010X098 837 2400 DELIVERY

IMPLEMENTATION

HEALTH CARE SERVICES DELIVERY

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

1 208

Notes:

1. The HSD segment is used to specify the delivery pattern of the health care services. This is how it is used: HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means one visit. Between HSD02 and HSD03 verbally insert a per every. HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means three days. Between HSD04 and HSD05 verbally insert a for. HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means 21 days. The total message reads: HSD*VS*1*DA*3*7*21~ = One visit per every three days for 21 days. Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days. An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means 1 visit on Wednesday and Thursday morning.

7 112

2. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearly substantiate medical treatment and if information is different than that given at claim level (Loop ID-2300). Example: HSDVVSV1VDAV1V7V10~ (This indicates 1 visit every (per) 1 day (daily) for 10 days) Example: HSDVVSV1VDAVVVVW~ (This indicates 1 visit per day whenever necessary)

9 109 0 110
STANDARD

HSD Health Care Services Delivery

Level: Detail Position: 491 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To specify the delivery pattern of health care services

MAY 2000

491

004010X098 837 2400 HSD HEALTH CARE SERVICES DELIVERY

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Syntax:

1. P0102 If either HSD01 or HSD02 is present, then the other is required. 2. C0605 If HSD06 is present, then HSD05 is required.

DIAGRAM

HSD01

673

HSD02

380

HSD03

355

HSD04

1167

HSD05

615

HSD06

616

HSD V
X

Quantity Qualifier
ID 2/2

V
X

Quantity
R 1/15

Unit/Basis Meas Code

O ID 2/2

Sample Sel Modulus

O R 1/6

V Time Period V Qualifier

X ID 1/2

Number of Periods
O N0 1/3

HSD07

678

HSD08

679

Ship/Del or V Calend Code

O ID 1/2

Ship/Del Time Code

O ID 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

SITUATIONAL

HSD01

673

Quantity Qualifier
Code specifying the type of quantity
INDUSTRY: Visits
SYNTAX:

ID

2/2

P0102

2239

Required if information is different than that given at claim level (Loop ID-2300).
CODE DEFINITION

VS SITUATIONAL HSD02 380 Quantity

Visits X R 1/15

Numeric value of quantity

INDUSTRY: Number
SYNTAX:

of Visits

P0102

2164 2239
SITUATIONAL HSD03 355

HDS02 qualifies HSD01. Required if information is different than that given at claim level (Loop ID-2300). Unit or Basis for Measurement Code O ID 2/2
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
INDUSTRY: Frequency

Period

2239

Required if information is different than that given at claim level (Loop ID-2300).
CODE DEFINITION

DA MO

Days Months Month

1369

492

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 HSD HEALTH CARE SERVICES DELIVERY

Q1 WK SITUATIONAL HSD04 1167

Quarter (Time) Week O R 1/6

Sample Selection Modulus

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
INDUSTRY: Frequency

Count

2239
SITUATIONAL HSD05 615

Required if information is different than that given at claim level (Loop ID-2300). Time Period Qualifier
Code defining periods
INDUSTRY: Duration
SYNTAX:

ID

1/2

of Visits Units

C0605

2239

Required if information is different than that given at claim level (Loop ID-2300).
CODE DEFINITION

7 34 35 SITUATIONAL HSD06 616

Day Month Week O N0 1/3

Number of Periods
Total number of periods
INDUSTRY: Duration
SYNTAX:

of Visits, Number of Units

C0605

2239
SITUATIONAL HSD07 678

Required if information is different than that given at claim level (Loop ID-2300). Ship/Delivery or Calendar Pattern Code
INDUSTRY: Ship,

ID

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

Delivery or Calendar Pattern Code

2239

Required if information is different than that given at claim level (Loop ID-2300).
CODE DEFINITION

1 2 3 4 5 6 7 A B

1st Week of the Month 2nd Week of the Month 3rd Week of the Month 4th Week of the Month 5th Week of the Month 1st & 3rd Weeks of the Month 2nd & 4th Weeks of the Month Monday through Friday Monday through Saturday

MAY 2000

493

004010X098 837 2400 HSD HEALTH CARE SERVICES DELIVERY

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

C D E F G H J K L N O SA SB SC SD SG SL SP SX SY SZ W SITUATIONAL HSD08 679

Monday through Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday through Thursday As Directed Daily Mon. through Fri. Sunday, Monday, Thursday, Friday, Saturday Tuesday through Saturday Sunday, Wednesday, Thursday, Friday, Saturday Monday, Wednesday, Thursday, Friday, Saturday Tuesday through Friday Monday, Tuesday and Thursday Monday, Tuesday and Friday Wednesday and Thursday Monday, Wednesday and Thursday Tuesday, Thursday and Friday Whenever Necessary O ID 1/1

Ship/Delivery Pattern Time Code

INDUSTRY: Delivery

Code which specifies the time for routine shipments or deliveries

Pattern Time Code

2239

Required if information is different than that given at claim level (Loop ID-2300).
CODE DEFINITION

D E F

A.M. P.M. As Directed

494

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

HEALTH CARE PRICING

004010X098 837 2400 HCP LINE PRICING/REPRICING INFORMATION

HCP

LINE PRICING/REPRICING HCP 004010X098 837 2400 INFORMATION

IMPLEMENTATION

LINE PRICING/REPRICING INFORMATION

Loop: 2400 SERVICE LINE Usage: SITUATIONAL Repeat: 1

5 185 5 109
STANDARD

Notes:

1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.

Example: HCPV03V100V10VRPO12345~

HCP Health Care Pricing

Level: Detail Position: 492 Loop: 2400 Requirement: Optional Max Use: 1 Purpose: To specify pricing or repricing information about a health care claim or line item Syntax: 1. R0113 At least one of HCP01 or HCP13 is required. 2. P0910 If either HCP09 or HCP10 is present, then the other is required. 3. P1112 If either HCP11 or HCP12 is present, then the other is required.
DIAGRAM

HCP01

1473

HCP02

782

HCP03

782

HCP04

127

HCP05

118

HCP06

127

HCP

Pricing V Methodology
X ID 2/2 O

Monetary Amount
R 1/18

V
O

Monetary Amount
R 1/18

Reference Ident
O AN 1/30

V
O

Rate
R 1/9

Reference Ident
O AN 1/30

HCP07

782

HCP08

234

HCP09

235

HCP10

234

HCP11

355

HCP12

380

V
O

Monetary Amount
R 1/18

Product/ Service ID
O AN 1/48

V
X

Prod/Serv ID Qual
ID 2/2

V
X

Product/ Service ID
AN 1/48

Unit/Basis Meas Code

X ID 2/2

V
X

Quantity
R 1/15

HCP13

901

HCP14

1526

HCP15

1527

Reject V V Policy Comp V Reason Code Code

X ID 2/2 O ID 1/2

Exception Code
O ID 1/2

MAY 2000

495

004010X098 837 2400 HCP LINE PRICING/REPRICING INFORMATION ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

HCP01

1473

Pricing Methodology

ID

2/2

Code specifying pricing methodology at which the claim or line item has been priced or repriced
ALIAS: Pricing/repricing
SYNTAX:

methodology

R0113

1296

Trading partners need to agree on the codes to use in this element. There do not appear to be standard definitions for the code elements. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

1855

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 REQUIRED HCP02 782

Monetary amount

Zero Pricing (Not Covered Under Contract) Priced as Billed at 100% Priced at the Standard Fee Schedule Priced at a Contractual Percentage Bundled Pricing Peer Review Pricing Per Diem Pricing Flat Rate Pricing Combination Pricing Maternity Pricing Other Pricing Lower of Cost Ratio of Cost Cost Reimbursed Adjustment Pricing O R 1/18

Monetary Amount
INDUSTRY: Repriced

Allowed Amount Allowed Amount

ALIAS: Pricing/Repricing
SEMANTIC:

HCP02 is the allowed amount.

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.

496

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 HCP LINE PRICING/REPRICING INFORMATION

SITUATIONAL

HCP03

782

Monetary Amount
Monetary amount
INDUSTRY: Repriced

1/18

Saving Amount Savings Amount

ALIAS: Pricing/Repricing
SEMANTIC:

HCP03 is the savings amount.

1855
SITUATIONAL HCP04 127

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Repricing

Organization Identifier Identification Number

ALIAS: Pricing/Repricing
SEMANTIC:

HCP04 is the repricing organization identification number.

1855
SITUATIONAL HCP05 118

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Rate
INDUSTRY: Repricing

1/9

Rate expressed in the standard monetary denomination for the currency specified

Per Diem or Flat Rate Amount Rate

ALIAS: Pricing/Repricing
SEMANTIC:

HCP05 is the pricing rate associated with per diem or flat rate repricing.

1855
SITUATIONAL HCP06 127

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Reference Identification O AN 1/30
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Repriced ALIAS: Approved
SEMANTIC:

Approved Ambulatory Patient Group Code

APG code, Pricing

HCP06 is the approved DRG code.

COMMENT: HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.

1855
SITUATIONAL HCP07 782

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Monetary Amount
Monetary amount
INDUSTRY: Repriced ALIAS: Approved
SEMANTIC:

1/18

Approved Ambulatory Patient Group Amount

APG amount, Pricing

HCP07 is the approved DRG amount.

1855
NOT USED HCP08 234

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Product/Service ID O AN 1/48

MAY 2000

497

004010X098 837 2400 HCP LINE PRICING/REPRICING INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

HCP09

235

Product/Service ID Qualifier

ID

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)
INDUSTRY: Product
SYNTAX:

or Service ID Qualifier

P0910

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

HC

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMAs CPT codes are also level 1 HCPCS codes, they are reported under HC.
CODE SOURCE 130:

1297

Health Care Financing Administration Common Procedural Coding System

IV

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513:

Home Infusion EDI Coalition (HIEC) Product/Service Code List

ZZ

Mutually Defined Jurisdictionally Defined Procedure and Supply Codes. (Used for Workers Compensation claims). Contact your local (State) Jurisdiction for a list of these codes.

1843

SITUATIONAL

HCP10

234

Product/Service ID
Identifying number for a product or service
INDUSTRY: Procedure

AN

1/48

Code Approved Procedure Code

ALIAS: Pricing/Repricing
SYNTAX:

P0910 HCP10 is the approved procedure code.

SEMANTIC:

1855
SITUATIONAL HCP11 355

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Unit or Basis for Measurement Code X ID 2/2
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SYNTAX:

P1112

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

DA UN

Days Unit

498

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2400 HCP LINE PRICING/REPRICING INFORMATION

SITUATIONAL

HCP12

380

Quantity
Numeric value of quantity
INDUSTRY: Repriced

1/15

Approved Service Unit Count Approved Units or Inpatient Days

ALIAS: Pricing/Repricing
SYNTAX:

P1112 HCP12 is the approved service units or inpatient days.

SEMANTIC:

1855
SITUATIONAL HCP13 901

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. Reject Reason Code
Code assigned by issuer to identify reason for rejection
ALIAS: Reject
SYNTAX:

ID

2/2

reason code

R0113

SEMANTIC:

HCP13 is the rejection message returned from the third party organization.

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

T1

Cannot Identify Provider as TPO (Third Party Organization) Participant Cannot Identify Payer as TPO (Third Party Organization) Participant Cannot Identify Insured as TPO (Third Party Organization) Participant Payer Name or Identifier Missing Certification Information Missing Claim does not contain enough information for repricing O ID 1/2

T2

T3

T4 T5 T6 SITUATIONAL

HCP14

1526

Policy Compliance Code

Code specifying policy compliance
ALIAS: Policy

compliance code

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

1 2

Procedure Followed (Compliance) Not Followed - Call Not Made (Non-Compliance Call Not Made) Not Medically Necessary (Non-Compliance NonMedically Necessary) Not Followed Other (Non-Compliance Other) Emergency Admit to Non-Network Hospital

4 5

MAY 2000

499

004010X098 837 2400 HCP LINE PRICING/REPRICING INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

HCP15

1527

Exception Code

ID

1/2

Code specifying the exception reason for consideration of out-of-network health care services
ALIAS: Exception
SEMANTIC:

code

HCP15 is the exception reason generated by a third party organization.

1855

Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
CODE DEFINITION

Non-Network Professional Provider in Network Hospital Emergency Care Services or Specialist not in Network Out-of-Service Area State Mandates Other

2 3 4 5 6

500

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2420A NM1 RENDERING PROVIDER NAME

NM1

004010X098 PROVIDER NAME RENDERING 837 2420A NM1

IMPLEMENTATION

RENDERING PROVIDER NAME

Loop: 2420A RENDERING PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required if the Rendering Provider NM1 information is different than that carried in the 2310B (claim) loop, or if the Rendering provider information is carried at the Billing/Pay-to Provider loop level (2010AA/AB) and this particular service line has a different Rendering Provider that what is given in the 2010AA/AB loop. The identifying payer-specific numbers are those that belong to the destination payer identified in loop 2010BB. 3. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a subsitute provider (locum tenans) was used, that person should be entered here.

5 263

0 250

9 129
STANDARD

Example: NM1V82V1VSMITHVJUNEVLVVVXXV87654321~

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

Syntax:

MAY 2000

501

004010X098 837 2420A NM1 RENDERING PROVIDER NAME DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1060

The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CODE DEFINITION

82 REQUIRED NM102 1065

Rendering Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 REQUIRED NM103 1035

Person Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Rendering ALIAS: Rendering

Provider Last or Organization Name

Provider Last Name

1618 1618
SITUATIONAL NM104 1036

NSF Reference: FB1-14.0 Name First

Individual first name
INDUSTRY: Rendering

AN

1/25

Provider First Name

1619 1619 1245

NSF Reference: FB1-15.0 Required if NM102=1 (person).

502

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420A NM1 RENDERING PROVIDER NAME

SITUATIONAL

NM105

1037

Name Middle
Individual middle name or initial
INDUSTRY: Rendering

AN

1/25

Provider Middle Name

1620 1620 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: FB1-16.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Rendering ALIAS: Rendering

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058
REQUIRED NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2502 2502

NSF Reference: FA0-57.0

CODE DEFINITION

24 34

Employers Identification Number Social Security Number Social Security Number cannot be used for Medicare claims.

2636
XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Rendering ALIAS: Rendering
SYNTAX:

Provider Identifier

Provider Primary Identifier

P0809

2504 2504
NOT USED NOT USED NM110 NM111 706 98

NSF Reference: FA0-23.0, FA0-58.0 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

503

004010X098 837 2420A PRV RENDERING PROVIDER SPECIALTY INFORMATION

PROVIDER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PRV

RENDERING 837 2420A PRV 004010X098 PROVIDER SPECIALTY INFORMATION

IMPLEMENTATION

RENDERING PROVIDER SPECIALTY INFORMATION

Loop: 2420A RENDERING PROVIDER NAME Usage: REQUIRED Repeat: 1

3 279 7 235
STANDARD

Notes:

1. PRV02 qualifies PRV03.

Example: PRVVPEVZZV203BA050N~

PRV Provider Information

Level: Detail Position: 505 Loop: 2420 Requirement: Optional Max Use: 1 Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

PRV02

128

PRV03

127

PRV04

156

PRV05

C035

PRV06

1223

PRV V
M

Provider Code
ID 1/3

Reference Ident Qual

M ID 2/3

Reference Ident
M AN 1/30

State or Prov Code

O ID 2/2

V
O

Provider Spec. Inf.

V
O

Provider Org Code

ID 3/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code
Code indentifying the type of provider
CODE DEFINITION

ID

1/3

PE REQUIRED PRV02 128

Performing M ID 2/3

Reference Identification Qualifier

Code qualifying the Reference Identification

2360

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

ZZ

Mutually Defined Health Care Provider Taxonomy Code list

2359

504

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420A PRV RENDERING PROVIDER SPECIALTY INFORMATION

REQUIRED

PRV03

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Provider ALIAS: Provider

Taxonomy Code

Specialty Code

1009 1009
NOT USED NOT USED NOT USED PRV04 PRV05 PRV06 156 C035 1223

NSF Reference: FA0-37.0 State or Province Code PROVIDER SPECIALTY INFORMATION Provider Organization Code O O O ID 3/3 ID 2/2

MAY 2000

505

004010X098 837 2420A N2 ADDITIONAL RENDERING PROVIDER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2420A PROVIDER NAME INFORMATION 004010X098 RENDERING N2

IMPLEMENTATION

ADDITIONAL RENDERING PROVIDER NAME INFORMATION

Loop: 2420A RENDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 510 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Rendering ALIAS: Rendering

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

506

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2420A REF RENDERING PROVIDER SECONDARY IDENTIFICATION

REF

RENDERING 837 2420A REF 004010X098 PROVIDER SECONDARY IDENTIFICATION

IMPLEMENTATION

RENDERING PROVIDER SECONDARY IDENTIFICATION

Loop: 2420A RENDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1B 1C 1D 1G 1H

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number

MAY 2000

507

004010X098 837 2420A REF RENDERING PROVIDER SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

EI G2 LU N5 SY

Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Rendering
SYNTAX:

Provider Secondary Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

508

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2420B NM1 PURCHASED SERVICE PROVIDER NAME

NM1

004010X098 SERVICE PROVIDER NAME PURCHASED 837 2420B NM1

IMPLEMENTATION

PURCHASED SERVICE PROVIDER NAME

Loop: 2420B PURCHASED SERVICE PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required if purchased services are being billed/reported on this claim. Purchased services are situations where (for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination payer identified in the 2010BB loop.

5 250

5 105
STANDARD

Example: NM1VQBV2VXYZ HOLTER MONITOR INCVVVVV34V444556666~

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

509

004010X098 837 2420B NM1 PURCHASED SERVICE PROVIDER NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1060

The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CODE DEFINITION

QB REQUIRED NM102 1065

Purchase Service Provider M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 2 NOT USED NOT USED NOT USED NOT USED NOT USED SITUATIONAL NM103 NM104 NM105 NM106 NM107 NM108 1035 1036 1037 1038 1039 66

Person Non-Person Entity O O O O O X AN AN AN AN AN ID 1/35 1/25 1/25 1/10 1/10 1/2

Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2506

Required if either Employers Identification/Social Security Number or National Provider Identifier is known.
CODE DEFINITION

24 34 XX

Employers Identification Number Social Security Number Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

510

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420B NM1 PURCHASED SERVICE PROVIDER NAME

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Purchased ALIAS: Purchased
SYNTAX:

AN

2/80

Service Provider Identifier

Service Providers Primary Identification Number

P0809

1622 1622 2506

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: FB0-11.0 Required if either Employers Identification/Social Security Number or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

511

004010X098 837 2420B REF PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

PURCHASED 837 2420B REF 004010X098 SERVICE PROVIDER SECONDARY IDENTIFICATION

IMPLEMENTATION

PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION

Loop: 2420B PURCHASED SERVICE PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1A 1B 1C 1D 1G

State License Number Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number

512

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420B REF PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION

1H EI G2 LU N5 SY

CHAMPUS Identification Number Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
U3 X5 REQUIRED REF02 127

Unique Supplier Identification Number (USIN) State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Purchased
SYNTAX:

Service Provider Secondary Identifier

R0203

1295 1295
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FB0-11.0 Description REFERENCE IDENTIFIER X O AN 1/80

MAY 2000

513

004010X098 837 2420C NM1 SERVICE FACILITY LOCATION

INDIVIDUAL OR ORGANIZATIONAL NAME

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM1

004010X098 837 LOCATION SERVICE FACILITY 2420C NM1

IMPLEMENTATION

SERVICE FACILITY LOCATION

Loop: 2420C SERVICE FACILITY LOCATION Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required when the location of health care service for this service line is different than that carried in the 2010AA (Billing Provider), 2010AB (Pay-to Provider), or 2310D Service Facility Location loops. All payerspecific identifying numbers belong to the destination payer identified in the 2010BB loop.

7 263

7 123
STANDARD

Example: NM1VTLV2VA-OK MOBILE CLINICVVVVV24V11122333~

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

514

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2420C NM1 SERVICE FACILITY LOCATION

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1060

The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CODE DEFINITION

77

Service Location Use when other codes in this element do not apply.

2511
FA LI TL REQUIRED NM102 1065

Facility Independent Lab Testing Laboratory M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 SITUATIONAL NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Laboratory ALIAS: Service

or Facility Name

Facility Location Name

1741 1741 2512

NOT USED NOT USED NOT USED NOT USED SITUATIONAL NM104 NM105 NM106 NM107 NM108 1036 1037 1038 1039 66

NSF Reference: GX0-25.0 Required except when service was rendered in the patients home. Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier O O O O X AN AN AN AN ID 1/25 1/25 1/10 1/10 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2714

Required if either Employers Identification/Social Security Number (tax ID of service location) or National Provider Identifier is known.
CODE DEFINITION

24 34

Employers Identification Number Social Security Number Do not use for Medicare claims.

2713

MAY 2000

515

004010X098 837 2420C NM1 SERVICE FACILITY LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Laboratory ALIAS: Service
SYNTAX:

or Facility Primary Identifier

Facility Location Identification Number

P0809

2715
NOT USED NOT USED NM110 NM111 706 98

Required if either Employers Identification/Social Security Number (tax ID of service location) or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

516

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDITIONAL NAME INFORMATION

004010X098 837 2420C N2 ADDITIONAL SERVICE FACILITY LOCATION NAME INFORMATION

N2

ADDITIONAL 837 2420C N2 004010X098 SERVICE FACILITY LOCATION NAME INFORMATION

IMPLEMENTATION

ADDITIONAL SERVICE FACILITY LOCATION NAME INFORMATION

Loop: 2420C SERVICE FACILITY LOCATION Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 510 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Laboratory ALIAS: Service

AN

1/60

or Facility Name Additional Text

Facility Location Additional Name

O AN 1/60

NOT USED

N202

93

Name

MAY 2000

517

004010X098 837 2420C N3 SERVICE FACILITY LOCATION ADDRESS

ADDRESS INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N3

SERVICE FACILITY 2420C N3 004010X098 837 LOCATION ADDRESS

IMPLEMENTATION

SERVICE FACILITY LOCATION ADDRESS

Loop: 2420C SERVICE FACILITY LOCATION Usage: REQUIRED Repeat: 1

5 251

Notes:

1. If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (e.g., crossroad of State Road 34 and 45" or Exit near Mile marker 265 on Interstate 80".)

0 108
STANDARD

Example: N3V2400 HEALTHY WAY~

N3 Address Information
Level: Detail Position: 514 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Laboratory ALIAS: Service

AN

1/55

or Facility Address Line

Facility Location Address 1

1733 1733
SITUATIONAL N302 166

NSF Reference: GX2-04.0 Address Information

Address information
INDUSTRY: Laboratory ALIAS: Service

AN

1/55

or Facility Address Line

Facility Location Address 2

1734 1734 2205

NSF Reference: GX2-05.0 Required if a second address line exists.

518

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GEOGRAPHIC LOCATION

004010X098 837 2420C N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP

N4

SERVICE FACILITY 2420C N4 004010X098 837 LOCATION CITY/STATE/ZIP

IMPLEMENTATION

SERVICE FACILITY LOCATION CITY/STATE/ZIP

Loop: 2420C SERVICE FACILITY LOCATION Usage: REQUIRED Repeat: 1

7 251

Notes:

1. If service facility location is in an area where there are no street addresses, enter the name of the nearest town, state and zip of where the service was rendered.

1 108
STANDARD

Example: N4VHYANNISVMAV02601~

N4 Geographic Location
Level: Detail Position: 520 Loop: 2420 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Laboratory ALIAS: Service

AN

2/30

or Facility City Name

Facility Location City

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1735 1735

NSF Reference: GX2-06.0

MAY 2000

519

004010X098 837 2420C N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

N402

156

State or Province Code

INDUSTRY: Laboratory ALIAS: Service
COMMENT:

ID

2/2

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

or Facility State or Province Code

Facility Location State

States and Outlying Areas of the U.S.

N402 is required only if city name (N401) is in the U.S. or Canada.

CODE SOURCE 22:

1736 1736
REQUIRED N403 116

NSF Reference: GX2-07.0 Postal Code O ID 3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Laboratory ALIAS: Service

or Facility Postal Zone or ZIP Code

Facility Location ZIP Code

ZIP Code

CODE SOURCE 51:

1737 1737
SITUATIONAL N404 26

NSF Reference: GX2-08.0 Country Code

Code identifying the country
ALIAS: Service
CODE SOURCE 5:

ID

2/3

Facility Location Country Code

Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

520

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2420C REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

REF

SERVICE FACILITY 2420C REF 004010X098 837 LOCATION SECONDARY IDENTIFICATION

IMPLEMENTATION

SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

Loop: 2420C SERVICE FACILITY LOCATION Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1A 1B 1C 1D 1G

State License Number Blue Cross Provider Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number

MAY 2000

521

004010X098 837 2420C REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

1H G2 LU N5 TJ X4

CHAMPUS Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Federal Taxpayers Identification Number Clinical Laboratory Improvement Amendment Number State Industrial Accident Provider Number X AN 1/30

X5 REQUIRED REF02 127

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Service ALIAS: Service
SYNTAX:

Facility Location Secondary Identifier

Facility Location Secondary Identification Number

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

522

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2420D NM1 SUPERVISING PROVIDER NAME

NM1

004010X098 837 2420D NAME SUPERVISING PROVIDER NM1

IMPLEMENTATION

SUPERVISING PROVIDER NAME

Loop: 2420D SUPERVISING PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required when rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. All paye-specific identifying numbers belong to the destination payer identified in loop 2010BB.

1 224

3 130
STANDARD

Example: NM1VDQV1VKILLIANVBARTVBVVIIV24V222334444~

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

523

004010X098 837 2420D NM1 SUPERVISING PROVIDER NAME ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

DQ REQUIRED NM102 1065

Supervising Physician M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Supervising

Provider Last Name

1623 1623
REQUIRED NM104 1036

NSF Reference: FB1-18.0 Name First

Individual first name
INDUSTRY: Supervising

AN

1/25

Provider First Name

1624 1624
SITUATIONAL NM105 1037

NSF Reference: FB1-19.0 Name Middle

Individual middle name or initial
INDUSTRY: Supervising

AN

1/25

Provider Middle Name

1625 1625 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: FB1-20.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Supervising ALIAS: Supervising

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058

Required if known.

524

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420D NM1 SUPERVISING PROVIDER NAME

SITUATIONAL

NM108

66

Identification Code Qualifier

ID

1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2725

Required if either Employers Identification/Social Security Number (Supervising providers tax ID) or National Provider Identifier is known.
CODE DEFINITION

24 34

Employers Identification Number Social Security Number The social security number may not be used for Medicare.

2376
XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Supervising ALIAS: Supervising
SYNTAX:

Provider Identifier

Providers Identification Number

P0809

1300 1300 2726

NOT USED NOT USED

NSF Reference: FB1-21.0 Required if either Employers Identification/Social Security Number (Supervising providers tax ID) or National Provider Identifier is known. NM110 NM111 706 98 Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

525

004010X098 837 2420D N2 ADDITIONAL SUPERVISING PROVIDER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2420D N2 004010X098 SUPERVISING PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL SUPERVISING PROVIDER NAME INFORMATION

Loop: 2420D SUPERVISING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 510 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Supervising ALIAS: Supervising

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

526

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2420D REF SUPERVISING PROVIDER SECONDARY IDENTIFICATION

REF

SUPERVISING PROVIDER REF 004010X098 837 2420D SECONDARY IDENTIFICATION

IMPLEMENTATION

SUPERVISING PROVIDER SECONDARY IDENTIFICATION

Loop: 2420D SUPERVISING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1B 1C 1D 1G 1H

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number

MAY 2000

527

004010X098 837 2420D REF SUPERVISING PROVIDER SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

EI G2 LU N5 SY

Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Supervising
SYNTAX:

Provider Secondary Identifier

R0203

1626 1626
NOT USED NOT USED REF03 REF04 352 C040

NSF Reference: FB1-21.0 Description REFERENCE IDENTIFIER X O AN 1/80

528

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2420E NM1 ORDERING PROVIDER NAME

NM1

004010X098PROVIDER NAME ORDERING 837 2420E NM1

IMPLEMENTATION

ORDERING PROVIDER NAME

Loop: 2420E ORDERING PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required if a service or supply was ordered by a provider and that provider is a different entity than the rendering provider for this service line. All payer-specific identifiers belong to the destination payer identified in the 2010BB loop.

8 263

4 130
STANDARD

Example: NM1VDKV1VRICHARDSONVTRENTVVVV34V555667778~

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.
DIAGRAM

Syntax:

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

MAY 2000

529

004010X098 837 2420E NM1 ORDERING PROVIDER NAME ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

1060

The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CODE DEFINITION

DK REQUIRED NM102 1065

Ordering Physician M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Ordering

Provider Last Name

1627 1627
REQUIRED NM104 1036

NSF Reference: FB1-06.0 Name First

Individual first name
INDUSTRY: Ordering

AN

1/25

Provider First Name

1628 1628
SITUATIONAL NM105 1037

NSF Reference: FB1-07.0 Name Middle

Individual middle name or initial
INDUSTRY: Ordering

AN

1/25

Provider Middle Name

1629 1629 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: FB1-08.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Ordering ALIAS: Ordering

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058

Required if known.

530

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420E NM1 ORDERING PROVIDER NAME

SITUATIONAL

NM108

66

Identification Code Qualifier

ID

1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2727

Required if either Employers Identification/Social Security Number (Ordering providers tax ID) or National Provider Identifier is known.
CODE DEFINITION

24 34

Employers Identification Number Social Security Number The social security number may not be used for Medicare.

2376
XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Ordering ALIAS: Ordering
SYNTAX: P0809

Provider Identifier

Provider Primary Identifier

2284 2284 2727

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: FB0-09.0, FB1-09.0, GX0-29.0 Required if either Employers Identification/Social Security Number (Ordering providers tax ID) or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

531

004010X098 837 2420E N2 ADDITIONAL ORDERING PROVIDER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2420E N2 004010X098 ORDERING PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL ORDERING PROVIDER NAME INFORMATION

Loop: 2420E ORDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 510 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Ordering ALIAS: Ordering

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

532

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ADDRESS INFORMATION

004010X098 837 2420E N3 ORDERING PROVIDER ADDRESS

N3

ORDERING 837 2420E N3 004010X098PROVIDER ADDRESS

IMPLEMENTATION

ORDERING PROVIDER ADDRESS

Loop: 2420E ORDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

3 112

Notes:

1. Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (Medicare DMERC CMN) is used on service line for Medicare claims.

0 108
STANDARD

Example: N3V2400 HEALTHY WAY~

N3 Address Information
Level: Detail Position: 514 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party
DIAGRAM

N301

166

N302

166

N3 V

Address Information
M AN 1/55

Address Information
O AN 1/55

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information
Address information
INDUSTRY: Ordering ALIAS: Ordering

AN

1/55

Provider Address Line

Provider Address 1

1630 1630
SITUATIONAL N302 166

NSF Reference: FB2-06.0 Address Information

Address information
INDUSTRY: Ordering ALIAS: Ordering

AN

1/55

Provider Address Line

Provider Address 2

1631 1631 2205

NSF Reference: FB2-07.0 Required if a second address line exists.

MAY 2000

533

004010X098 837 2420E N4 ORDERING PROVIDER CITY/STATE/ZIP CODE

GEOGRAPHIC LOCATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N4

ORDERING 837 2420E N4 004010X098PROVIDER CITY/STATE/ZIP CODE

IMPLEMENTATION

ORDERING PROVIDER CITY/STATE/ZIP CODE

Loop: 2420E ORDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

3 112

Notes:

1. Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (Medicare DMERC CMN) is used on service line for Medicare claims.

1 108
STANDARD

Example: N4VHYANNISVMAV02601~

N4 Geographic Location
Level: Detail Position: 520 Loop: 2420 Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party Syntax:
DIAGRAM

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

N401

19

N402

156

N403

116

N404

26

N405

309

N406

310

N4 V
O

City Name
AN 2/30

State or Prov Code

O ID 2/2

V
O

Postal Code
ID 3/15

V
O

Country Code
ID 2/3

V
X

Location Qualifier
ID 1/2

V
O

Location Identifier
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N401

19

City Name
Free-form text for city name
INDUSTRY: Ordering ALIAS: Ordering

AN

2/30

Provider City Name

Provider City

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

1632 1632

NSF Reference: FB2-08.0

534

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420E N4 ORDERING PROVIDER CITY/STATE/ZIP CODE

REQUIRED

N402

156

State or Province Code

INDUSTRY: Ordering ALIAS: Ordering
COMMENT:

ID

2/2

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

Provider State Code

Provider State
States and Outlying Areas of the U.S.

N402 is required only if city name (N401) is in the U.S. or Canada.

CODE SOURCE 22:

1634 1634
REQUIRED N403 116

NSF Reference: FB0-10.0, FB2-09.0 Postal Code O ID 3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
INDUSTRY: Ordering ALIAS: Ordering
CODE SOURCE 51:

Provider Postal Zone or ZIP Code

Provider Zip Code

ZIP Code

1635 1635
SITUATIONAL N404 26

NSF Reference: FB2-10.0 Country Code

Code identifying the country
ALIAS: Ordering
CODE SOURCE 5:

ID

2/3

Provider Country Code

Countries, Currencies and Funds

1067
NOT USED NOT USED N405 N406 309 310

Required if the address is out of the U.S. Location Qualifier Location Identifier X O ID AN 1/2 1/30

MAY 2000

535

004010X098 837 2420E REF ORDERING PROVIDER SECONDARY IDENTIFICATION

REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

ORDERING 837 2420E REF 004010X098PROVIDER SECONDARY IDENTIFICATION

IMPLEMENTATION

ORDERING PROVIDER SECONDARY IDENTIFICATION

Loop: 2420E ORDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1B 1C 1D 1G 1H

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number

536

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420E REF ORDERING PROVIDER SECONDARY IDENTIFICATION

EI G2 LU N5 SY

Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Ordering
SYNTAX:

Provider Secondary Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

MAY 2000

537

004010X098 837 2420E PER ORDERING PROVIDER CONTACT INFORMATION

ADMINISTRATIVE COMMUNICATIONS CONTACT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PER

ORDERING 837 2420E PER 004010X098PROVIDER CONTACT INFORMATION

IMPLEMENTATION

ORDERING PROVIDER CONTACT INFORMATION

Loop: 2420E ORDERING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

3 100

Notes:

1. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g., (534) 224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number. 2. Required when services involving an oxygen therapy certificate of medical necessity (CMN) is being billed/reported on this service line. 3. By definition of the standard, if PER03 is used, PER04 is required.

2 224 1 279 2 108

STANDARD

Example: PERVICVJOHN SMITHVTEV2015551212~

PER Administrative Communications Contact

Level: Detail Position: 530 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To identify a person or office to whom administrative communications should be directed Syntax: 1. P0304 If either PER03 or PER04 is present, then the other is required. 2. P0506 If either PER05 or PER06 is present, then the other is required. 3. P0708 If either PER07 or PER08 is present, then the other is required.

538

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DIAGRAM

004010X098 837 2420E PER ORDERING PROVIDER CONTACT INFORMATION

PER01

366

PER02

93

PER03

365

PER04

364

PER05

365

PER06

364

PER

Contact Funct Code

M ID 2/2

V
O

Name
AN 1/60

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

PER07

365

PER08

364

PER09

443

Comm V Number Qual

X ID 2/2 X

Comm Number
AN 1/80

V Contact Inq
Reference
O AN 1/20

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PER01

366

Contact Function Code

CODE DEFINITION

ID

2/2

Code identifying the major duty or responsibility of the person or group named

IC REQUIRED PER02 93 Name

Free-form name

Information Contact O AN 1/60

INDUSTRY: Ordering

Provider Contact Name

X ID 2/2

REQUIRED

PER03

365

Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

P0304
DEFINITION

CODE

EM FX TE REQUIRED PER04 364

Electronic Mail Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0304

2639 2639
SITUATIONAL PER05 365

NSF Reference: GX0-30.0, GU0-23.0 Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0506

2225

Used at discretion of submitter.

CODE DEFINITION

EM EX FX TE
MAY 2000

Electronic Mail Telephone Extension Facsimile Telephone

539

004010X098 837 2420E PER ORDERING PROVIDER CONTACT INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

PER06

364

Communication Number

AN

1/80

Complete communications number including country or area code when applicable

SYNTAX:

P0506

2225
SITUATIONAL PER07 365

Used at discretion of submitter. Communication Number Qualifier

Code identifying the type of communication number
SYNTAX:

ID

2/2

P0708

2225

Used at discretion of submitter.

CODE DEFINITION

EM EX FX TE SITUATIONAL PER08 364

Electronic Mail Telephone Extension Facsimile Telephone X AN 1/80

Communication Number

Complete communications number including country or area code when applicable

SYNTAX:

P0708

2225
NOT USED PER09 443

Used at discretion of submitter. Contact Inquiry Reference O AN 1/20

540

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2420F NM1 REFERRING PROVIDER NAME

NM1

004010X098 837 2420F NM1 REFERRING PROVIDER NAME

IMPLEMENTATION

REFERRING PROVIDER NAME

Loop: 2420F REFERRING PROVIDER NAME Repeat: 2 Usage: SITUATIONAL Repeat: 1

7 221

Notes:

1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required if this service line involves a referral and the referring provider is different than the rendering provider and if the referring provider differs from that reported at the claim level (loop 2310A). All payer-specific identifying numbers belong to the destination payer identified in the 2010BB loop. 3. When there is only one referral on the service line use code DN Referring Provider. When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this service line. Use code P3 - Primary Care Provider in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patients episode of care being billed/reported in this transaction.

0 264

4 278

3 123
STANDARD

Example: NM1VDNV1VWELBYVMARCUSVWVVJRV34V444332222~

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required. 2. C1110 If NM111 is present, then NM110 is required.

Syntax:

MAY 2000

541

004010X098 837 2420F NM1 REFERRING PROVIDER NAME DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1

V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

DN

Referring Provider Use on the first iteration of this loop. Use if loop is used only once.

2738
P3

Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop.

2739
REQUIRED NM102 1065

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

ID

1/1

NM102 qualifies NM103.

DEFINITION

CODE

1 REQUIRED NM103 1035

Person O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Referring

Provider Last Name

1637 1637
REQUIRED NM104 1036

NSF Reference: FB1-10.0 Name First

Individual first name
INDUSTRY: Referring

AN

1/25

Provider First Name

1638 1638

NSF Reference: FB1-11.0

542

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420F NM1 REFERRING PROVIDER NAME

SITUATIONAL

NM105

1037

Name Middle
Individual middle name or initial
INDUSTRY: Referring

AN

1/25

Provider Middle Name

1639 1639 1848

NOT USED SITUATIONAL NM106 NM107 1038 1039

NSF Reference: FB1-12.0 Required if NM102=1 and the middle name/initial of the person is known. Name Prefix Name Suffix
Suffix to individual name
INDUSTRY: Referring ALIAS: Referring

O O

AN AN

1/10 1/10

Provider Name Suffix

Provider Generation

1058
SITUATIONAL NM108 66

Required if known. Identification Code Qualifier X ID 1/2

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809

2728

Required if either Employers Identification/Social Security Number (Referring Provider tax ID) or National Provider Identifier is known.
CODE DEFINITION

24 34

Employers Identification Number Social Security Number The social security number may not be used for Medicare.

2729
XX

Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. X AN 2/80

SITUATIONAL

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Referring ALIAS: Referring
SYNTAX:

Provider Identifier

Providers Identification Number

P0809

1706 1706 2728

NOT USED NOT USED NM110 NM111 706 98

NSF Reference: FB1-13.0, FA0-24.0 Required if either Employers Identification/Social Security Number (Referring Provider tax ID) or National Provider Identifier is known. Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

543

004010X098 837 2420F PRV REFERRING PROVIDER SPECIALTY INFORMATION

PROVIDER INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PRV

REFERRING PROVIDER SPECIALTY INFORMATION 004010X098 837 2420F PRV

IMPLEMENTATION

REFERRING PROVIDER SPECIALTY INFORMATION

Loop: 2420F REFERRING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

7 249 3 279 4 102

STANDARD

Notes:

1. Required if required under provider-payer contract. 2. PRV02 qualifies PRV03.

Example: PRVVRFVZZV363LP0200N~

PRV Provider Information

Level: Detail Position: 505 Loop: 2420 Requirement: Optional Max Use: 1 Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

PRV02

128

PRV03

127

PRV04

156

PRV05

C035

PRV06

1223

PRV V
M

Provider Code
ID 1/3

Reference Ident Qual

M ID 2/3

Reference Ident
M AN 1/30

State or Prov Code

O ID 2/2

V
O

Provider Spec. Inf.

V
O

Provider Org Code

ID 3/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code
Code indentifying the type of provider
CODE DEFINITION

ID

1/3

RF

Referring

544

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420F PRV REFERRING PROVIDER SPECIALTY INFORMATION

REQUIRED

PRV02

128

Reference Identification Qualifier

Code qualifying the Reference Identification

ID

2/3

2360

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

ZZ

Mutually Defined Health Care Provider Taxonomy Code list

2359
REQUIRED PRV03 127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Provider ALIAS: Provider

Taxonomy Code

Specialty Code
O O O ID 3/3 ID 2/2

NOT USED NOT USED NOT USED

PRV04 PRV05 PRV06

156 C035 1223

State or Province Code PROVIDER SPECIALTY INFORMATION Provider Organization Code

MAY 2000

545

004010X098 837 2420F N2 ADDITIONAL REFERRING PROVIDER NAME INFORMATION

ADDITIONAL NAME INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2

ADDITIONAL 837 2420F N2 004010X098 REFERRING PROVIDER NAME INFORMATION

IMPLEMENTATION

ADDITIONAL REFERRING PROVIDER NAME INFORMATION

Loop: 2420F REFERRING PROVIDER NAME Usage: SITUATIONAL Repeat: 1

2 220

Notes:

1. Required if the name in NM103 is greater than 35 characters. See example in Loop ID-1000A Submitter, NM1 and N2 for how to handle long names.

4 123
STANDARD

Example: N2VADDITIONAL NAME INFO~

N2 Additional Name Information

Level: Detail Position: 510 Loop: 2420 Requirement: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length
DIAGRAM

N201

93

N202

93

N2 V
M

Name
AN 1/60

V
O

Name
AN 1/60

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

N201

93

Name
Free-form name
INDUSTRY: Referring ALIAS: Referring

AN

1/60

Provider Name Additional Text

Provider Additional Name Information

O AN 1/60

NOT USED

N202

93

Name

546

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REFERENCE IDENTIFICATION

004010X098 837 2420F REF REFERRING PROVIDER SECONDARY IDENTIFICATION

REF

REFERRING PROVIDER SECONDARY IDENTIFICATION 004010X098 837 2420F REF

IMPLEMENTATION

REFERRING PROVIDER SECONDARY IDENTIFICATION

Loop: 2420F REFERRING PROVIDER NAME Usage: SITUATIONAL Repeat: 5

6 220

Notes:

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

4 110
STANDARD

Example: REFV1DVA12345~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

0B 1B 1C 1D 1G 1H

State License Number Blue Shield Provider Number Medicare Provider Number Medicaid Provider Number Provider UPIN Number CHAMPUS Identification Number

MAY 2000

547

004010X098 837 2420F REF REFERRING PROVIDER SECONDARY IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

EI G2 LU N5 SY

Employers Identification Number Provider Commercial Number Location Number Provider Plan Network Identification Number Social Security Number The social security number may not be used for Medicare.

2376
X5 REQUIRED REF02 127

State Industrial Accident Provider Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Referring
SYNTAX:

Provider Secondary Identifier

R0203

NOT USED NOT USED

REF03 REF04

352 C040

Description REFERENCE IDENTIFIER

X O

AN

1/80

548

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDIVIDUAL OR ORGANIZATIONAL NAME

004010X098 837 2420G NM1 OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

NM1

004010X098 837 2420G NM1 OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

IMPLEMENTATION

OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

Loop: 2420G OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Repeat: 4 Usage: SITUATIONAL Repeat: 1

2 264

Notes:

1. Required when it is necessary, in COB situations, to send a payerspecific line level referral number or prior authorization number. The payer-specific numbers carried in the REF in this loop belong to the non-destination (COB) payers. 2. The strategy in using this loop is to use NM109 to identify which payer the prior authorization/referral number carried in the REF of this loop belongs to. For example, if there are 2 COB payers (non-destination payers) who have additional referral numbers for this service line the data string for the 2420G loop would look like this: NM1*PR*2******PI*PAYER #1 ID~ (This payer ID would be identified in an iteration of loop 2330B in its own 2320 loop) REF*9F*AAAAAAA~ NM1*PR*2******PI*PAYER#2 ID~ (This payer ID would also be identified in an interation of loop 2330B in its own 2320 loop) REF*9F*2BBBBBB~

5 278

7 221

3. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. Example: NM1VPRV2VUNION MUTUAL OF OREGONVVVVVPIV223345~

9 280
STANDARD

NM1 Individual or Organizational Name

Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. 1. P0809 If either NM108 or NM109 is present, then the other is required.

Syntax:

MAY 2000

549

004010X098 837 2420G NM1 OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

2. C1110 If NM111 is present, then NM110 is required.

DIAGRAM

NM101

98

NM102

1065

NM103

1035

NM104

1036

NM105

1037

NM106

1038

NM1 V
M

Entity ID Code
ID 2/3

Entity Type Qualifier

M ID 1/1

Name Last/ Org Name

O AN 1/35

V
O

Name First
AN 1/25

V
O

Name Middle
AN 1/25

V
O

Name Prefix
AN 1/10

NM107

1039

NM108

66

NM109

67

NM110

706

NM111

98

V
O

Name Suffix
AN 1/10

V
X

ID Code Qualifier
ID 1/2

V
X

ID Code
AN 2/80

Entity Relat Code

X ID 2/2

V
O

Entity ID Code
ID 2/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

NM101

98

Entity Identifier Code

ID

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION

PR REQUIRED NM102 1065

Payer M ID 1/1

Entity Type Qualifier

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

DEFINITION

CODE

2 REQUIRED NM103 1035

Non-Person Entity O AN 1/35

Name Last or Organization Name

Individual last name or organizational name
INDUSTRY: Payer

Name
O O O O X AN AN AN AN ID 1/25 1/25 1/10 1/10 1/2

NOT USED NOT USED NOT USED NOT USED REQUIRED

NM104 NM105 NM106 NM107 NM108

1036 1037 1038 1039 66

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
SYNTAX:

P0809
DEFINITION

CODE

PI XV

Payor Identification Health Care Financing Administration National PlanID Required if the National PlanID is mandated for use. Otherwise, one of the other listed codes may be used.
CODE SOURCE 540:

Health Care Financing Administration

National PlanID

550

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420G NM1 OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

REQUIRED

NM109

67

Identification Code
Code identifying a party or other code
INDUSTRY: Other ALIAS: Other
SYNTAX:

AN

2/80

Payer Identification Number

Payer Identification

P0809

2643
NOT USED NOT USED NM110 NM111 706 98

Must match corresponding Other Payer Identifier in NM109 in 2330B loop(s). Entity Relationship Code Entity Identifier Code X O ID ID 2/2 2/3

MAY 2000

551

004010X098 837 2420G REF OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER
REFERENCE IDENTIFICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF

OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER 004010X098 837 2420G REF

IMPLEMENTATION

OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

Loop: 2420G OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Usage: REQUIRED Repeat: 2

7 278 4 264
STANDARD

Notes:

1. Non-destination (COB) payers provider identification number(s).

Example: REFVG1VAB333-Y5~

REF Reference Identification

Level: Detail Position: 525 Loop: 2420 Requirement: Optional Max Use: 20 Purpose: To specify identifying information Syntax:
DIAGRAM

1. R0203 At least one of REF02 or REF03 is required.

REF01

128

REF02

127

REF03

352

REF04

C040

REF V

Reference Ident Qual

M ID 2/3

V
X

Reference Ident
AN 1/30

Description
X AN 1/80

Reference Identifier
O

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

Code qualifying the Reference Identification
CODE DEFINITION

ID

2/3

9F G1 REQUIRED REF02 127

Referral Number Prior Authorization Number X AN 1/30

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:

Payer Prior Authorization or Referral Number

R0203

NOT USED

REF03

352

Description

AN

1/80

552

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2420G REF OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

NOT USED

REF04

C040

REFERENCE IDENTIFIER

MAY 2000

553

004010X098 837 2430 SVD LINE ADJUDICATION INFORMATION

SERVICE LINE ADJUDICATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SVD

LINE ADJUDICATION INFORMATION 004010X098 837 2430 SVD

IMPLEMENTATION

LINE ADJUDICATION INFORMATION

Loop: 2430 LINE ADJUDICATION INFORMATION Repeat: 25 Usage: SITUATIONAL Repeat: 1

1 011 100

Notes:

1. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for examples) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. If a line item control number (REF01 = 6R) exists for the line, that number may be used in SVD06 instead of the LX number when a line is unbundled. 2. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 3. Required if claim has been previously adjudicated by payer identified in Loop 2330B and service line has adjustments applied to it.

7 221

3 224 5 110
STANDARD

Example: SVDV43V55VHC:84550VV3~

SVD Service Line Adjudication

Level: Detail Position: 540 Loop: 2430 Repeat: >1 Requirement: Optional Max Use: 1 Purpose: To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Set Notes:
DIAGRAM

1. SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.

SVD01

67

SVD02

782

SVD03

C003

SVD04

234

SVD05

380

SVD06

554

SVD V
M

ID Code
AN 2/80

V
M

Monetary Amount
R 1/18

V Comp. Med. Proced. ID

O

Product/ Service ID
O AN 1/48

V
O

Quantity
R 1/15

V
O

Assigned Number
N0 1/6

554

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 837 2430 SVD LINE ADJUDICATION INFORMATION

USAGE

NAME

ATTRIBUTES

REQUIRED

SVD01

67

Identification Code
Code identifying a party or other code
INDUSTRY: Other ALIAS: Other
SEMANTIC:

AN

2/80

Payer Primary Identifier

Payer identification code

SVD01 is the payer identification code.

1306
REQUIRED SVD02 782

This number should match NM109 in Loop ID-2330B identifying Other Payer. Monetary Amount
Monetary amount
INDUSTRY: Service ALIAS: Paid
SEMANTIC:

1/18

Line Paid Amount

Amount

SVD02 is the amount paid for this service line.

2645 2645 2244 2646

REQUIRED SVD03 C003

NSF Reference: FA0-52.0 Zero 0" is an acceptable value for this element. The FA0-52.0 NSF crosswalk is only used in payer-to-payer COB situations. COMPOSITE MEDICAL PROCEDURE IDENTIFIER O

To identify a medical procedure by its standardized codes and applicable modifiers

1801 2245
REQUIRED SVD03 - 1

ALIAS: Procedure

identifier

This element contains the procedure code that was used to pay this service line. It crosswalks from SVC01 in the 835 transmission. 235 Product/Service ID Qualifier M ID 2/2
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
INDUSTRY: Product
CODE DEFINITION

or Service ID Qualifier

HC

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMAs CPT codes are also level 1 HCPCS codes, they are reported under HC.
CODE SOURCE 130:

1297

Health Care Financing Administration Common Procedural Coding System

IV

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513:

Home Infusion EDI Coalition (HIEC) Product/Service Code List

N1

National Drug Code in 4-4-2 Format

CODE SOURCE 240:

National Drug Code by Format

MAY 2000

555

004010X098 837 2430 SVD LINE ADJUDICATION INFORMATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

N2 N3 N4 ZZ

National Drug Code in 5-3-2 Format

CODE SOURCE 240:

National Drug Code by Format

National Drug Code in 5-4-1 Format

CODE SOURCE 240:

National Drug Code by Format

National Drug Code in 5-4-2 Format

CODE SOURCE 240:

National Drug Code by Format

Mutually Defined Jurisdictionally Defined Procedure and Supply Codes. (Used for Workers Compensation claims). Contact your local (State) Jurisdiction for a list of these codes.

1843

REQUIRED

SVD03 - 2

234

Product/Service ID
Identifying number for a product or service
INDUSTRY: Procedure

AN

1/48

Code
O AN 2/2

SITUATIONAL

SVD03 - 3

1339

Procedure Modifier

This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 1

1091 2578
SITUATIONAL SVD03 - 4 1339

Use this modifier for the first procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 2

1092 2578
SITUATIONAL SVD03 - 5 1339

Use this modifier for the second procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 3

1093 2578
SITUATIONAL SVD03 - 6 1339

Use this modifier for the third procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code. Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the service, as defined by trading partners
ALIAS: Procedure

Modifier 4

1094 2578

Use this modifier for the fourth procedure code modifier. Required when a modifier clarifies/improves the reporting accuracy of the associated procedure code.

556

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2430 SVD LINE ADJUDICATION INFORMATION

SITUATIONAL

SVD03 - 7

352

Description

AN

1/80

A free-form description to clarify the related data elements and their content
INDUSTRY: Procedure

Code Description

2246
NOT USED REQUIRED SVD04 SVD05 234 380

Required if SVC01-7 was returned in the 835 transaction. Product/Service ID Quantity

Numeric value of quantity
INDUSTRY: Paid ALIAS: Paid
SEMANTIC:

O O

AN R

1/48 1/15

Service Unit Count

units of service

SVD05 is the paid units of service.

2247
SITUATIONAL SVD06 554

Crosswalk from SVC05 in 835 or, if not present in 835, use original billed units. Assigned Number
Number assigned for differentiation within a transaction set
INDUSTRY: Bundled

N0

1/6

or Unbundled Line Number Line Number

ALIAS: Bundled/Unbundled

COMMENT: SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.

2153 2248

Use the LX from this transaction which points to the bundled/unbundled line. Required if payer bundled/unbundled this service line.

MAY 2000

557

004010X098 837 2430 CAS LINE ADJUSTMENT

CLAIMS ADJUSTMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CAS

LINE ADJUSTMENT 004010X098 837 2430 CAS

IMPLEMENTATION

LINE ADJUSTMENT
Loop: 2430 LINE ADJUDICATION INFORMATION Usage: SITUATIONAL Repeat: 99

2 138

Notes:

1. Required if the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. 2. Mapping CAS information into a flat file format may involve reading specific Claim Adjustment Reason Codes and then mapping the subsequent Monetary Amount and/or Quantity elements to specific fields in the flat file. 3. There are some NSF COB elements which are covered through the use of the CAS segment. Please see the claim level CAS segment for a note on handling those crosswalks at the claim level. Some of that information may apply at the line level. Further information is given below which is more specific to line level issues. Balance bill limiting charge (FA0-54.0). The adjustment for this information would be conveyed in a CAS amount element if the provider billed for more than they were allowed to under contract.

7 170

7 264

8 264 1 110 2 110

STANDARD

4. The Claim Adjustment Reason codes are located on the Washington Publishing Company web site http://www.wpc-edi.com. Example: CASVPRV1V7.93~ Example: CASVOAV93V15.06~

CAS Claims Adjustment

Level: Detail Position: 545 Loop: 2430 Requirement: Optional Max Use: 99 Purpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Syntax: 1. L050607 If CAS05 is present, then at least one of CAS06 or CAS07 are required. 2. C0605 If CAS06 is present, then CAS05 is required. 3. C0705 If CAS07 is present, then CAS05 is required.

558

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2430 CAS LINE ADJUSTMENT

4. L080910 If CAS08 is present, then at least one of CAS09 or CAS10 are required. 5. C0908 If CAS09 is present, then CAS08 is required. 6. C1008 If CAS10 is present, then CAS08 is required. 7. L111213 If CAS11 is present, then at least one of CAS12 or CAS13 are required. 8. C1211 If CAS12 is present, then CAS11 is required. 9. C1311 If CAS13 is present, then CAS11 is required. 10. L141516 If CAS14 is present, then at least one of CAS15 or CAS16 are required. 11. C1514 If CAS15 is present, then CAS14 is required. 12. C1614 If CAS16 is present, then CAS14 is required. 13. L171819 If CAS17 is present, then at least one of CAS18 or CAS19 are required. 14. C1817 If CAS18 is present, then CAS17 is required. 15. C1917 If CAS19 is present, then CAS17 is required.
DIAGRAM

CAS01

1033

CAS02

1034

CAS03

782

CAS04

380

CAS05

1034

CAS06

782

CAS

Claim Adj V Claim Adj V Group Code Reason Code

M ID 1/2 M ID 1/5 M

Monetary Amount
R 1/18

V
O

Quantity
R 1/15

Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

CAS07

380

CAS08

1034

CAS09

782

CAS10

380

CAS11

1034

CAS12

782

V
X

Quantity
R 1/15

Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

V
X

Quantity
R 1/15

Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

CAS13

380

CAS14

1034

CAS15

782

CAS16

380

CAS17

1034

CAS18

782

V
X

Quantity
R 1/15

V Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

V
X

Quantity
R 1/15

V Claim Adj V Reason Code

X ID 1/5 X

Monetary Amount
R 1/18

CAS19

380

V
X

Quantity
R 1/15

MAY 2000

559

004010X098 837 2430 CAS LINE ADJUSTMENT ELEMENT SUMMARY

REF. DES. DATA ELEMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

USAGE

NAME

ATTRIBUTES

REQUIRED

CAS01

1033

Claim Adjustment Group Code

Code identifying the general category of payment adjustment
ALIAS: Adjustment
CODE

ID

1/2

Group Code

DEFINITION

CO CR OA PI PR REQUIRED CAS02 1034

Contractual Obligations Correction and Reversals Other adjustments Payor Initiated Reductions Patient Responsibility M ID 1/5

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
CODE SOURCE 139:

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Line Level

Claim Adjustment Reason Code

2655 2655 2154

REQUIRED CAS03 782

NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB317.0 Use the Claim Adjustment Reason Code list (See Appendix C). Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SEMANTIC:

1/18

Amount

Amount - Line Level

CAS03 is the amount of adjustment.

COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero.

2747 2747

NSF Reference: FA0-27.0, FA0-28.0, FA0-35.0, FA0-48.0, FB0-06.0, FB0-07.0, FB008.0, FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0, FA0-53.0, FA0-54.0 Use this amount for the adjustment amount. CAS04 380 Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SEMANTIC:

1031
SITUATIONAL

1/15

Quantity

Units - Line Level

CAS04 is the units of service being adjusted.

1056 2050

Use this quantity for the units of service being adjusted. Use as needed to show payer adjustment.

560

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2430 CAS LINE ADJUSTMENT

SITUATIONAL

CAS05

1034

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Line Level

L050607, C0605, C0705 Claim Adjustment Reason Code

CODE SOURCE 139:

2655 2655 2050 2154

SITUATIONAL CAS06 782

NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB317.0 Use as needed to show payer adjustment. Use the Claim Adjustment Reason Code list (See Appendix C). Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Line Level

L050607, C0605 CAS06 is the amount of the adjustment.

SEMANTIC:

2747 2747 1031 2050

SITUATIONAL CAS07 380

NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB318.0, FA0-53.0, FA0-54.0 Use this amount for the adjustment amount. Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Line Level

L050607, C0705 CAS07 is the units of service being adjusted.

SEMANTIC:

1056 2050

Use this quantity for the units of service being adjusted. Use as needed to show payer adjustment.

MAY 2000

561

004010X098 837 2430 CAS LINE ADJUSTMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CAS08

1034

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Line Level

L080910, C0908, C1008 Claim Adjustment Reason Code

CODE SOURCE 139:

2655 2655 2050 2154

SITUATIONAL CAS09 782

NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB317.0 Use as needed to show payer adjustment. Use the Claim Adjustment Reason Code list (See Appendix C). Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Line Level

L080910, C0908 CAS09 is the amount of the adjustment.

SEMANTIC:

2747 2747 1031 2050

SITUATIONAL CAS10 380

NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB318.0, FA0-53.0, FA0-54.0 Use this amount for the adjustment amount. Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Line Level

L080910, C1008 CAS10 is the units of service being adjusted.

SEMANTIC:

1056 2050

Use this quantity for the units of service being adjusted. Use as needed to show payer adjustment.

562

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2430 CAS LINE ADJUSTMENT

SITUATIONAL

CAS11

1034

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Line Level

L111213, C1211, C1311 Claim Adjustment Reason Code

CODE SOURCE 139:

2655 2655 2050 2154

SITUATIONAL CAS12 782

NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB317.0 Use as needed to show payer adjustment. Use the Claim Adjustment Reason Code list (See Appendix C). Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Line Level

L111213, C1211 CAS12 is the amount of the adjustment.

SEMANTIC:

2747 2747 1031 2050

SITUATIONAL CAS13 380

NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB318.0, FA0-53.0, FA0-54.0 Use this amount for the adjustment amount. Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Line Level

L111213, C1311 CAS13 is the units of service being adjusted.

SEMANTIC:

1056 2050

Use this quantity for the units of service being adjusted. Use as needed to show payer adjustment.

MAY 2000

563

004010X098 837 2430 CAS LINE ADJUSTMENT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

CAS14

1034

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Line Level

L141516, C1514, C1614 Claim Adjustment Reason Code

CODE SOURCE 139:

2655 2655 2050 2154

SITUATIONAL CAS15 782

NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB317.0 Use as needed to show payer adjustment. Use the Claim Adjustment Reason Code list (See Appendix C). Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Line Level

L141516, C1514 CAS15 is the amount of the adjustment.

SEMANTIC:

2747 2747 1031 2050

SITUATIONAL CAS16 380

NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB318.0, FA0-53.0, FA0-54.0 Use this amount for the adjustment amount. Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Line Level

L141516, C1614 CAS16 is the units of service being adjusted.

SEMANTIC:

1056 2050

Use this quantity for the units of service being adjusted. Use as needed to show payer adjustment.

564

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2430 CAS LINE ADJUSTMENT

SITUATIONAL

CAS17

1034

Claim Adjustment Reason Code

INDUSTRY: Adjustment ALIAS: Adjustment
SYNTAX:

ID

1/5

Code identifying the detailed reason the adjustment was made

Reason Code

Reason Code - Line Level

L171819, C1817, C1917 Claim Adjustment Reason Code

CODE SOURCE 139:

2655 2655 2050 2154

SITUATIONAL CAS18 782

NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB317.0 Use as needed to show payer adjustment. Use the Claim Adjustment Reason Code list (See Appendix C). Monetary Amount
Monetary amount
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/18

Amount

Amount - Line Level

L171819, C1817 CAS18 is the amount of the adjustment.

SEMANTIC:

2747 2747 1031 2050

SITUATIONAL CAS19 380

NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB318.0, FA0-53.0, FA0-54.0 Use this amount for the adjustment amount. Use as needed to show payer adjustment. Quantity
Numeric value of quantity
INDUSTRY: Adjustment ALIAS: Adjusted
SYNTAX:

1/15

Quantity

Units - Line Level

L171819, C1917 CAS19 is the units of service being adjusted.

SEMANTIC:

1056 2050

Use this quantity for the units of service being adjusted. Use as needed to show payer adjustment.

MAY 2000

565

004010X098 837 2430 DTP LINE ADJUDICATION DATE

DATE OR TIME OR PERIOD

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

DTP

LINE ADJUDICATION DATE 004010X098 837 2430 DTP

IMPLEMENTATION

LINE ADJUDICATION DATE

Loop: 2430 LINE ADJUDICATION INFORMATION Usage: REQUIRED Repeat: 1

6 110
STANDARD

Example: DTPV573VD8V19970131~

DTP Date or Time or Period

Level: Detail Position: 550 Loop: 2430 Requirement: Optional Max Use: 9 Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

374

DTP02

1250

DTP03

1251

DTP V

Date/Time Qualifier
M ID 3/3

Date Time format Qual

M ID 2/3

Date Time Period

M AN 1/35

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

ID

3/3

Time Qualifier
DEFINITION

573 REQUIRED DTP02 1250

Date Claim Paid M ID 2/3

Date Time Period Format Qualifier

SEMANTIC:

Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03.
DEFINITION

CODE

D8 REQUIRED DTP03 1251

Date Expressed in Format CCYYMMDD M AN 1/35

Date Time Period

INDUSTRY: Adjudication

Expression of a date, a time, or range of dates, times or dates and times

or Payment Date

566

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INDUSTRY CODE

004010X098 837 2440 LQ FORM IDENTIFICATION CODE

LQ

FORM IDENTIFICATION CODE 004010X098 837 2440 LQ

IMPLEMENTATION

FORM IDENTIFICATION CODE

Loop: 2440 FORM IDENTIFICATION CODE Repeat: 5 Usage: SITUATIONAL Repeat: 1

3 266

Notes:

1. Required if the provider is required to routinely include supporting documentation (a standardized paper form) in electronic format. An example is for Medicare DMERC claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician. Medicare or other payers may require other supporting documentation for other types of claims (e.g., home health). 2. The 2440 loop is designed to allow providers to attach any type of standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=0102A identifies which DMERC CMN form is being used. See Appendix K and the FRM segment for further notes on use of this loop. 3. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then the LQ and FRM segments are Required. 4. Loop 2440 was approved by ASC X12 in the version 004011 Data Dictionary but is included in this guide to provide standard way to report DMERC claims within the HIPAA implementation time frame. It is recommended that entitles who have a need to submit or receive DMERC claims customize their 004010 translator map to allow this loop.

4 266

5 266

7 273

9 219
STANDARD

Example: LQVUTV0102A~

LQ Industry Code
Level: Detail Position: 551 Loop: 2440 Repeat: >1 Requirement: Optional Max Use: 1 Purpose: Code to transmit standard industry codes Set Notes: Syntax: 1. Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/370. 1. C0102 If LQ01 is present, then LQ02 is required.

MAY 2000

567

004010X098 837 2440 LQ FORM IDENTIFICATION CODE DIAGRAM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

LQ01

1270

LQ02

1271

LQ

Code List Qual Code

O ID 1/3

V
X

Industry Code
AN 1/30

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

LQ01

1270

Code List Qualifier Code

Code identifying a specific industry code list
ALIAS: Form
SYNTAX:

ID

1/3

Identification Code

C0102
DEFINITION

CODE

AS

Form Type Code Use code AS to indicate that a Home Health form is being identified.

2667
UT

Health Care Financing Administration (HCFA) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms X AN 1/30

REQUIRED

LQ02

1271

Industry Code
Code indicating a code from a specific industry code list
INDUSTRY: Form
SYNTAX:

Identifier

C0102

2184 2184

NSF Reference: GU0-25.0

568

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SUPPORTING DOCUMENTATION

004010X098 837 2440 FRM SUPPORTING DOCUMENTATION

FRM

SUPPORTING DOCUMENTATION 004010X098 837 2440 FRM

IMPLEMENTATION

SUPPORTING DOCUMENTATION
Loop: 2440 FORM IDENTIFICATION CODE Usage: REQUIRED Repeat: 99

1 226

Notes:

1. The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in the 2440. The FRM segment is used to answer specific questions on the form identified in the LQ. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQ*UT*0802~). See Appendix K - Supporting Documentation Example, for a more detailed explaination of how to use the 2440 Loop.

3 275

2. Loop 2440 was approved by ASC X12 in the version 004011 Data Dictionary but is included in this guide to provide standard way to report DMERC claims within the HIPAA implementation time frame. It is recommended that entitles who have a need to submit or receive DMERC claims customize their 004010 translator map to allow this loop. Example: FRMV1AVVJ0234~ FRMV1BVV500~ FRMV1CVV4~ FRMV4VY~ FRMV5AVV5~ FRMV5BVV3~ FRMV8VMETHODIST HOSPITAL~ FRMV9VINDIANAPOLIS~ FRMV10VVINDIANA~ FRMV11VVV19971101~ FRMV12VY~ FRMV1VN~

3 217

STANDARD

FRM Supporting Documentation

Level: Detail Position: 552 Loop: 2440 Requirement: Mandatory

MAY 2000

569

004010X098 837 2440 FRM SUPPORTING DOCUMENTATION

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Max Use: 99 Purpose: To specify information in response to a codified questionnaire document. Set Notes: Syntax:
DIAGRAM

1. FRM segment provides question numbers and responses for the questions on the medical necessity information form identified in LQ position 551. 1. R02030405 At least one of FRM02, FRM03, FRM04 or FRM05 is required.

FRM01

350

FRM02

1073

FRM03

127

FRM04

373

FRM05

332

FRM V
M

Assigned ID
AN 1/20

V Yes/No Cond V Resp Code

X ID 1/1 X

Reference Ident
AN 1/30

V
X

Date
DT 8/8

Allow/Chrg Percent
X R 1/6

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

FRM01

350

Assigned Identification
INDUSTRY: Question
SEMANTIC:

AN

1/20

Alphanumeric characters assigned for differentiation within a transaction set

Number/Letter

FRM01 is the question number on a questionnaire or codified form.

SITUATIONAL

FRM02

1073

Yes/No Condition or Response Code

Code indicating a Yes or No condition or response
INDUSTRY: Question
SYNTAX:

ID

1/1

Response

R02030405

SEMANTIC:

FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01.

2307 2307

NSF Reference: GU0-26.0, GU0-27.0, GU0-28.0, GU0-29.0, GU0-30.0, GU0-31.0, GU032.0, GU0-33.0, GU0-34.0, GU0-35.0, GU0-36.0, GU0-37.0, GU0-38.0, GU0-39.0, GU0-40.0, GU0-43.0, GU0-44.0 FRM02, 03, 04, or 05 is required. Used to answer question identified in FRM01 which utilizes a Yes/No response format.
CODE DEFINITION

2249 2671

N W Y

No Not Applicable Yes

570

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 2440 FRM SUPPORTING DOCUMENTATION

SITUATIONAL

FRM03

127

Reference Identification

AN

1/30

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
INDUSTRY: Question
SYNTAX:

Response

R02030405

2329 2329

NSF Reference: GU0-28.0, GU0-31.0, GU0-33.0, GU0-45.0, GU0-46.0, GU0-47.0, GU048.0, GU0-49.0, GU0-50.0, GU0-51.0, GU0-57.0, GU0-58.0, GU0-59.0, GU0-60.0, GU0-61.0, GU0-62.0, GU0-63.0, GU0-64.0, GU0-65.0, GU066.0, GU0-67.0, GU0-68.0 FRM02, 03, 04, or 05 is required. Used to answer question identified in FRM01 which utilizes a text or uncodified response format. FRM04 373 Date
Date expressed as CCYYMMDD
INDUSTRY: Question
SYNTAX: R02030405

2249 2668
SITUATIONAL

DT

8/8

Response

2333 2333 2249 2673

SITUATIONAL FRM05 332

NSF Reference: GU0-53.0, GU0-54.0, GU0-55.0, GU0-56.0 FRM02, 03, 04, or 05 is required. Used to answer question identified in FRM01 which utilizes a date response format. Percent
Percent expressed as a percent
INDUSTRY: Question
SYNTAX:

1/6

Response

R02030405

2336 2336 2249 2672

NSF Reference: GU0-69.0, GU0-70.0, GU0-71.0 FRM02, 03, 04, or 05 is required. Used to answer question identified in FRM01 which utilizes a percent response format.

MAY 2000

571

004010X098 837 SE TRANSACTION SET TRAILER

TRANSACTION SET TRAILER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SE

TRANSACTION SET TRAILER 004010X098 837 SE

IMPLEMENTATION

TRANSACTION SET TRAILER

Usage: REQUIRED Repeat: 1

9 107
STANDARD

Example: SEV211V987654~

SE Transaction Set Trailer

Level: Detail Position: 555 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
DIAGRAM

SE01

96

SE02

329

SE V

Number of Inc Segs

M N0 1/10

TS Control Number
M AN 4/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

SE01

96

Number of Included Segments

N0

1/10

Total number of segments included in a transaction set including ST and SE segments

INDUSTRY: Transaction ALIAS: Segment

Segment Count

Count
M AN 4/9

REQUIRED

SE02

329

Transaction Set Control Number

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
ALIAS: Transaction

Set Control Number

1840

The Transaction Set Control Numbers in ST02 and SE02 must be identical. The Transaction Set Control Number is assigned by the originator and must be unique within a functional group (GS-GE) and interchange (ISA-IEA). This unique number also aids in error resolution research.

572

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

4 EDI Transmission Examples for Different Business Uses

4.1
4.1.1

Professional
Example 1
Patient is the same person as the Subscriber. Payer is an HMO. Encounter is transmitted through a clearinghouse. Submitter is the billing service, receiver is a repricer. SUBSCRIBER/PATIENT: Ted Smith, ADDRESS:236 N. Main St., Miami, Fl, 33413, TELEPHONE NUMBER: 305-555-1111 SEX: M DOB: 05/01/43 EMPLOYER: ACME Inc. GROUP #: 12312-A PAYER ID NUMBER: SSN SSN: 000-22-1111 DESTINATION PAYER: Alliance Health and Life Insurance Company (AHLIC), PAYOR ADDRESS: 2345 West Grand Blvd, Detroit, MI 48202. , AHLIC #: 741234 RECEIVER: XYZ REPRICER EDI #: 66783JJT BILLING PROVIDER/SENDER: Premier Billing Service, ADDRESS: 234 Seaway St, Miami, FL, 33111 TIN: 587654321, EDI #: TGJ23 CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231 PAY-TO PROVIDER: Kildare Associates, PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111. PROVIDER ID: 99878-ABA TIN: 581234567 RENDERING PROVIDER: Dr. Ben Kildare/Family Practitioner AHLIC PROVIDER ID#: 9741234 PATIENT ACCOUNT NUMBER: 2-646-2967 CASE:Patient has sore throat. DOS=10/03/98. POS=Office, TOS=06 (office visit)/08 (lab) SERVICES RENDERED: Office visit, intermediate service, established patient, throat culture. FOLLOW-UP VISIT: DOS=10/10/97 because antibiotics didnt work (pain continues). SERVICES: Office visit, intermediate service, established patient, mono screening. CHARGES: Office first visit = $40.00, Lab test for strep = $15.00, lab test for mono = $10.00, Follow-up visit = $35.00. Total charges - $100.00.

MAY 2000

573

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ELECTRONIC ROUTE: billing provider(sender) to Clearinghouse to XYW REPRICER (receiver) to AHLIC (not shown); Clearinghouse claim identification number = 17312345600006351.

SEG #

LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*0021~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19981015*1023*RP~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~ 1000A SUBMITTER NM1 SUBMITTER NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JERRY*TE*3055552222*EX*231~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*REPRICER XYZ*****46*66783JJT~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL-BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NAME NM1*85*2*PREMIER BILLING SERVICE*****MI*587654321~ N3 BILLING PROVIDER ADDRESS N3*234 Seaway St~ N4 BILLING PROVIDER LOCATION N4*Miami*FL*33111~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~ N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~ N4 PAY-TO PROVIDER CITY N4*MIAMI*FL*33111~ 2000B SUBSCRIBER HL LOOP HL-SUBSCRIBER HL*2*1*22*0~

2 3 4

5 6

9 10 11

12 13 14

574

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

15 16

SBR SUBSCRIBER INFORMATION SBR*P*18*12312-A******HM~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*SMITH*TED****34*000221111~ N3 SUBSCRIBER ADDRESS N3*236 N MAIN ST~ N4 SUBSCRIBER CITY N4*MIAMI*FL*33413~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*M~ 2010BB SUBSCRIBER/PAYER NM1 PAYER NAME NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE *****PI*741234~ N2 PAYER ADDITIONAL NAME INFORMATION N2*COMPANY~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*26462967*100***11::1*Y*A*Y*Y*C~ DTP DATE OF ONSET DTP*431*D8*19981003~ REF CLEARING HOUSE CLAIM NUMBER (Added by C.H.) REF*D9*17312345600006351~ HI HEALTH CARE DIAGNOSIS CODES HI*BK:0340*BF:V7389~ 2310B RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN***34*112233334~ PRV RENDERING PROVIDER INFORMATION PRV*PE*ZZ*203BF0100Y~ 2310D SERVICE LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~ N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~

17 18 19 20

21 22

23 24

25 26

27 28

29 30

MAY 2000

575

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

31

2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99213*40*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:99214*15*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:87072*35*UN*1***2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*4~ SV1 PROFESSIONAL SERVICE SV1*HC:86663*10*UN*1***2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981010~ TRAILER SE TRANSACTION SET TRAILER SE*43*0021~

32 33 34

35 36 37

38 39 40

41 42 43

Complete data string:

ST*837*0021~BHT*0019*00*0123*19981015*1023*RP~REF* 87*004010X098~NM1*41*2*PREMIER BILLING SERVICE** ***46*TGJ23~PER*IC*JERRY*TE*3055552222*EX*231~NM1* 40*2*REPRICER XYZ*****46*66783JJT~HL*1**20*1~NM1* 85*2*PREMIER BILLING SERVICE*****24*587654321~N3* 234 Seaway St~N4*Miami*FL*33111~NM1*87*2*KILDARE ASSOC*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI *FL*33111~HL*2*1*22*0~SBR*P*18*12312-A******HM~NM1 *IL*1*SMITH*TED****34*000221111~N3*236 N MAIN ST~

576

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

N4*MIAMI*FL*33413~DMG*D8*19430501*M~NM1*PR*2* ALLIANCE HEALTH AND LIFE INSURANCE *****PI*741234~ N2*COMPANY~CLM*26462967*100***11::1*Y*A*Y*Y*C~DTP* 431*D8*19981003~REF*D9*17312345600006351~HI*BK:0340 *BF:V7389~NM1*82*1*KILDARE*BEN****34*112233334~PRV *PE*ZZ*203BF0100Y~ NM1*77*2*KILDARE ASSOCIATES** ***24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL* 33111~LX*1~SV1*HC:99213*40*UN*1***1**N~DTP*472*D8* 19981003~LX*2~SV1*HC:99214*15*UN*1***1**N~DTP*472* D8*19981003~LX*3~SV1*HC:87072*35*UN*1***2**N~DTP* 472*D8*19981003~LX*4~SV1*HC:86663*10*UN*1***2**N~ DTP*472*D8*19981010~SE*43*0021~

4.1.2

Example 2
Patient is a different person than the Subscriber. Payer is commercial health insurance company. SUBSCRIBER: Jane Smith PATIENT ADDRESS:236 N. Main St., Miami, Fl, 33413 TELEPHONE NUMBER: 305-555-1111 SEX: F DOB: 05/01/43 EMPLOYER: ACME Inc. GROUP #: 2222-SJ KEY INSURANCE COMPANY ID #: JS00111223333 SSN: 111-22-3333 PATIENT: Ted Smith PATIENT ADDRESS:236 N. Main St., Miami, Fl, 33413 TELEPHONE NUMBER: 305-555-1111 SEX: M DOB: 05/01/73 KEY INSURANCE COMPANY ID #: JS01111223333 SSN: 000-22-1111 DESTINATION PAYER: Key Insurance Company PAYOR ADDRESS: 3333 Ocean St. South Miami, FL 33000 RECEIVER: XYZ REPRICER EDI #:66783JJT BILLING PROVIDER/SENDER: Premier Billing Service TIN: 587654321 ADDRESS: 234 Seaway St, Miami, FL, 33111 EDI #: TGJ23 KEY INSURANCE COMPANY PAYOR ID #: PBS3334 PAY-TO PROVIDER: Kildare Associates, PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111., PROVIDER KEY Insurance Company ID: 99878-ABA, TIN: 581234567

MAY 2000

577

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

RENDERING PROVIDER: Dr. Ben Kildare KEY INSURANCE COMPANY PROVIDER ID#: KA6663 TIN: 999996666 PATIENT ACCOUNT NUMBER: 2-640-3774 CASE:Patient has sore throat. DOS=10/03/97. POS=Office, TOS=06 (office visit)/08 (lab) SERVICES RENDERED: Office visit, intermediate service, established patient, throat culture: FOLLOW-UP VISIT DOS=10/10/97 because antibiotics didnt work (pain continues). SERVICES: Office visit, intermediate service, established patient, mono screening. CHARGES: Office first visit = $40.00, Lab test for strep = $15.00, lab test for mono = $10.00, Follow-up visit = $35.00. Total charges - $100.00. ELECTRONIC ROUTE: billing provider (sender), VAN to XYZ Repricer (receiver) to AHLIC (not shown); VAN claim identification number = 17312345600006351.
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*3456~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*244579*19981015*1023*CH~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~ 1000A SUBMITTER NM1 SUBMITTER NAME NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JERRY*3055552222~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*ABC VALUE ADDED NETWORK*****46*6666VAN~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL - BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NAME NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~ N3 BILLING PROVIDER ADDRESS N3*234 SEAWAY ST~ N4 BILLING PROVIDER LOCATION N4*MIAMI*FL*33111~
MAY 2000

2 3 4

5 6

9 10

578

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

11

REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*G2*PBS3334~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~ N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~ N4 PAY-TO PROVIDER CITY N4*MAIMI*FL*33111~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*G2*99878-ABA~ 2000B SUBSCRIBER HL LOOP HL - SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*P**2222-SJ******CI~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*SMITH*JANE****MI*111223333~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*F~ 2010BB PAYER NM1 PAYER NAME NM1*PR*2*KEY INSURANCE COMPANY*****24*999996666~ N3 PAYER ADDRESS N3*3333 OCEAN ST~ N4 PAYER CITY/STATE/ZIP CODE N4*SOUTH MIAMI*FL*33000~ 2000C PATIENT HL LOOP HL - PATIENT HL*3*2*23*0~ PAT PATIENT INFORMATION PAT*19~ 2010CA PATIENT NM1 PATIENT NAME NM1*QC*1*SMITH*TED****MI*JS01111223333~ N3 PATIENT ADDRESS N3*236 N MAIN ST~

12

13 14 15 16

17 18

19 20

21 22 23

24 25

26

MAY 2000

579

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

27 28 29 30

N4 PATIENT CITY/STATE/ZIP N4*MIAMI*FL*33413~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19730501*M~ REF PATIENT SECONDARY IDENTIFICATION REF*SY*000221111~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*26463774*100***11::1*Y*A*Y*Y*S~ REF CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES (added by C.H.) REF*D9*17312345600006351~ HI HEALTH CARE DIAGNOSIS CODES HI*BK:0340*BF:V7389~ 2310 RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN****24*999996666~ PRV RENDERING PROVIDER INFORMATION PRV*PE*ZZ*203BF0100Y~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*G2*KA6663~ 2210D SERVICE LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~ N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99213*40*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~

31

32 33

34 35

36

37 38 39

40 41 42

580

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

43 44 45

SV1 PROFESSIONAL SERVICE SV1*HC:99214*15*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:87072*35*UN*1***2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*4~ SV1 PROFESSIONAL SERVICE SV1*HC:86663*10*UN*1***2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981010~ TRAILER SE TRANSACTION SET TRAILER SE*51*3456~

46 47 48

49 50 51

Complete Data String:

ST*837*3456~BHT*0019*00*244579*19981015*1023*CH~ REF*87*004010X098~NM1*41*2*PREMIER BILLING SERVICE *****46*TGJ23~PER*IC*JERRY*3055552222~NM1*40*2*ABC VALUE ADDED NETWORK*****46*6666VAN~HL*1**20*1~NM1 *85*2*PREMIER BILLING SERVICE*****24*587654321~N3 *234 SEAWAY ST~N4*MIAMI*FL*33111~REF*G2*PBS3334~ NM1*87*2*KILDARE ASSOC*****24*581234567~N3*2345 OCEAN BLVD~N4*MAIMI*FL*33111~REF*G2*99878-ABA~ HL*2*1*22*1~SBR*P**2222-SJ******CI~NM1*IL*1*SMITH* JANE****34*11223333~DMG*D8*19430501*F~NM1*PR*2*KEY INSURANCE COMPANY*****24*999996666~N3*3333 OCEAN ST~N4*SOUTH MIAMI*FL*33000~HL*3*2*23*0~PAT*19~NM1* QC*1*SMITH*TED****MI*JS01111223333~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19730501*M~REF*SY* 000221111~CLM*26463774*100***11::1*Y*A*Y*Y*S~REF*D9 *17312345600006351~HI*BK:0340*BF:V7389~NM1*82*1* KILDARE*BEN****24*999996666~PRV*PE*ZZ*203BF0100Y~ REF*G2*KA6663~NM1*77*2*KILDARE ASSOCIATES*****24* 581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~
MAY 2000

581

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

LX*1~SV1*HC:99213*40*UN*1***1**N~DTP*472*D8*1998100 3~LX*2~SV1*HC:99214*15*UN*1***1**N~DTP*472*D8*19981 003~LX*3~SV1*HC:87072*35*UN*1***2**N~DTP*472*D8*199 81003~LX*4~SV1*HC:86663*10*UN*1***2**N~DTP*472*D8*1 9981010~SE*51*3456~

4.1.3

Example 3
Coordination of benefits; patient is not the subscriber; payers are commercial health insurance companies, provider-to payer COB model. SUBSCRIBER FOR PAYER A: Jane Smith ADDRESS: 236 N. Main St., Miami, Fl 33413 TELEPHONE NUMBER: 305-555-1111 SEX:F DOB:05/01/43 EMPLOYER: Acme, Inc. PAYER A ID NUMBER: JS00111223333 SSN:111-22-3333 SUBSCRIBER FOR PAYER B: Jack Smith ADDRESS: 236 N. Main St., Miami, Fl 33413 TELEPHONE NUMBER: 305-555-1111 SEX: M DOB: 10/22/43 EMPLOYER: Telecom of Florida PAYER B ID NUMBER: T55TY666 SSN: 222-33-4444 PATIENT: Ted Smith ADDRESS: 236 N. Main St., Miami, Fl 33413 TELEPHONE NUMBER: 305-555-1111 SEX: M DOB: 05/01/73 PAYER A ID NUMBER: JS01111223333 PAYER B ID NUMBER: T55TY666-01 SSN:000-22-1111 DESTINATION PAYER A: Key Insurance Company PAYER A ADDRESS: 3333 Ocean St., South Miami, FL, 33000 PAYER A ID NUMBER: (TIN) 999996666 RECEIVER FOR PAYER A: XYZ REPRICER EDI #: 66783JJT DESTINATION PAYER B (RECEIVER): Great Prairies Health PAYER B ADDRESS: 4456 South Shore Blvd., Chicago, IL 44444 PAYER B ID NUMBER: 567890 EDI #: 567890 BILLING PROVIDER/SENDER: Premier Billing Service ADDRESS: 234 Seaway St, Miami, FL, 33111 PAYER A ID NUMBER: PBS3334 PAYER B ID NUMBER: EJ6666 TIN: 587654321

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

EDI # FOR RECEIVER A: TGJ23 EDI # FOR PAYER B: 12EEER000-TY PAY-TO PROVIDER: Kildare Associates, ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111. PAYER A ID NUMBER: 99878-ABA PAYER B ID NUMBER: EX7777 TIN: 581234567 RENDERING PROVIDER: Dr. Ben Kildare PAYER A ID NUMBER: KA6663 PAYER B ID NUMBER: 88877 TIN: 999996666 PATIENT ACCOUNT NUMBER: 2-640-7789 CASE: Patient came to office for routine hyperlipidemia check. DOS=10/03/97, POS=Office; Patient also complained of hay fever and heart burn. SERVICES RENDERED: Patient received injection for hyperlipidemia and hay fever. CHARGES: Patient was charged for office visit ($43.00), and two injections ($15.00 and $21.04). ELECTRONIC PATH: The billing provider (sender) transmits the claim to Payer A (receiver) (Example 3.a) who adjudicates the claim. Payer A transmits back an 835 to the billing provider. The billing provider then submits a second claim to Payer B (receiver) (Example 3.b). Example 3.A Claim to Payer A from Billing Provider
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*0002~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19981015*1023*CH~ REF TRANSACTION TYPE IDENTIFICATION REF*87*004010X098~ 1000A SUBMITTER NM1 SUBMITTER NAME NM1*41*2*PREMIER BILLING SERVICE*****46*567890~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JERRY*3055552222~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*XYZ REPRICER*****46*66783JJT~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL - BILLING PROVIDER HL*1**20*1~

2 3 4

5 6

MAY 2000

583

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

2010AA BILLING PROVIDER NM1 BILLING PROVIDER NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~ N3 BILLING PROVIDER ADDRESS N3*1234 SEAWAY ST~ N4 BILLING PROVIDER CITY/STATE/ZIP N4*MIAMI*FL*33111~ REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*G2*PBS3334~ PER BILLING PROVIDER CONTACT INFORMATION PER*IC*CONNIE*TE*3055551234~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~ N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~ N4 PAY-TO PROVIDER CITY/STATE/ZIP N4*MIAMI*FL*33111~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*G2*99878-ABA~ 2000B SUBSCRIBER HL LOOP HL - SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*P********CI~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*SMITH*JANE****34*111223333~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*F~ REF SUBSCRIBER SECONDARY IDENTIFICATION REF*IW*JS00111223333~ 2010BB PAYER NM1 PAYER NAME NM1*IN*2*KEY INSURANCE COMPANY*****24*999996666~ N3 PAYER ADDRESS N3*3333 OCEAN ST~

9 10 11

12 13

14 15 16 17

18 19

20 21 22

23

584

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

24 25

N4 PAYER CITY/STATE/ZIP N4*SOUTH MIAMI*FL*33000~ 2000C PATIENT HL LOOP HL - PATIENT HL*3*1*23*0~ PAT PATIENT INFORMATION PAT*02~ 2010CA PATIENT NM1 PATIENT NAME NM1*QC*1*SMITH*TED****MI*JS01111223333~ N3 PATIENT ADDRESS N3*236 N MAIN ST~ N4 PATIENT CITY/STATE/ZIP N4*MIAMI*FL*33413~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19730501*M~ REF PATIENT SECONDARY IDENTIFICATION NUMBER REF*SY*000221111~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*26407789*79.04***11::1*Y*A*Y*Y*B~ HI HEALTH CARE DIAGNOSIS CODES HI*BK:4779*BF:2724*BF:2780*BF:53081~ 2310A RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN****24*999996666~ PRV RENDERING PROVIDER INFORMATION PRV*PE*ZZ*203BF0100Y~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*G2*KA6663~ 2310D SERVICE FACILITY LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~ N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~

26 27

28 29 30 31 32

33 34

35 36

37

38 39

MAY 2000

585

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

40

2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99213*43*UN*1***1:2:3:4**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:90782*15*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:J3301*21.04*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ TRAILER SE TRANSACTION SET TRAILER SE*49*0002~

41 42 43

44 45 46

47 48 49

Complete Data String For Example 3.A:

ST*837*0002~BHT*0019*00*0123*19981015*1023*CH~ REF*87*004010X098~NM1*41*2*PREMIER BILLING SERV ICE*****46*567890~PER*IC*JERRY*3055552222~NM1* 40*2*XYZ REPRICER*****46*66783JJT~HL*1**20*1~ NM1*85*2*PREMIER BILLING SERVICE*****24*587654 321~N3*1234 SEAWAY ST~N4*MIAMI*FL*33111~REF*G2 *TGJ23~PER*IC*CONNIE*TE*3055551234~NM1*87*2*KIL DARE ASSOC*****24*581234567~N3*2345 OCEAN BLVD~ N4*MIAMI*FL*33111~REF*G2*99878ABA~HL*2*1*22*1~SBR *P********CI~NM1*IL*1*SMITH*JANE****34*111223333~ DMG*D8*19430501*F~REF*IW*JS00111223333~NM1*IN*2* KEY INSURANCE COMPANY*****24*999996666~N3*3333 OCEAN ST~N4*SOUTH MIAMI*FL*33000~HL*3*1*23*0~ PAT *02~NM1*QC*1*SMITH*TED****MI*JS01111223333~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19730501*M~REF* SY*000221111~CLM*26407789*79.04***11::1*Y*A*Y*Y*B~

586

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

HI*BK:4779*BF:2724*BF:2780*BF:53081~NM1*82*1*KIL DARE*BEN****24*999996666~PRV*PE*ZZ*203BF0100Y~REF *G2*KA6663~NM1*77*2*KILDARE ASSOCIATES*****24* 581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~ LX*1~SV1*HC:99213*43*UN*1***1:2:3:4**N~DTP*472* D8*19971003~LX*2~SV1*HC:90782*15*UN*1***1:2**N~ DTP*472*D8*19971003~LX*3~SV1*HC:J3301*21.04*UN* 1***1:2**N~DTP*472*D8*19971003~SE*49*0002~
+++++++++++++++++++++++++++++++++++++++++++++ Payer A returned an electronic remittance advice (835) to the Billing Provider with the following amounts and Claim Adjustment Reason Codes: SUBMITTED CHARGES (CLP03): 79.04 AMOUNT PAID (CLP04): 39.15 PATIENT RESPONSIBILITY (CLP05): 36.89 The CAS at the Claim level was: CAS*PR*1*21.89*3*15~ (INDICATES A $15.00 CO-INSURANCE PAYMENT AND $21.89 DEDUCTIBLE PAYMENT IS DUE FROM PATIENT). In addition, Payer A adjusted the office visit charges to $40.00 by contractual agreement. The CAS on line 1 was: CAS*CO*42*3~. Because the other lines did not have adjustments, there are no CAS segments for those lines. See the Introduction for a discussion on crosswalking 835s to 837s. +++++++++++++++++++++++++++++++++++++++++++++ Example 3.B Claim to Payer B from Billing Provider
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*1234~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19981015*1023*CH~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~ 1000A SUBMITTER NM1 SUBMITTER NM1*41*2*PREMIER BILLING SERVICE*****46*12EEER000TY~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JERRY*3055552222~ 1000B RECEIVER NM1 RECEIVER NM1*40*2*REPRICER XYZ*****46*66783JJT~

2 3 4

5 6

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

2000A BILLING/PAY-TO PROVIDER HL LOOP HL - BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~ N3 BILLING PROVIDER ADDRESS N3*1234 SEAWAY ST~ N4 BILLING PROVIDER CITY N4*MIAMI*FL*33111~ REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*G2*EJ6666~ PER BILLING CONTACT INFORMATION PER*IC*CONNIE*TE*3055551234~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~ N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~ N4 PAY-TO PROVIDER CITY N4*MIAMI*FL*33111~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*G2*EX7777~ 2000B SUBSCRIBER HL LOOP HL - SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*S********CI~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*SMITH*JACK****34*222334444~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19431022*M~ REF SUBSCRIBER SECONDARY IDENTIFICATION REF*1W*T55TY666~ 2010BB PAYER NM1 PAYER NAME NM1*IN*2*GREAT PRAIRIES HEALTH*****34*111223333~
MAY 2000

9 10 11

12 13

14 15 16 17

18 19

20 21 22

588

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

23 24 25 26

N3 PAYER ADDRESS N3*4456 South Shore Blvd~ N4 PAYER CITY/STATE/ZIP CODE N4*Chicago*IL*44444~ REF PAYER SECONDARY IDENTIFICATION REF*2U*567890~ 2000C PATIENT HL LOOP HL - PATIENT HL*3*2*23*0~ PAT PATIENT INFORMATION PAT*19~ 2010CA PATIENT NM1 PATIENT NAME NM1*QC*1*SMITH*TED****MI*T55TY666-01~ N3 PATIENT ADDRESS N3*236 N MAIN ST~ N4 PATIENT CITY N4*MIAMI*FL*33413~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19730501*M~ REF PATIENT SECONDARY IDENTIFICATION NUMBER REF*SY*000221111~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*26407789*79.04***11::1*Y*A*Y*Y*B~ HI HEALTH CARE DIAGNOSIS CODES HI*BK:4779*BF:2724*BF:2780*BF:53081~ 2310A RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN****24*999996666~ PRV RENDERING PROVIDER INFORMATION PRV*PE*ZZ*203BF0100Y~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*G2*88877~ 2310D SERVICE FACILITY LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~

27 28

29 30 31 32 33

34 35

36 37

38

39
MAY 2000

589

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

40 41

N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~ 2320 OTHER SUBSCRIBER INFORMATION SBR OTHER SUBSCRIBER INFORMATION SBR*P*32***CI****CI~ CAS CLAIM LEVEL ADJUSTMENTS AND AMOUNTS CAS*PR*1*21.89**3*15~ AMT COORDINATION OF BENEFITS - PAYOR PAID AMOUNT AMT*D*42.15~ AMT COORDINATION OF BENEFITS - PATIENT RESPONSBILITY AMT*F2*36.89~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*F~ OI OTHER INSURANCE COVERAGE INFORMATION OI***Y*B**Y~ 2330A OTHER SUBSCRIBER NAME NM1 OTHER SUBSCRIBER NAME NM1*IL*1*SMITH*JANE****MI*JS00111223333~ N3 OTHER SUBSCRIBER ADDRESS N3*236 N MAIN ST~ N4 OTHER SUBSCRIBER CITY N4*MIAMI*FL*33111~ 2330B OTHER SUBSCRIBER/PAYER NM1 OTHER PAYER NAME NM1*IN*2*KEY INSURANCE COMPANY*****24*999996666~ 2400 SERVICE LINE LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99213*43*UN*1***1:2:3:4**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2420 LINE ADJUDICATION INFORMATION SVD LINE ADJUDICATION INFORMATION SVD*111223333*40*HC:99213**1~ CAS LINE ADJUSTMENT CAS*CO*42*3~ DTP LINE ADJUDICATION DATE DTP*573*D8*19981015~
MAY 2000

42 43

44

45 46 47

48 49 50

51 52 53 54

55 56

590

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

57

2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:90782*15*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:J3301*21.04*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ TRAILER SE TRANSACTION SET TRAILER SE*63*1234~

58 59 60

61 62 63

Complete Data String for Example 3.B:

ST*837*1234~BHT*0019*00*0123*19981015*1023*CH~REF*8 7*004010X098~NM1*41*2*PREMIER BILLING SERVICE***** 46*12EEER000TY~PER*IC*JERRY*3055552222~NM1*40*2*RE PRICER XYZ*****46*66783JJT~HL*1**20*1~NM1*85*2* PREMIER BILLING SERVICE*****24*587654321~N3*1234 SEAWAY ST~N4*MIAMI*FL*33111~REF*G2*EJ6666~PER*IC* CONNIE*TE*3055551234~NM1*87*2*KILDARE ASSOC***** 24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~ REF*G2*EX7777~HL*2*1*22*1~SBR*S********CI~NM1*IL*1 *SMITH*JACK****34*222334444~DMG*D8*19431022*M~REF* 1W*T55TY666~NM1*IN*2*GREAT PRAIRIES HEALTH***** 34*111223333~N3*4456 South Shore Blvd~N4*Chicago *IL*44444~REF*2U*567890~HL*3*2*23*0~PAT*19~NM1*QC* 1*SMITH*TED****MI*T55TY666-01~N3*236 N MAIN ST~ N4*MIAMI*FL*33413~DMG*D8*19730501*M~REF*SY*0002211 11~CLM*26407789*79.04***11::1*Y*A*Y*Y*B~HI*BK:4779 *BF:2724*BF:2780*BF:53081~NM1*82*1*KILDARE*BEN**** 24*999996666~PRV*PE*ZZ*203BF0100Y~REF*G2*88877~SBR *P*32***CI****CI~CAS*PR*1*21.89**3*15~AMT*D*42.15~ AMT*F2*36.89~DMG*D8*19430501*F~OI***Y*B**Y~NM1*IL* 1*SMITH*JANE****MI*JS00111223333~N3*236 N MAIN ST~ N4*MIAMI*FL*33111~NM1*IN*2*KEY INSURANCE COMPANY *****24*999996666~ NM1*77*2*KILDARE ASSOCIATES**
MAY 2000

591

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

***24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL *33111~LX*1~SV1*HC:99213*43*UN*1***1:2:3:4**N~DTP* 472*D8*19981003~SVD*111223333*40*HC:99213**1~CAS*C O*42*3~DTP*573*D8*19981015~LX*2~SV1*HC:90782*15*UN *1***1:2**N~DTP*472*D8*19971003~LX*3~SV1*HC:J3301* 21.04*UN*1***1:2**N~DTP*472*D8*19971003~SE*63*1234~

Example 3.C Claim to Payer A from Billing Provider in Payer-to-Payer COB Situation (Payer A will pass the claim to Payer B). If this claim were to go from the Billing Provider to Payer A and then Payer A were to send the claim directly to Payer B, the transaction would then look like this as it comes out of the Billing Providers translator going to Payer A. In this situation, the Billing Provider must send Payer A all the COB information on Payer B.
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*0002~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19981015*1023*CH~ REF TRANSACTION TYPE IDENTIFICATION REF*87*004010X098~ 1000A SUBMITTER NM1 SUBMITTER NAME NM1*41*2*PREMIER BILLING SERVICE*****46*567890~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JERRY*3055552222~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*XYZ REPRICER*****46*66783JJT~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL - BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~ N3 BILLING PROVIDER ADDRESS N3*1234 SEAWAY ST~ N4 BILLING PROVIDER CITY/STATE/ZIP N4*MIAMI*FL*33111~

2 3 4

5 6

9 10

592

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

11

REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*G2*PBS3334~ PER BILLING PROVIDER CONTACT INFORMATION PER*IC*CONNIE*TE*3055551234~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~ N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~ N4 PAY-TO PROVIDER CITY/STATE/ZIP N4*MIAMI*FL*33111~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*G2*99878-ABA~ 2000B SUBSCRIBER HL LOOP HL - SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*P********CI~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*SMITH*JANE****34*111223333~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*F~ REF SUBSCRIBER SECONDARY IDENTIFICATION REF*IW*JS00111223333~ 2010BB PAYER NM1 PAYER NAME NM1*IN*2*KEY INSURANCE COMPANY*****24*999996666~ N3 PAYER ADDRESS N3*3333 OCEAN ST~ N4 PAYER CITY/STATE/ZIP N4*SOUTH MIAMI*FL*33000~ 2000C PATIENT HL LOOP HL - PATIENT HL*3*1*23*0~ PAT PATIENT INFORMATION PAT*02~

12 13

14 15 16 17

18 19

20 21 22

23 24 25

26

MAY 2000

593

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

27

2010CA PATIENT NM1 PATIENT NAME NM1*QC*1*SMITH*TED****MI*JS01111223333~ N3 PATIENT ADDRESS N3*236 N MAIN ST~ N4 PATIENT CITY/STATE/ZIP N4*MIAMI*FL*33413~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19730501*M~ REF PATIENT SECONDARY IDENTIFICATION NUMBER REF*SY*000221111~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*26407789*79.04***11::1*Y*A*Y*Y*B~ HI HEALTH CARE DIAGNOSIS CODES HI*BK:4779*BF:2724*BF:2780*BF:53081~ 2310A RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN****24*999996666~ PRV RENDERING PROVIDER INFORMATION PRV*PE*S3*203BF0100Y~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*G2*KA6663~ 2310D SERVICE FACILITY LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~ N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~ 2320 OTHER SUBSCRIBER INFORMATION SBR OTHER SUBSCRIBER INFORMATION SBR*P*01***C1****LI~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19431022*M~ 2330A OTHER SUBSCRIBER NAME NM1 OTHER SUBSCRIBER NAME NM1*IL*1*SMITH*JACK***MI*T55TY666~

28 29 30 31 32

33 34

35 36

37

38 39 40

41 42

594

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

43 44 45

N3 OTHER SUBSCRIBER ADDRESS N3*236 N. MAIN ST~ N4 OTHER SUBSCRIBER CITY/STATE/ZIP N4*MIAMI*FL*33413~ 2330B OTHER PAYER NAME NM1 OTHER PAYER NAME NM1*PR*2*GREAT PRAIRIES HEALTH****PI*567890~ 2330C OTHER PAYER PATIENT INFORMATION NM1 OTHER PAYER PATIENT INFORMATION NM1*QC*1******MI*T55TY666-01~ 2330E OTHER PAYER RENDERING PROVIDER NM1 OTHER PAYER RENDERING PROVIDER NM1*82*1~ REF OTHER PAYER RENDERING PROVIDER IDENTIFICATION REF*G2*88877~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99213*43*UN*1***1:2:3:4**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:90782*15*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:J3301*21.04*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ TRAILER SE TRANSACTION SET TRAILER SE*58*0002~

46

47

48

49

50 51 52

53 54 55

56 57 58

MAY 2000

595

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Complete Data String for Example 3.C:

ST*837*0002~BHT*0019*00*0123*19981015*1023*CH~REF*8 7*004010X098~NM1*41*2*PREMIER BILLING SERVICE *****46*567890~PER*IC*JERRY*3055552222~NM1*40*2*XY Z REPRICER*****46*66783JJT~HL*1**20*1~NM1*85*2* PREMIER BILLING SERVICE*****24*587654321~N3*1234 SEAWAY ST~N4*MIAMI*FL*33111~REF*G2*PBS3334~PER*IC* CONNIE*TE*3055551234~NM1*87*2*KILDARE ASSOC***** 24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~ REF*G2*99878-ABA~HL*2*1*22*1~SBR*P********CI~NM1* IL*1*SMITH*JANE****34*111223333~DMG*D8*19430501*F~ REF*IW*JS00111223333~NM1*IN*2*KEY INSURANCE COMP ANY*****24*999996666~N3*3333 OCEAN ST~N4*SOUTH MIAMI*FL*33000~HL*3*1*23*0~PAT*02~NM1*QC*1*SMITH*TED ****MI*JS01111223333~N3*236 N MAIN ST~N4*MIAMI*FL* 33413~DMG*D8*19730501*M~REF*SY*000221111~CLM*26407 789*79.04***11::1*Y*A*Y*Y*B~HI*BK:4779*BF:2724*BF: 2780*BF:53081~NM1*82*1*KILDARE*BEN****24*999996666 ~PRV*PE*S3*203BF0100Y~REF*G2*KA6663~NM1*77*2*KILDA RE ASSOCIATES*****24*581234567~N3*2345 OCEAN BLVD~ N4*MIAMI*FL*33111~SBR*P*01***C1****LI~DMG*D8* 19431022*M~NM1*IL*1*SMITH*JACK***MI*T55TY666~N3*23 6 N. MAIN ST~N4*MIAMI*FL*33413~NM1*PR*2*GREAT PRAIRIES HEALTH****PI*567890~NM1*QC*1******MI *T55TY666-01~NM1*82*1~REF*G2*88877~LX*1~SV1*HC: 99213*43*UN*1***1:2:3:4**N~DTP*472*D8*19971003~LX* 2~SV1*HC:90782*15*UN*1***1:2**N~DTP*472*D8*1997100 3~LX*3~SV1*HC:J3301*21.04*UN*1***1:2**N~DTP*472*D8 *19971003~SE*58*0002~
Example 3.D Payer A sends the claim to Payer B after adjudication. If Payer A were to then adjudicate the claim and send the claim to Payer B with the payment information, Payer A would send the transaction shown below.
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*1234~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19981015*1023*CH~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~

2 3

596

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

1000A SUBMITTER NM1 SUBMITTER NM1*41*2*KEY INSURANCE COMPANY*****46*999996666~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*COB CUSTOMER SERVICE*3031112222~ 1000B RECEIVER NM1 RECEIVER NM1*40*2*GREAT PRAIRIES HEALTH*****46*567890~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL - BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~ N3 BILLING PROVIDER ADDRESS N3*1234 SEAWAY ST~ N4 BILLING PROVIDER CITY N4*MIAMI*FL*33111~ REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*G2*EJ6666~ PER BILLING CONTACT INFORMATION PER*IC*CONNIE*TE*3055551234~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~ N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~ N4 PAY-TO PROVIDER CITY N4*MIAMI*FL*33111~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*G2*EX7777~ 2000B SUBSCRIBER HL LOOP HL - SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*S********CI~

5 6

9 10 11

12 13

14 15 16 17

18

MAY 2000

597

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

19

2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*SMITH*JACK****34*222334444~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19431022*M~ REF SUBSCRIBER SECONDARY IDENTIFICATION REF*1W*T55TY666~ 2010BB PAYER NM1 PAYER NAME NM1*IN*2*GREAT PRAIRIES HEALTH*****24*111223333~ N3 PAYER ADDRESS N3*4456 South Shore Blvd~ N4 PAYER CITY/STATE/ZIP CODE N4*Chicago*IL*44444~ REF PAYER SECONDARY IDENTIFICATION REF*2U*567890~ 2000C PATIENT HL LOOP HL - PATIENT HL*3*2*23*0~ PAT PATIENT INFORMATION PAT*19~ 2010CA PATIENT NM1 PATIENT NAME NM1*QC*1*SMITH*TED****MI*T55TY666-01~ N3 PATIENT ADDRESS N3*236 N MAIN ST~ N4 PATIENT CITY N4*MIAMI*FL*33413~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19730501*M~ REF PATIENT SECONDARY IDENTIFICATION NUMBER REF*SY*000221111~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*26407789*79.04***11::1*Y*A*Y*Y*B~ HI HEALTH CARE DIAGNOSIS CODES HI*BK:4779*BF:2724*BF:2780*BF:53081~ 2310A RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN****34*999996666~
MAY 2000

20 21 22

23 24 25 26

27 28

29 30 31 32 33

34 35

598

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

36 37

PRV RENDERING PROVIDER INFORMATION PRV*PE*ZZ*203BF0100Y~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*G2*88877~ 2310D SERVICE FACILITY LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~ N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~ 2320 OTHER SUBSCRIBER INFORMATION SBR OTHER SUBSCRIBER INFORMATION SBR*P*32***CI****CI~ CAS CLAIM LEVEL ADJUSTMENTS AND AMOUNTS CAS*PR*1*21.89**3*15~ AMT COORDINATION OF BENEFITS - PAYOR PAID AMOUNT AMT*D*42.15~ AMT COORDINATION OF BENEFITS - PATIENT RESPONSBILITY AMT*F2*36.89~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*F~ OI OTHER INSURANCE COVERAGE INFORMATION OI***Y*B**Y~ 2330A OTHER SUBSCRIBER NAME NM1 OTHER SUBSCRIBER NAME NM1*IL*1*SMITH*JANE****MI*JS00111223333~ N3 OTHER SUBSCRIBER ADDRESS N3*236 N MAIN ST~ N4 OTHER SUBSCRIBER CITY N4*MIAMI*FL*33111~ 2330B OTHER SUBSCRIBER/PAYER NM1 OTHER PAYER NAME NM1*IN*2*KEY INSURANCE COMPANY*****24*999996666~

38

39 40 41

42 43

44

45 46 47

48 49 50

MAY 2000

599

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

51

2330C OTHER PAYER PATIENT INFORMATION NM1 OTHER PAYER PATIENT INFORMATION NM1*QC*1******MI*JS01111223333~ 2330E OTHER PAYER RENDERING PROVIDER NM1 OTHER PAYER RENDERING PROVIDER NM1*82*1~ REF OTHER PAYER RENDERING PROVIDER IDENTIFICATION REF*G2*88877~ 2400 SERVICE LINE LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99213*43*UN*1***1:2:3:4**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~ 2420 LINE ADJUDICATION INFORMATION SVD LINE ADJUDICATION INFORMATION SVD*111223333*40*HC:99213**1~ CAS LINE ADJUSTMENT CAS*CO*42*3~ DTP LINE ADJUDICATION DATE DTP*573*D8*19981015~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:90782*15*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~

52

53

54 55 56 57

58 59 60

61 62
LOOP SESEGMENT/ELEMENT G STRING #

6 2400 3 SERVICE LINE LX SERVICE LINE COUNTER LX*3~

600

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

64 65 66

SV1 PROFESSIONAL SERVICE SV1*HC:J3301*21.04*UN*1***1:2**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19971003~ TRAILER SE TRANSACTION SET TRAILER SE*66*1234~

Complete Data String for Example 3.D:

ST*837*1234~BHT*0019*00*0123*19981015*1023*CH~REF*8 7*004010X098~NM1*41*2*KEY INSURANCE COMPANY***** 46*999996666~PER*IC*COB CUSTOMER SERVICE*30311 12222~NM1*40*2*GREAT PRAIRIES HEALTH*****46* 567890~HL*1**20*1~NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~N3*1234 SEAWAY ST~N4*MIAMI*FL *33111~REF*G2*EJ6666~PER*IC*CONNIE*TE*3055551234~ NM1*87*2*KILDARE ASSOC*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~REF*G2*EX7777~HL*2*
HEADER ST BHT REF SUBMITTER (LOOP 1000A) NM1 (BILLING PROVIDER A) PER RECEIVER (LOOP 1000B) NM1 (DESTINATION PAYER) HL - BILLING/PAY-TO PROVIDER (LOOP 2000A) HL BILLING PROVIDER (LOOP 2010AA) NM1 (BILLING PROVIDER) N3 (BILLING PROVIDER ADDRESS) N4 (BILLING PROVIDER CITY/STATE/ZIP) HL - SUBSCRIBER (LOOP 2000B) HL (HL04=1) SBR (INFO FOR SUBSCRIBER A) SUBSCRIBER (LOOP 2010BA) NM1 (SUBSCRIBER A NAME & ID) PAYER (LOOP 2010BB) NM1 (PAYER NAME & ID) HL - PATIENT (LOOP 2000C) HL PAT (PATIENT A1 INFO) PATIENT (LOOP 2010CA) NM1 (PATIENT A1 NAME & ID) N3 (PATIENT A1 ADDRESS) N4 (PATIENT A1 CITY/STATE/ZIP) DMG (PATIENT A1 DEMOGRAPHIC INFO) CLAIM INFORMATION (LOOP 2300) CLM (CLAIM INFO FOR PATIENT A1)

HEADER INFO

BILLING PROV INFO

SUBSCRIBER A

PATIENT A1

MAY 2000

601

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

PATIENT A1 CLAIM INFO

PATIENT A2 CLAIM

SUBSCRIBER B CLAIM

DTP (ANY APPROPRIATE DATES TO THIS CLAIM) AMT (ANY APPROPRIATE AMOUNTS TO THIS CLAIM) REF (ANY APPROPRIATE REFERENCE NUMBERS TO THIS CLAIM) HI (ALL DIAGNOSES (up to 8) APPROPRIATE TO THIS CLAIM) RENDERING PROVIDER (LOOP 2310B) NM1 (RENDERING PROVIDER NAME & ID) PRV (RENDERING PROVIDER SPECIALTY) SERVICE FACILITY LOCATION NM1 (SERVICE LOCATION NAME & ID) N3 (SERVICE LOCATION ADDRESS) N4 (SERVICE LOCATION CITY/STATE/ZIP) SERVICE LINE (LOOP 2400 - REPEAT AS MANY TIMES AS NECESSARY (up to 50 lines)) LX SV1 (SERVICE LINE INFO) DTP (DATE OF SERVICE) DTP (ANY OTHER DATES APPROPRIATE TO THIS SERVICE LINE) REF (LINE ITEM CONTROL NUMBER & ANY OTHER REFERENCE NUMBERS APPROPRIATE TO THIS SERVICE LINE) AMT (ANY AMOUNTS APPROPRIATE TO THIS SERVICE LINE) HL - PATIENT (LOOP 2000C) HL PAT (PATIENT A2 INFO) PATIENT (LOOP 2010CA) NM1 (PATIENT A2 NAME & ID) N3 (PATIENT A2 ADDRESS) N4 (PATIENT A2 CITY/STATE/ZIP) DMG (PATIENT A2 DEMOGRAPHIC INFO) CLAIM INFORMATION (LOOP 2300) CLM (CLAIM INFO FOR PATIENT A2) DTP (ANY APPROPRIATE DATES TO THIS CLAIM) AMT (ANY APPROPRIATE AMOUNTS TO THIS CLAIM) REF (ANY APPROPRIATE REFERENCE NUMBERS TO THIS CLAIM) HI (ALL DIAGNOSES (up to 8) APPROPRIATE TO THIS CLAIM) RENDERING PROVIDER (LOOP 2310B) NM1 (RENDERING PROVIDER NAME & ID) PRV (RENDERING PROVIDER SPECIALTY) SERVICE FACILITY LOCATION NM1 (SERVICE LOCATION NAME & ID) N3 (SERVICE LOCATION ADDRESS) N4 (SERVICE LOCATION CITY/STATE/ZIP) SERVICE LINE (LOOP 2400) LX SV1 (SERVICE LINE INFO) DTP (DATE OF SERVICE) DTP (ANY OTHER DATES APPROPRIATE TO THIS SERVICE LINE) REF (LINE ITEM CONTROL NUMBER & ANY OTHER REFERENCE NUMBERS APPROPRIATE TO THIS SERVICE LINE) AMT (ANY AMOUNTS APPROPRIATE TO THIS SERVICE LINE) HL - SUBSCRIBER (LOOP 2000B) HL (HL04=0) SBR (INFO FOR SUBSCRIBER B) SUBSCRIBER (LOOP 2010BA) NM1 (PATIENT B NAME & ID) (The subscriber is the patient in this case) N3 (PATIENT B ADDRESS) N4 (PATIENT B CITY/STATE/ZIP) PAYER (LOOP 2010BB) NM1 (PAYER NAME & ID) CLAIM INFORMATION (LOOP 2300)

602

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SUBSCRIBER C CLAIM

CLM (CLAIM INFORMATION FOR PATIENT B) DTP (ANY APPROPRIATE DATES TO THIS CLAIM) AMT (ANY APPROPRIATE AMOUNTS TO THIS CLAIM) REF (ANY APPROPRIATE REFERENCE NUMBERS TO THIS CLAIM) HI (ALL DIAGNOSES (up to 8) APPROPRIATE TO THIS CLAIM) RENDERING PROVIDER (LOOP 2310B) NM1 (RENDERING PROVIDER NAME & ID) PRV (RENDERING PROVIDER SPECIALTY) SERVICE FACILITY LOCATION NM1 (SERVICE LOCATION NAME & ID) N3 (SERVICE LOCATION ADDRESS) N4 (SERVICE LOCATION CITY/STATE/ZIP) SERVICE LINE (LOOP 2400 - REPEAT AS NECESSARY) LX SV1 (SERVICE LINE INFO) DTP (DATE OF SERVICE) DTP (ANY OTHER DATES APPROPRIATE TO THIS SERVICE LINE) REF (LINE ITEM CONTROL NUMBER & ANY OTHER REFERENCE NUMBERS APPROPRIATE TO THIS SERVICE LINE) AMT (ANY AMOUNTS APPROPRIATE TO THIS SERVICE LINE) HL - SUBSCRIBER (LOOP 2000B) HL (HL04=0) SBR (INFO FOR SUBSCRIBER C) SUBSCRIBER (LOOP 2010BA) NM1 (PATIENT C NAME & ID) N3 (PATIENT C ADDRESS) N4 (PATIENT C CITY/STATE/ZIP) PAYER (LOOP 2010BB) NM1 (PAYER NAME & ID) CLAIM INFORMATION (LOOP 2300) CLM (CLAIM INFORMATION FOR PATIENT C) DTP (ANY APPROPRIATE DATES TO THIS CLAIM) AMT (ANY APPROPRIATE AMOUNTS TO THIS CLAIM) REF (ANY APPROPRIATE REFERENCE NUMBERS TO THIS CLAIM) HI (ALL DIAGNOSES (up to 8) APPROPRIATE TO THIS CLAIM) REFERRING PROVIDER (LOOP 2310A) NM1 (REFERRING PROVIDER NAME & ID) PRV (REFERRING PROVIDER SPECIALTY) RENDERING PROVIDER (LOOP 2310B) NM1 (RENDERING PROVIDER NAME & ID) PRV (RENDERING PROVIDER SPECIALTY) SERVICE FACILITY LOCATION NM1 (SERVICE LOCATION NAME & ID) N3 (SERVICE LOCATION ADDRESS) N4 (SERVICE LOCATION CITY/STATE/ZIP) SERVICE LINE (LOOP 2400 - REPEAT AS NECESSARY) LX SV1 (SERVICE LINE INFO) DTP (DATE OF SERVICE) DTP (ANY OTHER DATES APPROPRIATE TO THIS SERVICE LINE) REF (LINE ITEM CONTROL NUMBER & ANY OTHER REFERENCE NUMBERS APPROPRIATE TO THIS SERVICE LINE) AMT (ANY AMOUNTS APPROPRIATE TO THIS SERVICE LINE) RENDERING PROVIDER - LINE LEVEL (LOOP 2420A) (The rendering provider for this service line is different than that listed for the claim as a whole) NM1 (RENDERING PROVIDER NAME & ID) REFERRING PROVIDER - LINE LEVEL (LOOP 2420F) (The referring provider for this service line is different than that listed for the claim as a whole) NM1 (REFERRING PROVIDER NAME & ID)

MAY 2000

603

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SUBSCRIBER D

PATIENT D1 CLAIM

PRV (REFERRING PROVIDER SPECIALTY) HL - SUBSCRIBER (LOOP 2000B) HL (HL04=0) SBR (INFO FOR SUBSCRIBER D) SUBSCRIBER (LOOP 2010BA) NM1 (SUBSCRIBER D NAME & ID) PAYER (LOOP 2010BB) NM1 (PAYER NAME & ID) HL - PATIENT (LOOP 2000C) HL PAT (PATIENT D1 INFO) PATIENT (LOOP 2010CA) NM1 (PATIENT D1 NAME & ID) N3 (PATIENT D1 ADDRESS) N4 (PATIENT D1 CITY/STATE/ZIP) DMG (PATIENT D1 DEMOGRAPHIC INFO) CLAIM INFORMATION (LOOP 2300) CLM (CLAIM INFORMATION FOR PATIENT D1) DTP (ANY APPROPRIATE DATES TO THIS CLAIM) AMT (ANY APPROPRIATE AMOUNTS TO THIS CLAIM) REF (ANY APPROPRIATE REFERENCE NUMBERS TO THIS CLAIM) HI (ALL DIAGNOSES (up to 8) APPROPRIATE TO THIS CLAIM) SERVICE FACILITY LOCATION NM1 (SERVICE LOCATION NAME & ID) N3 (SERVICE LOCATION ADDRESS) N4 (SERVICE LOCATION CITY/STATE/ZIP) SERVICE LINE (LOOP 2400 - REPEAT AS NECESSARY) LX SV1 (SERVICE LINE INFO) DTP (DATE OF SERVICE) DTP (ANY OTHER DATES APPROPRIATE TO THIS SERVICE LINE) REF (LINE ITEM CONTROL NUMBER & ANY OTHER REFERENCE NUMBERS APPROPRIATE TO THIS SERVICE LINE) AMT (ANY AMOUNTS APPROPRIATE TO THIS SERVICE LINE) FORM IDENTIFICATION (LOOP 2440) FRM (IDENTIFIES FORM) LQ (ANSWERS QUESTIONS, ONE LQ PER QUESTION) SE (TRANSACTION SET TRAILER)

604

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

1*22*1~SBR*S********CI~NM1*IL*1*SMITH*JACK****34*2 22334444~DMG*D8*19431022*M~REF*1W*T55TY666~NM1*IN* 2*GREAT PRAIRIES HEALTH*****24*111223333~N3*4456 South Shore Blvd~N4*Chicago*IL*44444~REF*2U*567 890~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH*TED****MI*T 55TY666-01~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG* D8*19730501*M~REF*SY*000221111~CLM*26407789*79.04 ***11::1*Y*A*Y*Y*B~HI*BK:4779*BF:2724*BF:2780*BF:5 3081~NM1*82*1*KILDARE*BEN****34*999996666~PRV*PE* ZZ*203BF0100Y~REF*G2*88877~NM1*77*2*KILDARE ASSOCIATES*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~SBR*P*32***CI****CI~CAS*PR*1*21.89**3 *15~AMT*D*42.15~AMT*F2*36.89~DMG*D8*19430501*F~OI* **Y*B**Y~NM1*IL*1*SMITH*JANE****MI*JS00111223333~N 3*236 N MAIN ST~N4*MIAMI*FL*33111~NM1*IN*2*KEY INSURANCE COMPANY*****24*999996666~NM1*QC*1******MI* JS01111223333~NM1*82*1~REF*G2*88877~LX*1~SV1*HC:99 213*43*UN*1***1:2:3:4**N~DTP*472*D8*19981003~SVD*1 11223333*40*HC:99213***1~CAS*CO*42*3~DTP*573*D8*19 981015~LX*2~SV1*HC:90782*15*UN*1***1:2**N~DTP*472* D8*19971003~LX*3~SV1*HC:J3301*21.04*UN*1***1:2**N~ DTP*472*D8*19971003~SE*66*1234~

4.1.4

Example 4
Transaction containing several claims from a billing provider who is also the payto provider but is not the rendering provider. The various specialty information that may be included in a claim (e.g., CR2, CRC, etc), is not shown. In this example, the exact detail of the data is not shown. Rather, this example shows the progression of segments with a verbal description of the function of each segment. The purpose of this approach is to give an overall feel for the data string involved in a typical 837 data string. The billing Provider is the pay-to provider. Several Rendering and Referring providers are involved on the various claims (shown as Rendering A, Rendering B, etc). There is no COB involved in any of these claims. Subscribers and Patients: Subscriber A has two dependents (Patient A1 and Patient A2) Subscriber B has no dependents (Patient B) Subscriber C has no dependents (Patient C) This claim has line level provider information Subscriber D has one dependent (Patient D1) This claim has an attached form

SEGMENT SERIES

MAY 2000

605

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

4.2

Property and Casualty

Healthcare Bill to Property & Casualty Payer The requirements for submitting of Healthcare bills to Property & Casualty payers to ensure prompt processing, meet jurisdictional requirements, and avoid potential fines and penalties are presented here. 837 Transaction Set Bills resulting from accident or occupationally-related injuries and illnesses should be submitted to a Property & Casualty (P&C) payer. Because coverage is triggered by a specific event, certain information is critical for the payment process. Unlike health insurance where each bill is an individual claim, for P&C a bill is a piece of information that needs to be associated with an event. The ensuing P&C claim includes both the bill information as well as the information on the event that caused the injury or illness. Information concerning the event is necessary to associate a medical bill with the P&C claim. P&C is generally governed by State Insurance Regulations, Departments of Labor, Workers Compensation Boards, or other Jurisdictionally defined entities, which often mandates compliance with Jurisdiction-specific procedures. The Business Need: Provider to P&C Payer Bill Transmission The date of accident/occurrence/onset of symptoms (Date of Loss) is a critical piece of information and should always be transmitted in the Date - Accident DTP segment within Loop ID-2300 (Claim loop). This segment triggers the applicability of P&C for consideration of payment for the health care provided. A unique identification number, referred to in P&C as a claim number, should be transmitted along with the bill information to expedite the adjudication of the bill for payment. This information can be transmitted in the REF segment of Loop ID-2010BA if the patient is the subscriber or in the REF segment of Loop ID-2010CA if the patient is not the subscriber. If no claim number is assigned or available, then the subscribers policy number should be transmitted along with the date of loss. The REF segment of the Subscriber loop (Loop ID-2010BA) should be used to transmit the policy number. In the case of a work-related injury or illness, if no claim number or policy number is available, then it is necessary to include the employers information (at a minimum name, address, and telephone number) in the NM1 segment of the Subscriber loop (Loop ID-2010BA) and the patients name and Social Security Number in the NM1 segment of the patient loop (Loop ID-2010CA). Because most P&C coverage is based upon fee-for-service arrangements, it is necessary to itemize the services provided on a line-by-line basis. Each service line should be transmitted in its own SV1 segment in the Service Line Number loop (Loop ID-2400) for clarity.

4.2.1

Example 1
The patient is a different person than the subscriber. The payer is a commercial Property & Casualty Insurance Company. Date of Accident: 03/17/97

606

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

Subscriber: Graig Norton Subscriber Address: 72 Fairway Drive, Golfers Haven, FL, 91919 Policy Number: 970925824 Insurance Company: Last Chance Insurance Company Claim Number: 88-N5223-71 Patient: William Clifton Patient Address: 1600 Razorback Avenue, Little Rock, AR, 54321 Sex: M DOB: 10/13/49 SSN: 234-55-7329 Destination Payer/Receiver: Last Chance Insurance Company Payer Address: 1 Desert Line Road, Reno, NV, 44544 Payer ID: 123456789 Billing Provider/Sender: Presidential Chiropractic TIN: 222559999 National Provider Identifier: 777BH666 Address: 5 Lumbar Lane, Golfers Haven, FL, 91919 Telephone: 321-555-6677 Pay-To-Provider: Presidential Chiropractic Rendering Provider: Mack Donald, DC National Provider Identifier: 999OU812 TIN: 311235689 Referring Provider: THEODORE ZEUSS National Provider Identifier: 999DS427 Specialty: Family Practice Patient Account Number: 686868686 CASE: Patient was a guest in Subscribers home when he fell and injured his low back. DOS=03/18/97, POS=Office Diagnosis: 847.2 Services Rendered: Office visit, intermediate service, new patient; x-ray of spine; electrical stimulation; ultrasound; massage; and hot packs. CHARGES: Office visit = $60.00, x-ray = $75.00, electrical stimulation = $25.00, ultrasound = $25.00, massage = $35.00, hot packs = $25.00. Total charges = $245.00. Electronic Route: Billing provider (sender) to payer (receiver) via LAN.
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*872391~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19970410*1339*CH~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~

2 3

MAY 2000

607

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

1000A SUBMITTER NM1 SUBMITTER NM1*41*2*PRESIDENTIAL CHIROPRACTIC*****46*777BH666~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*LARRY*TE*3215556677~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*LAST CHANCE INSURANCE COMPANY*****46*123456789~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL-BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NAME NM1*85*2*PRESIDENTIAL CHIROPRACTIC*****XX*777BH666~ N3 BILLING PROVIDER ADDRESS N3*5 LUMBAR LANE~ N4 BILLING PROVIDER LOCATION N4*GOLFERS HAVEN*FL*91919~ REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*EI*222559999~ PER BILLING PROVIDER CONTACT INFORMATION PER*IC*SUSAN*TE*3215557777~ 2000B SUBSCRIBER HL LOOP HL-SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*P********LM~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*NORTON*GRAIG****MI*970925824~ 2010BB SUBSCRIBER/PAYER NM1 PAYER NAME NM1*PR*2*LAST CHANCE INSURANCE COMPANY*****XV*123456789~ N3 PAYER STREET ADDRESS N3*1 DESERT LINE ROAD~ N4 PAYER CITY/STATE/ZIP N4*RENO*NV*44544~
MAY 2000

5 6

9 10 11

12 13

14 15

16

17 18

608

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

19

2000C PATIENT HL LOOP HL-PATIENT HL*3*2*23*0~ PAT PATIENT INFORMATION PAT*41~ NM1 2010CA PATIENT NAME NM1 PATIENT NAME NM1*QC*1*CLIFTON*WILLIAM****34*234557329~ N3 PATIENT STREET ADDRESS N3*1600 RAZORBACK AVENUE~ N4 PATIENT CITY/STATE/ZIP N4*LITTLE ROCK*AR*54321~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19491013*M~ REF PROPERTY AND CASUALTY CLAIM NUMBER REF*Y4*88N522371~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*686868686*245***11::1*Y*A*Y*Y*B*OA~ DTP DATE - INITIAL TREATMENT DTP*454*D8*19970318~ DTP DATE - ACCIDENT DTP*439*D8*19970317~ CR2 SPINAL MANIPULATION SERVICE INFORMATION CR2*1*1***DA*1*1*A*Y***Y~ HEALTH CARE DIAGNOSIS CODES HI*BK:8472~ 2310A REFERRING PROVIDER NM1 REFERRING PROVIDER NM1*DN*1*ZEUSS*THEODORE****XX*999DS427~ REFERRING PROVIDER SPECIALTY INFORMATION PRV*RF*ZZ*203BF0100Y~ 2310B RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*DONALD*MACK****XX*999OU812~ PRV RENDERING PROVIDER SPECIALTY INFORMATION PRV*PE*ZZ*111NS0005N~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*EI*311235689~

20 21

22 23 24 25 26

27 28 29 30 31

32 33

34 35

MAY 2000

609

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

36

2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99204*60*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970318~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:72100*75*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970318~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:97010*25*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970318~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*4~ SV1 PROFESSIONAL SERVICE SV1*HC:97014*25*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970318~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*5~ SV1 PROFESSIONAL SERVICE SV1*HC:97124*35*UN*1***1**N~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970318~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*6~ SV1 PROFESSIONAL SERVICE SV1*HC:97035*25*UN*1***1**N~
MAY 2000

37 38 39

40 41 42

43 44 45

46 47 48

49 50 51

52

610

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

53 54

DTP DATE - SERVICE DATE(S) DTP*472*D8*19970318~ TRAILER SE TRANSACTION SET TRAILER SE*54*872391~

Entire data string: ST*837*872391~BHT*0019*00*0123*19970410*1339*CH~ REF *87*004010X098~NM1*41*2*PRESIDENTIAL CHIROPRACTIC*****46*777BH666~PER*IC*LARRY*TE*321555 6677~NM1*40*2*LAST CHANCE INSURANCE COMPANY***** 46*123456789~HL*1**20*1~NM1*85*2*PRESIDENTIAL CHIROPRACTIC*****XX*777BH666~N3*5 LUMBAR LANE~ N4*GOLFERS HAVEN*FL*91919~REF*EI*222559999~PER*IC* SUSAN*TE*3215557777~HL*2*1*22*1~SBR*P********LM~ NM1*IL*1*NORTON*GRAIG****MI*970925824~NM1*PR*2* LAST CHANCE INSURANCE COMPANY*****XV*123456789~N3* 1 DESERT LINE ROAD~N4*RENO*NV*44544~HL*3*2*23*0~ PAT*41~NM1*QC*1*CLIFTON*WILLIAM****34*234557329~ N3*1600 RAZORBACK AVENUE~N4*LITTLE ROCK*AR*54321~ DMG*D8*19491013*M~REF*Y4*88N522371~CLM*686868686*2 45***11::1*Y*A*Y*Y*B*OA~DTP*454*D8*19970318~DTP*43 9*D8*19970317~CR2*1*1***DA*1*1*A*Y***Y~HI*BK:8472~ NM1*DN*1*ZEUSS*THEODORE****XX*999DS427~PRV*RF*ZZ* 203BF0100Y~NM1*82*1*DONALD*MACK****XX*999OU812~ PRV*PE*ZZ*111NS0005N~REF*EI*311235689~LX*1~SV1*HC: 99204*60*UN*1***1**N~DTP*472*D8*19970318~LX*2~SV1* HC:72100*75*UN*1***1**N~DTP*472*D8*19970318~LX*3~ SV1*HC:97010*25*UN*1***1**N~DTP*472*D8*19970318~LX *4~SV1*HC:97014*25*UN*1***1**N~DTP*472*D8*19970318 ~LX*5~SV1*HC:97124*35*UN*1***1**N~DTP*472*D8*19970 318~LX*6~SV1*HC:97035*25*UN*1***1**N~DTP*472*D8*19 970318~SE*54*872391~

4.2.2

Example 2
The patient is a different person than the subscriber. The payer is a commercial Property & Casualty Insurance Company. Date of Accident: 02/12/97 Subscriber: Jen & Barrys Ice Cream Shoppe Subscriber Address: 123 Rocky Road, Cherry, VT, 55555

MAY 2000

611

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Policy Number: WC-96-2222-L Insurance Company: Basket & Roberts Insurance Company Claim Number: W9-1234-99 Patient: Penny Plump Patient Address: 265 Double Dip Lane, Sugar Cone, VT, 55544 Sex: F DOB: 02/11/77 SSN: 115-68-3870 Destination Payer/Receiver: Basket & Roberts Insurance Company Payer Address: 31 Flavor Street, Maple, VT, 55534 Payer ID: 345345345 Billing Provider/Sender: Speedy Billing Service TIN: 333119999 Address: 1 EDI Way, Walnut, VT, 55333 Contact: Sam Speedy 815-555-4444 Pay-To-Provider: Sam Sweettooth, MD TIN: 331330001 National Provider Identifier: 777ST123 Proprietary Payer Identifier: 331330001 Address: 837 Professional Drive, Pistachio, VT, 55557 Telephone: 617-555-3210 Rendering Provider: Sam Sweettooth, MD Service Location: Pistachio Emergency Services 123 Emergency Way, Pistachio, VT 55576 National Provider Identifier: ERP66655 Patient Account Number: 888-22-8888 CASE: Patient is an employee of Subscriber. She slammed her thumb in the freezer case. DOS=02/12/97, ER Attending Physician SERVICES RENDERED: ER Professional Component DOS=02/26/97, POS=Office, TOS=Medical Care & Diagnostic x-ray Diagnosis: 816.02 (Principle), 354.0 (Additional) Services Rendered: Office visit, x-ray, splint. CHARGES: ER visit = $210.00, F/U Office Visit = $120.00, X-ray = $50.00, Splint = $25.00. Total charges = $405.00 Electronic Route: Billing Service (sender), VAN to Payer (receiver).
SEG # LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*872401~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0124*19970411*0724*CH~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~

2 3

612

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

1000A SUBMITTER NM1 SUBMITTER NM1*41*2*SPEEDY BILLING SERVICE*****46*333119999~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*SAM SPEEDY*TE*8154445555~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*BASKET & ROBERTS INSURANCE COMPANY*****46*345345345~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL-BILLING PROVIDER HL*1**20*1~ 2010AA BILLING PROVIDER NM1 BILLING PROVIDER NAME NM1*85*2*SPEEDY BILLING SERVICE*****24*333119999~ N3 BILLING PROVIDER ADDRESS N3*1 EDI WAY~ N4 BILLING PROVIDER LOCATION N4*WALNUT*VT*55333~ 2010AB PAY-TO PROVIDER NM1 PAY-TO PROVIDER NAME NM1*87*1*SWEETTOOTH*SAM****XX*777ST123~ N3 PAY-TO PROVIDER ADDRESS N3*837 PROFESSIONAL DRIVE~ N4 PAY-TO PROVIDER CITY/STATE/ZIP N4*PISTACHIO*VT*55557~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*EI*331330001~ REF PAY-TO PROVIDER SECONDARY IDENTIFICATION REF*G2*331330001~ 2000B SUBSCRIBER HL LOOP HL-SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*P********WC~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*2*JEN & BARRYS ICE CREAM SHOPPE*****MI*WC962222L~

5 6

9 10 11

12 13 14 15 16

17 18

MAY 2000

613

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

19

2010BB SUBSCRIBER/PAYER NM1 PAYER NAME NM1*PR*2*BASKET & ROBERTS INSURANCE COMPANY*****XV*345345345~ N3 PAYER STREET ADDRESS N3*31 FLAVOR STREET~ N4 PAYER CITY/STATE/ZIP N4*MAPLE*VT*55222~ 2000C PATIENT HL LOOP HL-PATIENT HL*3*2*23*0~ PAT PATIENT INFORMATION PAT*20~ NM1 2010CA PATIENT NAME NM1 PATIENT NAME NM1*QC*1*PLUMP*PENNY****34*115683870~ N3 PATIENT STREET ADDRESS N3*265 DOUBLE DIP LANE~ N4 PATIENT CITY/STATE/ZIP N4*SUGAR CONE*VT*55544~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19770211*F~ REF PROPERTY AND CASUALTY CLAIM NUMBER REF*Y4*W9123499~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*888228888*405***11::1*Y*A*Y*Y*B*EM:OA~ 30 DTP DATE - ACCIDENT DTP*439*D8*19970212~ DTP DATE - INITIAL TREATMENT DTP*454*D8*19970212~ HEALTH CARE DIAGNOSIS CODES HI*BK:81602*BF:354~ 2310B RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*SWEETTOOTH*SAM****XX*777ST123~ RENDERING PROVIDER SPECIALTY INFORMATION PRV*PE*ZZ*203BE004Y~ REF RENDERING PROVIDER SECONDARY IDENTIFICATION REF*EI*331330001~
MAY 2000

20 21 22

23 24

25 26 27 28 29

31 32 33

34 35

614

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

36

2310D SERVICE FACILITY LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*1*PISTACHIO EMERGENCY SERVICES****XX* ERP66655~ N3 SERVICE FACILITY LOCATION ADDRESS N3*123 EMERGENCY WAY~ N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP N4*PISTACHIO*VT*55556~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99242*120*UN*1***1**Y~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970226~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:A4570*25*UN*1***1**Y~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970226~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*3~ SV1 PROFESSIONAL SERVICE SV1*HC:73140*50*UN*1***1**Y~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970226~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*4~ SV1 PROFESSIONAL SERVICE SV1*HC:99283*210*UN*1*23**1:2**Y~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19970212~ TRAILER SE TRANSACTION SET TRAILER SE*51*872401~

37 38 39

40 41 42

43 44 45

46 47 48

49 50 51

MAY 2000

615

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Entire data string: ST*837*872401~BHT*0019*00*0124*19970411*0724*CH~ REF *87*004010X098~NM1*41*2*SPEEDY BILLING SERVICE *****46*333119999~PER*IC*SAM SPEEDY*TE*8154445555~ NM1*40*2*BASKET & ROBERTS INSURANCE COMPANY***** 46*345345345~HL*1**20*1~NM1*85*2*SPEEDY BILLING SERVICE*****24*333119999~N3*1 EDI WAY~N4*WALNUT*VT *55333~ NM1*87*1*SWEETTOOTH*SAM****XX*777ST123~ N3*837 PROFESSIONAL DRIVE~N4*PISTACHIO*VT*55557~ REF*EI*331330001~REF*G2*331330001~ HL*2*1*22*1~SBR*P********WC~NM1*IL*2*JEN & BARRYS ICE CREAM SHOPPE*****MI*WC962222L~NM1*PR*2*BASKET & ROBERTS INSURANCE COMPANY*****XV*345345345~ N3*31 FLAVOR STREET~N4*MAPLE*VT*55222~ HL*3*2*23 *0~PAT*20~NM1*QC*1*PLUMP*PENNY****34*115683870~N3* 265 DOUBLE DIP LANE~N4*SUGAR CONE*VT*55544~DMG*D8* 19770211*F~REF*Y4*W9123499~CLM*888228888*405***11: :1*Y*A*Y*Y*B*EM:OA~DTP*439*D8*19970212~DTP*454*D8* 19970212~HI*BK:81602*BF:354~NM1*82*1*SWEETTOOTH* SAM****XX*777ST123~PRV*PE*ZZ*203BE004Y~REF*EI*3313 30001~NM1*77*1*PISTACHIO EMERGENCY SERVICES****XX* ERP66655~N3*123 EMERGENCY WAY~N4*PISTACHIO*VT* 55556~LX*1~SV1*HC:99242*120*UN*1***1**Y~DTP*472*D8 *19970226~LX*2~SV1*HC:A4570*25*UN*1***1**Y~DTP*472 *D8*19970226~LX*3~SV1*HC:73140*50*UN*1***1**Y~DTP* 472*D8*19970226~LX*4~SV1*HC:99283*210*UN*1*23**1:2 **Y~DTP*472*D8*19970212~SE*51*872401~

4.2.3

Example 3
The patient is a different person than the subscriber. The payer is a commercial Property & Casualty Insurance Company. Date of Accident: 06/17/94 Subscriber: Hal Howling Subscriber Address: 327 Bronco Drive, Getaway, CA, 99999 Policy Number: B999-777-91G Insurance Company: Heisman Insurance Company Claim Number: 32-3232-32 Patient: D.J. Dimpson Patient Address: 32 Buffalo Run, Rocking Horse, CA, 99666 Sex: M DOB: 06/01/48 SSN: 567-32-4788

616

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

Destination Payer/Receiver: Heisman Insurance Company Payer Address: 1 Trophy Lane, NYAC, NY, 10032 Payer ID: 999888777 Billing Provider/Sender: Fermann Hand & Foot Clinic TIN: 579999999 National Provider Identifier: 591PD123 Address: 10 1/2 Shoemaker Street, Cobbler, CA, 99997 Telephone: 212-555-7987 Pay-To-Provider: Fermann Hand & Foot Clinic Rendering Provider: Bruno Moglie, MD National Provider Identifier: 687AB861 Patient Account Number: 900-00-0032 CASE: The patient was a passenger in the subscribers automobile, and the patient reports that his hand was cut when the car was struck in the rear. Diagnosis: 884.2 Services Rendered: Office visit, Drain Abscess. DOS=06/20/94, POS=Office, TOS=Medical Care CHARGES: Office visit = $150.00, Drain Abscess = $35.00. Total charges = $185.00. Electronic Route: Billing provider (sender) to payer (receiver) via VAN.

SEG #

LOOP SEGMENT/ELEMENT STRING

HEADER ST TRANSACTION SET HEADER ST*837*872501~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0125*19970411*1524*CH~ REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098~ 1000A SUBMITTER NM1 SUBMITTER NM1*41*2*FERMANN HAND & FOOT CLINIC*****46*591PD123~ PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JAN FOOT*TE*8156667777~ 1000B RECEIVER NM1 RECEIVER NAME NM1*40*2*HEISMAN INSURANCE COMPANY*****46*555667777~ 2000A BILLING/PAY-TO PROVIDER HL LOOP HL-BILLING PROVIDER HL*1**20*1~

2 3 4

5 6

MAY 2000

617

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL LOOP SEGMENT/ELEMENT STRING

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SEG #

2010AA BILLING PROVIDER NM1 BILLING PROVIDER NAME NM1*85*2*FERMANN HAND & FOOT CLINIC*****XX*591PD123~ N3 BILLING PROVIDER ADDRESS N3*10 1/2 SHOEMAKER STREET~ N4 BILLING PROVIDER LOCATION N4*COBBLER*CA*99997~ REF BILLING PROVIDER SECONDARY IDENTIFICATION REF*EI*579999999~ 2000B SUBSCRIBER HL LOOP HL-SUBSCRIBER HL*2*1*22*1~ SBR SUBSCRIBER INFORMATION SBR*P********AM~ 2010BA SUBSCRIBER NM1 SUBSCRIBER NAME NM1*IL*1*HOWLING*HAL****MI*B99977791G~ 2010BB SUBSCRIBER/PAYER NM1 PAYER NAME NM1*PR*2*HEISMAN INSURANCE COMPANY*****XV*999888777~ N3 PAYER STREET ADDRESS N3*1 TROPHY LANE~ N4 PAYER CITY/STATE/ZIP N4*NYAC*NY*10032~ 2000C PATIENT HL LOOP HL-PATIENT HL*3*2*23*0~ PAT PATIENT INFORMATION PAT*41~ NM1 2010CA PATIENT NAME NM1 PATIENT NAME NM1*QC*1*DIMPSON*DJ****34*567324788~ N3 PATIENT STREET ADDRESS N3*32 BUFFALO RUN~ N4 PATIENT CITY/STATE/ZIP N4*ROCKING HORSE*CA*99666~ DMG PATIENT DEMOGRAPHIC INFORMATION DMG*D8*19480601*M~
MAY 2000

9 10 11

12

13 14

15

16 17 18

19 20

21 22 23

618

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE LOOP SEGMENT/ELEMENT STRING

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

SEG #

24 25

REF PROPERTY AND CASUALTY CLAIM NUMBER REF*Y4*32323232~ 2300 CLAIM CLM CLAIM LEVEL INFORMATION CLM*900000032*185***11::1*Y*A*Y*Y*B*AA~ DTP DATE - ACCIDENT DTP*439*D8*19940617~ HEALTH CARE DIAGNOSIS CODES HI*BK:8842~ 2310B RENDERING PROVIDER NM1 RENDERING PROVIDER NAME NM1*82*1*MOGLIE*BRUNO****XX*687AB861~ PRV RENDERING PROVIDER SPECIALTY INFORMATION PRV*PE*ZZ*203BE004Y~ 2320D SERVICE FACILITY LOCATION NM1 SERVICE FACILITY LOCATION NM1*77*2*FERMANN HAND & FOOT CLINIC*****XX*591PD123~ N3 SERVICE FACILITY LOCATION ADDRESS N3*10 1/2 SHOEMAKER STREET~ N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP N4*COBBLER*CA*99997~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*1~ SV1 PROFESSIONAL SERVICE SV1*HC:99201*150*UN*1***1**Y~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19940620~ 2400 SERVICE LINE LX SERVICE LINE COUNTER LX*2~ SV1 PROFESSIONAL SERVICE SV1*HC:26010*35*UN*1***1**Y~ DTP DATE - SERVICE DATE(S) DTP*472*D8*19940620~

26 27 28

29 30

31 32 33

34 35 36

37 38 39

TRAILER SE TRANSACTION SET TRAILER SE*39*872501~ Entire data string: ST*837*872501~BHT*0019*00*0125*19970411*1524*CH~

MAY 2000

619

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REF *87*004010X098~NM1*41*2*FERMANN HAND & FOOT CLINIC*****46*591PD123~PER*IC*JAN FOOT*TE*81566 67777~NM1*40*2*HEISMAN INSURANCE COMPANY*****46* 555667777~HL*1**20*1~NM1*85*2*FERMANN HAND & FOOT CLINIC*****XX*591PD123~N3*10 1/2 SHOEMAKER STREET~N4*COBBLER*CA*99997~REF*EI*579999999~HL*2* 1*22*1~SBR*P********AM~NM1*IL*1*HOWLING*HAL**** MI*B99977791G~NM1*PR*2*HEISMAN INSURANCE COMPANY *****XV*999888777~N3*1 TROPHY LANE~N4*NYAC*NY*100 32~HL*3*2*23*0~PAT*41~NM1*QC*1*DIMPSON*DJ****34* 567324788~N3*32 BUFFALO RUN~N4*ROCKING HORSE*CA* 99666~DMG*D8*19480601*M~REF*Y4*32323232~CLM*900000 032*185***11::1*Y*A*Y*Y*B*AA~DTP*439*D8*19940617~ HI*BK:8842~NM1*82*1*MOGLIE*BRUNO****XX*687AB861~ PRV*PE*ZZ*203BE004Y~NM1*77*2*FERMANN HAND & FOOT CLINIC*****XX*591PD123~N3*10 1/2 SHOEMAKER STREET~ N4*COBBLER*CA*99997~LX*1~SV1*HC:99201*150*UN*1*** 1**Y~DTP*472*D8*19940620~LX*2~SV1*HC:26010*35*UN*1 ***1**Y~DTP*472*D8*19940620~SE*39*872501~

620

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

A ASC X12 Nomenclature

A.1
A.1.1

Interchange and Application Control Structures

Interchange Control Structure
The transmission of data proceeds according to very strict format rules to ensure the integrity and maintain the efficiency of the interchange. Each business grouping of data is called a transaction set. For instance, a group of benefit enrollments sent from a sponsor to a payer is considered a transaction set. Each transaction set contains groups of logically related data in units called segments. For instance, the N4 segment used in the transaction set conveys the city, state, ZIP Code, and other geographic information. A transaction set contains multiple segments, so the addresses of the different parties, for example, can be conveyed from one computer to the other. An analogy would be that the transaction set is like a freight train; the segments are like the trains cars; and each segment can contain several data elements the same as a train car can hold multiple crates. The sequence of the elements within one segment is specified by the ASC X12 standard as well as the sequence of segments in the transaction set. In a more conventional computing environment, the segments would be equivalent to records, and the elements equivalent to fields.

Communications Transport Protocol ISA GS ST Interchange Control Header Functional Group Header Transaction Set Header FUNCTIONAL GROUP Detail Segments
for example, Benefit Enrollment

ST

Transaction Set Header Detail Segments

for example, Benefit Enrollment

SE GE GS ST

Transaction Set Trailer Functional Group Trailer FUNCTIONAL GROUP Functional Group Header Transaction Set Header Detail Segments
for example, Claim Payment

SE GE IEA

Transaction Set Trailer Functional Group Trailer Interchange Control Trailer

Communications Transport Trailer

Similar transaction sets, Figure A1. Transmission Control Schematic called functional groups, can be sent together within a transmission. Each functional group is prefaced by a group start segment; and a functional group is terminated by a group end segment. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer. Figure A1, Transmission Control Schematic, illustrates this interchange control.

MAY 2000

A.1

COMMUNICATIONS ENVELOPE

SE

Transaction Set Trailer

INTERCHANGE ENVELOPE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

The interchange header and trailer segments envelop one or more functional groups or interchange-related control segments and perform the following functions: 1. 2. 3. 4. Define the data element separators and the data segment terminator. Identify the sender and receiver. Provide control information for the interchange. Allow for authorization and security information.

A.1.2
A.1.2.1

Application Control Structure Definitions and Concepts

Basic Structure
A data element corresponds to a data field in data processing terminology. The data element is the smallest named item in the ASC X12 standard. A data segment corresponds to a record in data processing terminology. The data segment begins with a segment ID and contains related data elements. A control segment has the same structure as a data segment; the distinction is in the use. The data segment is used primarily to convey user information, but the control segment is used primarily to convey control information and to group data segments.

A.1.2.2

Basic Character Set

The section that follows is designed to have representation in the common character code schemes of EBCDIC, ASCII, and CCITT International Alphabet 5. The ASC X12 standards are graphic-character-oriented; therefore, common character encoding schemes other than those specified herein may be used as long as a common mapping is available. Because the graphic characters have an implied mapping across character code schemes, those bit patterns are not provided here. The basic character set of this standard, shown in figure A2, Basic Character Set, includes those selected from the uppercase letters, digits, space, and special characters as specified below.
A...Z 0...9 ! & ; ( ? ) = * +

. / : Figure A2. Basic Character Set

(space)

A.1.2.3

Extended Character Set

An extended character set may be used by negotiation between the two parties and includes the lowercase letters and other special characters as specified in figure A3, Extended Character Set.
a..z } % \ ~ | @ < [ > ] # _ $ {

Figure A3. Extended Character Set

Note that the extended characters include several character codes that have multiple graphical representations for a specific bit pattern. The complete list appears

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in other standards such as CCITT S.5. Use of the USA graphics for these codes presents no problem unless data is exchanged with an international partner. Other problems, such as the translation of item descriptions from English to French, arise when exchanging data with an international partner, but minimizing the use of codes with multiple graphics eliminates one of the more obvious problems.

A.1.2.4

Control Characters
Two control character groups are specified; they have only restricted usage. The common notation for these groups is also provided, together with the character coding in three common alphabets. In the matrix A1, Base Control Set, the column IA5 represents CCITT V.3 International Alphabet 5.

A.1.2.5

Base Control Set

The base control set includes those characters that will not have a disruptive effect on most communication protocols. These are represented by:
NOTATION NAME BEL bell HT horizontal tab LF line feed VT vertical tab FF form feed CR carriage return FS file separator GS group separator RS record separator US unit separator NL new line Matrix A1. Base Control Set EBCDIC 2F 05 25 0B 0C 0D 1C 1D 1E 1F 15 ASCII 07 09 0A 0B 0C 0D 1C 1D 1E 1F IA5 07 09 0A 0B 0C 0D 1C 1D 1E 1F

The Group Separator (GS) may be an exception in this set because it is used in the 3780 communications protocol to indicate blank space compression.

A.1.2.6

Extended Control Set

The extended control set includes those that may have an effect on a transmission system. These are shown in matrix A2, Extended Control Set.
NOTATION NAME SOH start of header STX start of text ETX end of text EOT end of transmission ENQ enquiry ACK acknowledge DC1 device control 1 DC2 device control 2 DC3 device control 3 DC4 device control 4 NAK negative acknowledge SYN synchronous idle ETB end of block Matrix A2. Extended Control Set EBCDIC 01 02 03 37 2D 2E 11 12 13 3C 3D 32 26 ASCII 01 02 03 04 05 06 11 12 13 14 15 16 17 IA5 01 02 03 04 05 06 11 12 13 14 15 16 17

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A.1.2.7

Delimiters
A delimiter is a character used to separate two data elements (or subelements) or to terminate a segment. The delimiters are an integral part of the data. Delimiters are specified in the interchange header segment, ISA. The ISA segment is a 105 byte fixed length record. The data element separator is byte number 4; the component element separator is byte number 105; and the segment terminator is the byte that immediately follows the component element separator. Once specified in the interchange header, the delimiters are not to be used in a data element value elsewhere in the interchange. For consistency, this implementation guide uses the delimiters shown in matrix A3, Delimiters, in all examples of EDI transmissions.
CHARACTER * : ~ Matrix A3. Delimiters NAME Asterisk Colon Tilde DELIMITER Data Element Separator Subelement Separator Segment Terminator

The delimiters above are for illustration purposes only and are not specific recommendations or requirements. Users of this implementation guide should be aware that an application system may use some valid delimiter characters within the application data. Occurrences of delimiter characters in transmitted data within a data element can result in errors in translation programs. The existence of asterisks (*) within transmitted application data is a known issue that can affect translation software.

A.1.3

Business Transaction Structure Definitions and Concepts

The ASC X12 standards define commonly used business transactions (such as a health care claim) in a formal structure called transaction sets. A transaction set is composed of a transaction set header control segment, one or more data segments, and a transaction set trailer control segment. Each segment is composed of the following: A unique segment ID One or more logically related data elements each preceded by a data element separator A segment terminator

A.1.3.1

Data Element
The data element is the smallest named unit of information in the ASC X12 standard. Data elements are identified as either simple or component. A data element that occurs as an ordinally positioned member of a composite data structure is identified as a component data element. A data element that occurs in a segment outside the defined boundaries of a composite data structure is identified as a simple data element. The distinction between simple and component data elements is strictly a matter of context because a data element can be used in either capacity.

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Data elements are assigned a unique reference number. Each data element has a name, description, type, minimum length, and maximum length. For ID type data elements, this guide provides the applicable ASC X12 code values and their descriptions or references where the valid code list can be obtained. Each data element is assigned a minimum and maximum length. The length of the data element value is the number of character positions used except as noted for numeric, decimal, and binary elements. The data element types shown in matrix A4, Data Element Types, appear in this implementation guide.
SYMBOL TYPE Nn Numeric R Decimal ID Identifier AN String DT Date TM Time B Binary Matrix A4. Data Element Types

A.1.3.1.1

Numeric
A numeric data element is represented by one or more digits with an optional leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be transmitted with the data. This set of guides denotes the number of implied decimal positions. The representation for this data element type is Nn where N indicates that it is numeric and n indicates the number of decimal positions to the right of the implied decimal point. If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted. EXAMPLE A transmitted value of 1234, when specified as numeric type N2, represents a value of 12.34. Leading zeros should be suppressed unless necessary to satisfy a minimum length requirement. The length of a numeric type data element does not include the optional sign.

A.1.3.1.2

Decimal
A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element type is represented as R. The decimal point always appears in the character stream if the decimal point is at any place other than the right end. If the value is an integer (decimal point at the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.

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Leading zeros should be suppressed unless necessary to satisfy a minimum length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the optional leading sign or decimal point. EXAMPLE A transmitted value of 12.34 represents a decimal value of 12.34.

A.1.3.1.3

Identifier
An identifier data element always contains a value from a predefined list of codes that is maintained by the ASC X12 Committee or some other body recognized by the Committee. Trailing spaces should be suppressed unless they are necessary to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is ID.

A.1.3.1.4

String
A string data element is a sequence of any characters from the basic or extended character sets. The significant characters shall be left justified. Leading spaces, when they occur, are presumed to be significant characters. Trailing spaces should be suppressed unless they are necessary to satisfy a minimum length. The representation for this data element type is AN.

A.1.3.1.5

Date
A date data element is used to express the standard date in either YYMMDD or CCYYMMDD format in which CC is the first two digits of the calendar year, YY is the last two digits of the calendar year, MM is the month (01 to 12), and DD is the day in the month (01 to 31). The representation for this data element type is DT. Users of this guide should note that all dates within transactions are 8-character dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA segment, and also used in the TA1 Interchange Acknowledgment, where the century can be readily interpolated because of the nature of an interchange header.

A.1.3.1.6

Time
A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00 to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is TM. The length of the data element determines the format of the transmitted time. EXAMPLE Transmitted data elements of four characters denote HHMM. Transmitted data elements of six characters denote HHMMSS.

A.1.3.2

Composite Data Structure

The composite data structure is an intermediate unit of information in a segment. Composite data structures are composed of one or more logically related simple data elements, each, except the last, followed by a sub-element separator. The final data element is followed by the next data element separator or the segment terminator. Each simple data element within a composite is called a component.

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Each composite data structure has a unique four-character identifier, a name, and a purpose. The identifier serves as a label for the composite. A composite data structure can be further defined through the use of syntax notes, semantic notes, and comments. Each component within the composite is further characterized by a reference designator and a condition designator. The reference designators and the condition designators are described below.

A.1.3.3

Data Segment
The data segment is an intermediate unit of information in a transaction set. In the data stream, a data segment consists of a segment identifier, one or more composite data structures or simple data elements each preceded by a data element separator and succeeded by a segment terminator. Each data segment has a unique two- or three-character identifier, a name, and a purpose. The identifier serves as a label for the data segment. A segment can be further defined through the use of syntax notes, semantic notes, and comments. Each simple data element or composite data structure within the segment is further characterized by a reference designator and a condition designator.

A.1.3.4

Syntax Notes
Syntax notes describe relational conditions among two or more data segment units within the same segment, or among two or more component data elements within the same composite data structure. For a complete description of the relational conditions, See A.1.3.8, Condition Designator.

A.1.3.5

Semantic Notes
Simple data elements or composite data structures may be referenced by a semantic note within a particular segment. A semantic note provides important additional information regarding the intended meaning of a designated data element, particularly a generic type, in the context of its use within a specific data segment. Semantic notes may also define a relational condition among data elements in a segment based on the presence of a specific value (or one of a set of values) in one of the data elements.

A.1.3.6

Comments
A segment comment provides additional information regarding the intended use of the segment.

A.1.3.7

Reference Designator
Each simple data element or composite data structure in a segment is provided a structured code that indicates the segment in which it is used and the sequential position within the segment. The code is composed of the segment identifier followed by a two-digit number that defines the position of the simple data element or composite data structure in that segment. For purposes of creating reference designators, the composite data structure is viewed as the hierarchical equal of the simple data element. Each component data element in a composite data structure is identified by a suffix appended to the reference designator for the composite data structure of which it is a member.

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This suffix is a two-digit number, prefixed with a hyphen, that defines the position of the component data element in the composite data structure. EXAMPLE The first simple element of the CLP segment would be identified as CLP01. The first position in the SVC segment is occupied by a composite data structure that contains seven component data elements, the reference designator for the second component data element would be SVC01-02.

A.1.3.8

Condition Designator
This section provides information about X12 standard conditions designators. It is provided so that users will have information about the general standard. Implementation guides may impose other conditions designators. See implementation guide section 3.1 Presentation Examples for detailed information about the implementation guide Industry Usage requirements for compliant implementation. Data element conditions are of three types: mandatory, optional, and relational. They define the circumstances under which a data element may be required to be present or not present in a particular segment.
DESIGNATOR M- Mandatory DESCRIPTION The designation of mandatory is absolute in the sense that there is no dependency on other data elements. This designation may apply to either simple data elements or composite data structures. If the designation applies to a composite data structure, then at least one value of a component data element in that composite data structure shall be included in the data segment. The designation of optional means that there is no requirement for a simple data element or composite data structure to be present in the segment. The presence of a value for a simple data element or the presence of value for any of the component data elements of a composite data structure is at the option of the sender. Relational conditions may exist among two or more simple data elements within the same data segment based on the presence or absence of one of those data elements (presence means a data element must not be empty). Relational conditions are specified by a condition code (see table below) and the reference designators of the affected data elements. A data element may be subject to more than one relational condition. The definitions for each of the condition codes used within syntax notes are detailed below: CONDITION CODE P- Paired or Multiple DEFINITION If any element specified in the relational condition is present, then all of the elements specified must be present. At least one of the elements specified in the condition must be present. Not more than one of the elements specified in the condition may be present. If the first element specified in the condition is present, then all other elements must be present. However, any or all of the elements not specified as the first element in the condition may appear without requiring that the first element be present. The order of the elements in the condition does not have to be the same as the order of the data elements in the data segment.

O- Optional

X- Relational

R- Required E- Exclusion C- Conditional

L- List

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL If the first element specified in the condition is present, then at least one of the remaining elements must be present. However, any or all of the elements not specified as the first element in the condition may appear without requiring that the first element be present. The order of the elements in the condition does not have to be the same as the order of the data elements in the data segment.

Table A5. Condition Designator

A.1.3.9

Absence of Data
Any simple data element that is indicated as mandatory must not be empty if the segment is used. At least one component data element of a composite data structure that is indicated as mandatory must not be empty if the segment is used. Optional simple data elements and/or composite data structures and their preceding data element separators that are not needed should be omitted if they occur at the end of a segment. If they do not occur at the end of the segment, the simple data element values and/or composite data structure values may be omitted. Their absence is indicated by the occurrence of their preceding data element separators, in order to maintain the elements or structures position as defined in the data segment. Likewise, when additional information is not necessary within a composite, the composite may be terminated by providing the appropriate data element separator or segment terminator.

A.1.3.10

Control Segments
A control segment has the same structure as a data segment, but it is used for transferring control information rather than application information.

A.1.3.10.1

Loop Control Segments

Loop control segments are used only to delineate bounded loops. Delineation of the loop shall consist of the loop header (LS segment) and the loop trailer (LE segment). The loop header defines the start of a structure that must contain one or more iterations of a loop of data segments and provides the loop identifier for this loop. The loop trailer defines the end of the structure. The LS segment appears only before the first occurrence of the loop, and the LE segment appears only after the last occurrence of the loop. Unbounded looping structures do not use loop control segments.

A.1.3.10.2

Transaction Set Control Segments

The transaction set is delineated by the transaction set header (ST segment) and the transaction set trailer (SE segment). The transaction set header identifies the start and identifier of the transaction set. The transaction set trailer identifies the end of the transaction set and provides a count of the data segments, which includes the ST and SE segments.

A.1.3.10.3

Functional Group Control Segments

The functional group is delineated by the functional group header (GS segment) and the functional group trailer (GE segment). The functional group header starts and identifies one or more related transaction sets and provides a control number

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and application identification information. The functional group trailer defines the end of the functional group of related transaction sets and provides a count of contained transaction sets.

A.1.3.10.4

Relations among Control Segments

The control segment of this standard must have a nested relationship as is shown and annotated in this subsection. The letters preceding the control segment name are the segment identifier for that control segment. The indentation of segment identifiers shown below indicates the subordination among control segments. GS Functional Group Header, starts a group of related transaction sets. ST Transaction Set Header, starts a transaction set. LS Loop Header, starts a bounded loop of data segments but is not part of the loop. LS Loop Header, starts an inner, nested, bounded loop. LE Loop Trailer, ends an inner, nested bounded loop. LE Loop Trailer, ends a bounded loop of data segments but is not part of the loop. SE Transaction Set Trailer, ends a transaction set. GE Functional Group Trailer, ends a group of related transaction sets. More than one ST/SE pair, each representing a transaction set, may be used within one functional group. Also more than one LS/LE pair, each representing a bounded loop, may be used within one transaction set.

A.1.3.11

Transaction Set
The transaction set is the smallest meaningful set of information exchanged between trading partners. The transaction set consists of a transaction set header segment, one or more data segments in a specified order, and a transaction set trailer segment. See figure A1, Transmission Control Schematic.

A.1.3.11.1

Transaction Set Header and Trailer

A transaction set identifier uniquely identifies a transaction set. This identifier is the first data element of the Transaction Set Header Segment (ST). A user assigned transaction set control number in the header must match the control number in the Trailer Segment (SE) for any given transaction set. The value for the number of included segments in the SE segment is the total number of segments in the transaction set, including the ST and SE segments.

A.1.3.11.2

Data Segment Groups

The data segments in a transaction set may be repeated as individual data segments or as unbounded or bounded loops.

A.1.3.11.3

Repeated Occurrences of Single Data Segments

When a single data segment is allowed to be repeated, it may have a specified maximum number of occurrences defined at each specified position within a given transaction set standard. Alternatively, a segment may be allowed to repeat

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an unlimited number of times. The notation for an unlimited number of repetitions is >1.

A.1.3.11.4

Loops of Data Segments

Loops are groups of semantically related segments. Data segment loops may be unbounded or bounded.

A.1.3.11.4.1

Unbounded Loops To establish the iteration of a loop, the first data segment in the loop must appear once and only once in each iteration. Loops may have a specified maximum number of repetitions. Alternatively, the loop may be specified as having an unlimited number of iterations. The notation for an unlimited number of repetitions is >1. A specified sequence of segments is in the loop. Loops themselves are optional or mandatory. The requirement designator of the beginning segment of a loop indicates whether at least one occurrence of the loop is required. Each appearance of the beginning segment defines an occurrence of the loop. The requirement designator of any segment within the loop after the beginning segment applies to that segment for each occurrence of the loop. If there is a mandatory requirement designator for any data segment within the loop after the beginning segment, that data segment is mandatory for each occurrence of the loop. If the loop is optional, the mandatory segment only occurs if the loop occurs.

A.1.3.11.4.2

Bounded Loops The characteristics of unbounded loops described previously also apply to bounded loops. In addition, bounded loops require a Loop Start Segment (LS) to appear before the first occurrence and a Loop End Segment (LE) to appear after the last occurrence of the loop. If the loop does not occur, the LS and LE segments are suppressed.

A.1.3.11.5

Data Segments in a Transaction Set

When data segments are combined to form a transaction set, three characteristics are applied to each data segment: a requirement designator, a position in the transaction set, and a maximum occurrence.

A.1.3.11.6

Data Segment Requirement Designators

A data segment, or loop, has one of the following requirement designators for health care and insurance transaction sets, indicating its appearance in the data stream of a transmission. These requirement designators are represented by a single character code.
DESIGNATOR M- Mandatory DESCRIPTION This data segment must be included in the transaction set. (Note that a data segment may be mandatory in a loop of data segments, but the loop itself is optional if the beginning segment of the loop is designated as optional.) The presence of this data segment is the option of the sending party.

O- Optional

A.1.3.11.7

Data Segment Position

The ordinal positions of the segments in a transaction set are explicitly specified for that transaction. Subject to the flexibility provided by the optional requirement designators of the segments, this positioning must be maintained.

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A.1.3.11.8

Data Segment Occurrence

A data segment may have a maximum occurrence of one, a finite number greater than one, or an unlimited number indicated by >1.

A.1.3.12

Functional Group
A functional group is a group of similar transaction sets that is bounded by a functional group header segment and a functional group trailer segment. The functional identifier defines the group of transactions that may be included within the functional group. The value for the functional group control number in the header and trailer control segments must be identical for any given group. The value for the number of included transaction sets is the total number of transaction sets in the group. See figure A1, Transmission Control Schematic.

A.1.4
A.1.4.1

Envelopes and Control Structures

Interchange Control Structures
Typically, the term interchange connotes the ISA/IEA envelope that is transmitted between trading/business partners. Interchange control is achieved through several control components. The interchange control number is contained in data element ISA13 of the ISA segment. The identical control number must also occur in data element 02 of the IEA segment. Most commercial translation software products will verify that these two fields are identical. In most translation software products, if these fields are different the interchange will be suspended in error. There are many other features of the ISA segment that are used for control measures. For instance, the ISA segment contains data elements such as authorization information, security information, sender identification, and receiver identification that can be used for control purposes. These data elements are agreed upon by the trading partners prior to transmission and are contained in the written trading partner agreement. The interchange date and time data elements as well as the interchange control number within the ISA segment are used for debugging purposes when there is a problem with the transmission or the interchange. Data Element ISA12, Interchange Control Version Number, indicates the version of the ISA/IEA envelope. The ISA12 does not indicate the version of the transaction set that is being transmitted but rather the envelope that encapsulates the transaction. An Interchange Acknowledgment can be denoted through data element ISA14. The acknowledgment that would be sent in reply to a yes condition in data element ISA14 would be the TA1 segment. Data element ISA15, Test Indicator, is used between trading partners to indicate that the transmission is in a test or production mode. This becomes significant when the production phase of the project is to commence. Data element ISA16, Subelement Separator, is used by the translator for interpretation of composite data elements. The ending component of the interchange or ISA/IEA envelope is the IEA segment. Data element IEA01 indicates the number of functional groups that are included within the interchange. In most commercial translation software products, an aggregate count of functional groups is kept while interpreting the interchange. This count is then verified with data element IEA01. If there is a discrep-

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ancy, in most commercial products, the interchange is suspended. The other data element in the IEA segment is IEA02 which is referenced above. See the Appendix B, EDI Control Directory, for a complete detailing of the interchange control header and trailer.

A.1.4.2

Functional Groups
Control structures within the functional group envelope include the functional identifier code in GS01. The Functional Identifier Code is used by the commercial translation software during interpretation of the interchange to determine the different transaction sets that may be included within the functional group. If an inappropriate transaction set is contained within the functional group, most commercial translation software will suspend the functional group within the interchange. The Application Senders Code in GS02 can be used to identify the sending unit of the transmission. The Application Receivers Code in GS03 can be used to identify the receiving unit of the transmission. For health care, this unit identification can be used to differentiate between managed care, indemnity, and Medicare. The functional group contains a creation date (GS04) and creation time (GS05) for the functional group. The Group Control Number is contained in GS06. These data elements (GS04, GS05, AND GS06) can be used for debugging purposes during problem resolution. GS08,Version/Release/Industry Identifier Code is the version/release/sub-release of the transaction sets being transmitted in this functional group. Appendix B provides guidance for the value for this data element. The GS08 does not represent the version of the interchange (ISA/IEA) envelope but rather the version/release/sub-release of the transaction sets that are encompassed within the GS/GE envelope. The Functional Group Control Number in GS06 must be identical to data element 02 of the GE segment. Data element GE01 indicates the number of transaction sets within the functional group. In most commercial translation software products, an aggregate count of the transaction sets is kept while interpreting the functional group. This count is then verified with data element GE01. See the Appendix B, EDI Control Directory, for a complete detailing of the functional group header and trailer.

A.1.4.3

HL Structures
The HL segment is used in several X12 transaction sets to identify levels of detail information using a hierarchical structure, such as relating dependents to a subscriber. Hierarchical levels may differ from guide to guide. The following diagram, from transaction set 837, illustrates a typical hierarchy.

Dependents

Subscribers

Provider

Each provider can bill for one or more subscribers, each subscriber can have one or more dependents and the subscriber and the dependents can make one or more claims. Each guide states what levels are available, the levels requirement, a repeat value, and whether that level has subordinate levels within a transmission.

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A.1.5
A.1.5.1

Acknowledgments
Interchange Acknowledgment, TA1
The Interchange or TA1 Acknowledgment is a means of replying to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. Transaction set-specific verification is accomplished through use of the Functional Acknowledgment Transaction Set, 997. See A.1.5.2, Functional Acknowledgment, 997, for more details. The TA1 is a single segment and is unique in the sense that this single segment is transmitted without the GS/GE envelope structures. A TA1 can be included in an interchange with other functional groups and transactions. Encompassed in the TA1 are the interchange control number, interchange date and time, interchange acknowledgment code, and the interchange note code. The interchange control number, interchange date and time are identical to those that were present in the transmitted interchange from the sending trading partner. This provides the capability to associate the TA1 with the transmitted interchange. TA104, Interchange Acknowledgment Code, indicates the status of the interchange control structure. This data element stipulates whether the transmitted interchange was accepted with no errors, accepted with errors, or rejected because of errors. TA105, Interchange Note Code, is a numerical code that indicates the error found while processing the interchange control structure. Values for this data element indicate whether the error occurred at the interchange or functional group envelope. The TA1 segment provides the capability for the receiving trading partner to notify the sending trading partner of problems that were encountered in the interchange control structure. Due to the uniqueness of the TA1, implementation should be predicated upon the ability for the sending and receiving trading partners commercial translators to accommodate the uniqueness of the TA1. Unless named as mandatory in the Federal Rules implementing HIPAA, use of the TA1, although urged by the authors, is not mandated. See the Appendix B, EDI Control Directory, for a complete detailing of the TA1 segment.

A.1.5.2

Functional Acknowledgment, 997

The Functional Acknowledgment Transaction Set, 997, has been designed to allow trading partners to establish a comprehensive control function as a part of their business exchange process. This acknowledgment process facilitates control of EDI. There is a one-to-one correspondence between a 997 and a functional group. Segments within the 997 can identify the acceptance or rejection of the functional group, transaction sets or segments. Data elements in error can also be identified. There are many EDI implementations that have incorporated the acknowledgment process in all of their electronic communications. Typically, the 997 is used as a functional acknowledgment to a previously transmitted functional group. Many commercially available translators can automatically generate this transaction set through internal parameter settings. Additionally translators will automatically reconcile received acknowledgments to functional groups that have been sent. The benefit to this process is that the sending trading partner

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can determine if the receiving trading partner has received ASC X12 transaction sets through reports that can be generated by the translation software to identify transmissions that have not been acknowledged. As stated previously the 997 is a transaction set and thus is encapsulated within the interchange control structure (envelopes) for transmission. As with any information flow, an acknowledgment process is essential. If an automatic acknowledgment process is desired between trading partners then it is recommended that the 997 be used. Unless named as mandatory in the Federal Rules implementing HIPAA, use of the 997, although recommended by the authors, is not mandated. See Appendix B, EDI Control Directory, for a complete detailing of transaction set 997.

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

B EDI Control Directory

B.1 Control Segments
ISA Interchange Control Header Segment IEA Interchange Control Trailer Segment GS Functional Group Header Segment GE Functional Group Trailer Segment TA1 Interchange Acknowledgment Segment

B.2

Functional Acknowledgment Transaction Set, 997

MAY 2000

B.1

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

B.2

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INTERCHANGE CONTROL HEADER

CONTROL SEGMENTS

ISA

004010X098 002 ISA INTERCHANGE CONTROL HEADER

MAY 19, 2000 IMPLEMENTATION

INTERCHANGE CONTROL HEADER

0 000 100
Notes: 1. The ISA is a fixed record length segment and all positions within each of the data elements must be filled. The first element separator defines the element separator to be used through the entire interchange. The segment terminator used after the ISA defines the segment terminator to be used throughout the entire interchange. Spaces in the example are represented by . for clarity.

1 000 100
STANDARD

Example: ISAV 00V ..........V 01V SECRET....V ZZV SUBMITTERS.ID..V ZZV RECEIVERS.ID...V 930602V 1253V UV 00401V 000000905V 1V TV :~

ISA Interchange Control Header

Purpose: To start and identify an interchange of zero or more functional groups and interchange-related control segments
DIAGRAM

ISA01

I01

ISA02

I02

ISA03

I03

ISA04

I04

ISA05

I05

ISA06

I06

ISA

Author Info Qualifer

M ID 2/2

Author Information
M AN 10/10

V
M

Security Info Qual

ID 2/2

Security Information
M AN 10/10

V Interchange V Interchange
ID Qual
ID

Sender ID

2/2

AN 15/15

ISA07

I05

ISA08

I07

ISA09

I08

ISA10

I09

ISA11

I10

ISA12

I11

Interchange ID Qual
M ID 2/2

Interchange Receiver ID
M AN 15/15

V Interchange Date
M DT 6/6

Interchange Time
M TM 4/4

Inter Ctrl Stand Ident

M ID 1/1

Inter Ctrl V Version Num

M ID 5/5

ISA13

I12

ISA14

I13

ISA15

I14

ISA16

I15

V
M

Inter Ctrl Number

N0 9/9

Ack Requested
M ID 1/1

V
M

Usage Indicator
ID 1/1

V Component ~ Elem Sepera

M 1/1

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

ISA01

I01

Authorization Information Qualifier

CODE DEFINITION

ID

2/2

Code to identify the type of information in the Authorization Information

00

No Authorization Information Present (No Meaningful Information in I02) ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OF ADDITIONAL IDENTIFICATION INFORMATION.

1000088

03 REQUIRED ISA02 I02

Additional Data Identification M AN 10/10

Authorization Information

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

MAY 2000

B.3

CONTROL SEGMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

ISA03

I03

Security Information Qualifier

CODE DEFINITION

ID

2/2

Code to identify the type of information in the Security Information

00

No Security Information Present (No Meaningful Information in I04) ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OF PASSWORD DATA.

1000089
01 REQUIRED ISA04 I04

Password M AN 10/10

Security Information

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

REQUIRED

ISA05

I05

Interchange ID Qualifier

ID

2/2

Qualifier to designate the system/method of code structure used to designate the sender or receiver ID element being qualified

1000002

This ID qualifies the Sender in ISA06.

CODE DEFINITION

01 14 20

Duns (Dun & Bradstreet) Duns Plus Suffix Health Industry Number (HIN)
CODE SOURCE 121:

Health Industry Identification Number

27

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA) Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA) Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA) U.S. Federal Tax Identification Number National Association of Insurance Commissioners Company Code (NAIC) Mutually Defined M AN 15/15

28

29

30 33

ZZ REQUIRED ISA06 I06

Interchange Sender ID

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

REQUIRED

ISA07

I05

Interchange ID Qualifier

ID

2/2

Qualifier to designate the system/method of code structure used to designate the sender or receiver ID element being qualified

1000003

This ID qualifies the Receiver in ISA08.

CODE DEFINITION

01

Duns (Dun & Bradstreet)

B.4

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONTROL SEGMENTS

14 20

Duns Plus Suffix Health Industry Number (HIN)

CODE SOURCE 121:

Health Industry Identification Number

27

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA) Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA) Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA) U.S. Federal Tax Identification Number National Association of Insurance Commissioners Company Code (NAIC) Mutually Defined M AN 15/15

28

29

30 33

ZZ REQUIRED ISA08 I07

Interchange Receiver ID

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

REQUIRED

ISA09

I08

Interchange Date
Date of the interchange

DT

6/6

1000006
REQUIRED ISA10 I09

The date format is YYMMDD. Interchange Time

Time of the interchange

TM

4/4

1000007
REQUIRED ISA11 I10

The time format is HHMM. Interchange Control Standards Identifier M ID 1/1

Code to identify the agency responsible for the control standard used by the message that is enclosed by the interchange header and trailer
CODE DEFINITION

U REQUIRED ISA12 I11

U.S. EDI Community of ASC X12, TDCC, and UCS M ID 5/5

Interchange Control Version Number

CODE DEFINITION

This version number covers the interchange control segments

00401

Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures Review Board through October 1997 M N0 9/9

REQUIRED

ISA13

I12

Interchange Control Number

A control number assigned by the interchange sender

1000004

The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.

MAY 2000

B.5

CONTROL SEGMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

ISA14

I13

Acknowledgment Requested

ID

1/1

Code sent by the sender to request an interchange acknowledgment (TA1)

1000038

See Section A.1.5.1 for interchange acknowledgment information.

CODE DEFINITION

0 1 REQUIRED ISA15 I14

No Acknowledgment Requested Interchange Acknowledgment Requested M ID 1/1

Usage Indicator

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

P T REQUIRED ISA16 I15

Production Data Test Data M 1/1

Component Element Separator

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter 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

B.6

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INTERCHANGE CONTROL TRAILER

CONTROL SEGMENTS

IEA

INTERCHANGE CONTROL TRAILER 004010X098 002 IEA

IMPLEMENTATION

INTERCHANGE CONTROL TRAILER

5 000 100
STANDARD

Example: IEAV1V000000905~

IEA Interchange Control Trailer

Purpose: To define the end of an interchange of zero or more functional groups and interchange-related control segments
DIAGRAM

IEA01

I16

IEA02

I12

IEA

V Num of Incl V Funct Group

M N0 1/5 M

Inter Ctrl Number

N0 9/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED REQUIRED

IEA01 IEA02

I16 I12

Number of Included Functional Groups Interchange Control Number

A control number assigned by the interchange sender

M M

N0 N0

1/5 9/9

A count of the number of functional groups included in an interchange

MAY 2000

B.7

CONTROL SEGMENTS
FUNCTIONAL GROUP HEADER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GS

FUNCTIONAL 002 GS 004010X098 GROUP HEADER

IMPLEMENTATION

FUNCTIONAL GROUP HEADER

4 005 100
STANDARD

Example: GSVHCVSENDER CODEVRECEIVER CODEV19940331V0802V1VXV004010X098~

GS Functional Group Header

Purpose: To indicate the beginning of a functional group and to provide control information
DIAGRAM

GS01

479

GS02

142

GS03

124

GS04

373

GS05

337

GS06

28

GS V

Functional ID Code
M ID 2/2

V Application V Sends Code

M AN 2/15

Application Recs Code

M AN 2/15

V
M

Date
DT 8/8

V
M

Time
TM 4/8

Group Ctrl Number

M N0 1/9

GS07

455

GS08

480

V Responsible V Agency Code

M ID 1/2

Ver/Release ID Code
M AN 1/12

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

GS01

479

Functional Identifier Code

CODE DEFINITION

ID

2/2

Code identifying a group of application related transaction sets

HC REQUIRED GS02 142

Health Care Claim (837) M AN 2/15

Application Senders Code

Code identifying party sending transmission; codes agreed to by trading partners

1000009
REQUIRED GS03 124

Use this code to identify the unit sending the information. Application Receivers Code M AN 2/15
Code identifying party receiving transmission. Codes agreed to by trading partners

1000010
REQUIRED GS04 373

Use this code to identify the unit receiving the information. Date
Date expressed as CCYYMMDD
SEMANTIC:

M
GS04 is the group date.

DT

8/8

1000011
REQUIRED GS05 337

Use this date for the functional group creation date. Time M TM 4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC:

GS05 is the group time.

1000012

Use this time for the creation time. The recommended format is HHMM.

B.8

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONTROL SEGMENTS

REQUIRED

GS06

28

Group Control Number

Assigned number originated and maintained by the sender
SEMANTIC:

N0

1/9

The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.

REQUIRED

GS07

455

Responsible Agency Code

ID

1/2

Code used in conjunction with Data Element 480 to identify the issuer of the standard
CODE DEFINITION

X REQUIRED GS08 480

Accredited Standards Committee X12 M AN 1/12

Version / Release / Industry Identifier Code

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

004010X098

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

MAY 2000

B.9

CONTROL SEGMENTS
FUNCTIONAL GROUP TRAILER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GE

FUNCTIONAL 002 GE 004010X098 GROUP TRAILER

IMPLEMENTATION

FUNCTIONAL GROUP TRAILER

3 001 100
STANDARD

Example: GEV1V1~

GE Functional Group Trailer

Purpose: To indicate the end of a functional group and to provide control information
DIAGRAM

GE01

97

GE02

28

GE

Number of TS Included
M N0 1/6

Group Ctrl Number

M N0 1/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

GE01

97

Number of Transaction Sets Included

N0

1/6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

REQUIRED

GE02

28

Group Control Number

Assigned number originated and maintained by the sender
SEMANTIC:

N0

1/9

The data interchange control number GE02 in this trailer must be identical to the same data element in the associated functional group header, GS06.

B.10

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

INTERCHANGE ACKNOWLEDGMENT

CONTROL SEGMENTS

TA1

INTERCHANGE ACKNOWLEDGMENT 004010X098 002 TA1

IMPLEMENTATION

INTERCHANGE ACKNOWLEDGMENT
4 001 100 5 001 100
Notes: 1. All fields must contain data. 2. This segment acknowledges the reception of an X12 interchange header and trailer from a previous interchange. If the header/trailer pair was received correctly, the TA1 reflects a valid interchange, regardless of the validity of the contents of the data included inside the header/trailer envelope. 3. See Section A.1.5.1 for interchange acknowledgment information. 4. Use of TA1 is subject to trading partner agreement and is neither mandated or prohibited in this Appendix. Example: TA1V000000905V940101V0100VAV000~

6 007 100 7 007 100 6 001 100

STANDARD

TA1 Interchange Acknowledgment

Purpose: To report the status of processing a received interchange header and trailer or the non-delivery by a network provider
DIAGRAM

TA101

I12

TA102

I08

TA103

I09

TA104

I17

TA105

I18

TA1 V
M

Inter Ctrl Number

N0 9/9

Interchange Date
M DT 6/6

V Interchange Time
M TM 4/4

Interchange Ack Code

M ID 1/1

V Interchange Note Code

M ID 3/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

TA101

I12

Interchange Control Number

A control number assigned by the interchange sender

N0

9/9

1000017

This number uniquely identifies the interchange data to the sender. It is assigned by the sender. Together with the sender ID it uniquely identifies the interchange data to the receiver. It is suggested that the sender, receiver, and all third parties be able to maintain an audit trail of interchanges using this number. In the TA1, this should be the interchange control number of the original interchange that this TA1 is acknowledging. TA102 I08 Interchange Date
Date of the interchange

1000018
REQUIRED

DT

6/6

1000019
REQUIRED TA103 I09

This is the date of the original interchange being acknowledged. (YYMMDD) Interchange Time
Time of the interchange

TM

4/4

1000020

This is the time of the original interchange being acknowledged. (HHMM)

MAY 2000

B.11

CONTROL SEGMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

REQUIRED

TA104

I17

Interchange Acknowledgment Code

CODE DEFINITION

ID

1/1

This indicates the status of the receipt of the interchange control structure

The Transmitted Interchange Control Structure Header and Trailer Have Been Received and Have No Errors. The Transmitted Interchange Control Structure Header and Trailer Have Been Received and Are Accepted But Errors Are Noted. This Means the Sender Must Not Resend This Data. The Transmitted Interchange Control Structure Header and Trailer are Rejected Because of Errors. M ID 3/3

R REQUIRED

TA105

I18

Interchange Note Code

This numeric code indicates the error found processing the interchange control structure
CODE DEFINITION

000 001

No error The Interchange Control Number in the Header and Trailer Do Not Match. The Value From the Header is Used in the Acknowledgment. This Standard as Noted in the Control Standards Identifier is Not Supported. This Version of the Controls is Not Supported The Segment Terminator is Invalid Invalid Interchange ID Qualifier for Sender Invalid Interchange Sender ID Invalid Interchange ID Qualifier for Receiver Invalid Interchange Receiver ID Unknown Interchange Receiver ID Invalid Authorization Information Qualifier Value Invalid Authorization Information Value Invalid Security Information Qualifier Value Invalid Security Information Value Invalid Interchange Date Value Invalid Interchange Time Value Invalid Interchange Standards Identifier Value Invalid Interchange Version ID Value Invalid Interchange Control Number Value

002

003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018

B.12

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CONTROL SEGMENTS

019 020 021 022 023 024

Invalid Acknowledgment Requested Value Invalid Test Indicator Value Invalid Number of Included Groups Value Invalid Control Structure Improper (Premature) End-of-File (Transmission) Invalid Interchange Content (e.g., Invalid GS Segment) Duplicate Interchange Control Number Invalid Data Element Separator Invalid Component Element Separator Invalid Delivery Date in Deferred Delivery Request Invalid Delivery Time in Deferred Delivery Request Invalid Delivery Time Code in Deferred Delivery Request Invalid Grade of Service Code

025 026 027 028 029 030

031

MAY 2000

B.13

CONTROL SEGMENTS

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

B.14

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 997 IMPLEMENTATION GUIDE ASC X12N INSURANCE SUBCOMMITTEE

004010X098 997

MAY 19, 2000 STANDARD

997

Functional Acknowledgment
Functional Group ID: FA
This Draft Standard for Trial Use contains the format and establishes the data contents of the Functional Acknowledgment Transaction Set (997) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents. The encoded documents are the transaction sets, which are grouped in functional groups, used in defining transactions for business data interchange. This standard does not cover the semantic meaning of the information encoded in the transaction sets.

Table 1 - Header
PAGE #
POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

010 020 030 040 050 060 070 080

ST AK1 AK2 AK3 AK4 AK5 AK9 SE

Transaction Set Header Functional Group Response Header LOOP ID - AK2 Transaction Set Response Header LOOP ID - AK2/AK3 Data Segment Note Data Element Note Transaction Set Response Trailer Functional Group Response Trailer Transaction Set Trailer

M M O O O M M M

1 1 999999 1 999999 1 99 1 1 1

NOTES: 1/010 These acknowledgments shall not be acknowledged, thereby preventing an endless cycle of acknowledgments of acknowledgments. Nor shall a Functional Acknowledgment be sent to report errors in a previous Functional Acknowledgment. 1/010 The Functional Group Header Segment (GS) is used to start the envelope for the Functional Acknowledgment Transaction Sets. In preparing the functional group of acknowledgments, the application senders code and the application receivers code, taken from the functional group being acknowledged, are exchanged; therefore, one acknowledgment functional group responds to only those functional groups from one application receivers code to one application senders code. 1/010 There is only one Functional Acknowledgment Transaction Set per acknowledged functional group. 1/020 AK1 is used to respond to the functional group header and to start the acknowledgement for a functional group. There shall be one AK1 segment for the functional group that is being acknowledged. 1/030 AK2 is used to start the acknowledgement of a transaction set within the received functional group. The AK2 segments shall appear in the same order as the transaction sets in the functional group that has been received and is being acknowledged. 1/040 The data segments of this standard are used to report the results of the syntactical analysis of the functional groups of transaction sets; they report the extent to which the syntax complies with the standards for transaction sets and functional groups. They do not report on the semantic meaning of the transaction sets (for example, on the ability of the receiver to comply with the request of the sender).

MAY 2000

B.15

004010X098 997 ST TRANSACTION SET HEADER

TRANSACTION SET HEADER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ST

TRANSACTION SET HEADER 004010X098 997 ST

IMPLEMENTATION

TRANSACTION SET HEADER

Usage: REQUIRED Repeat: 1

8 007 100

Notes:

1. Use of the 997 transaction is subject to trading partner agreement or accepted usage and is neither mandated nor prohibited in this Appendix.

500
STANDARD

Example: STV997V1234~

ST Transaction Set Header

Level: Header Position: 010 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To indicate the start of a transaction set and to assign a control number Set Notes: 1. These acknowledgments shall not be acknowledged, thereby preventing an endless cycle of acknowledgments of acknowledgments. Nor shall a Functional Acknowledgment be sent to report errors in a previous Functional Acknowledgment. 2. The Functional Group Header Segment (GS) is used to start the envelope for the Functional Acknowledgment Transaction Sets. In preparing the functional group of acknowledgments, the application senders code and the application receivers code, taken from the functional group being acknowledged, are exchanged; therefore, one acknowledgment functional group responds to only those functional groups from one application receivers code to one application senders code. 3. There is only one Functional Acknowledgment Transaction Set per acknowledged functional group.
DIAGRAM

ST01

143

ST02

329

ST V
M

TS ID Code
ID 3/3

TS Control Number
M AN 4/9

B.16

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE ELEMENT SUMMARY

REF. DES. DATA ELEMENT

004010X098 997 ST TRANSACTION SET HEADER

USAGE

NAME

ATTRIBUTES

REQUIRED

ST01

143

Transaction Set Identifier Code

Code uniquely identifying a Transaction Set
SEMANTIC:

ID

3/3

The transaction set identifier (ST01) used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
CODE DEFINITION

997 REQUIRED ST02 329

Functional Acknowledgment M AN 4/9

Transaction Set Control Number

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

501

The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). The number also aids in error resolution research. For example, start with the number 0001 and increment from there. Use the corresponding value in SE02 for this transaction set.

524

MAY 2000

B.17

004010X098 997 AK1 FUNCTIONAL GROUP RESPONSE HEADER

FUNCTIONAL GROUP RESPONSE HEADER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AK1

FUNCTIONAL 997 AK1 004010X098 GROUP RESPONSE HEADER

IMPLEMENTATION

FUNCTIONAL GROUP RESPONSE HEADER

Usage: REQUIRED Repeat: 1

502
STANDARD

Example: AK1VHCV1~

AK1 Functional Group Response Header

Level: Header Position: 020 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To start acknowledgment of a functional group Set Notes: 1. AK1 is used to respond to the functional group header and to start the acknowledgement for a functional group. There shall be one AK1 segment for the functional group that is being acknowledged.

DIAGRAM

AK101

479

AK102

28

AK1 V

Functional ID Code
M ID 2/2

Group Ctrl Number

M N0 1/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AK101

479

Functional Identifier Code

SEMANTIC:

ID

2/2

Code identifying a group of application related transaction sets AK101 is the functional ID found in the GS segment (GS01) in the functional group being acknowledged.
CODE DEFINITION

HC REQUIRED AK102 28

Health Care Claim (837) M N0 1/9

Group Control Number

Assigned number originated and maintained by the sender
SEMANTIC:

AK102 is the functional group control number found in the GS segment in the functional group being acknowledged.

B.18

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

TRANSACTION SET RESPONSE HEADER

004010X098 997 AK2 AK2 TRANSACTION SET RESPONSE HEADER

AK2

004010X098 997 AK2 AK2 HEADER TRANSACTION SET RESPONSE

IMPLEMENTATION

TRANSACTION SET RESPONSE HEADER

Loop: AK2 TRANSACTION SET RESPONSE HEADER Repeat: 999999 Usage: SITUATIONAL Repeat: 1

9 007 100 503

STANDARD

Notes:

1. Required when communicating information about a transaction set within the functional group identified in AK1.

Example: AK2V837V000000905~

AK2 Transaction Set Response Header

Level: Header Position: 030 Loop: AK2 Repeat: 999999 Requirement: Optional Max Use: 1 Purpose: To start acknowledgment of a single transaction set Set Notes: 1. AK2 is used to start the acknowledgement of a transaction set within the received functional group. The AK2 segments shall appear in the same order as the transaction sets in the functional group that has been received and is being acknowledged.

DIAGRAM

AK201

143

AK202

329

AK2 V
M

TS ID Code
ID 3/3

TS Control Number
M AN 4/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AK201

143

Transaction Set Identifier Code

Code uniquely identifying a Transaction Set
SEMANTIC:

ID

3/3

AK201 is the transaction set ID found in the ST segment (ST01) in the transaction set being acknowledged.
CODE DEFINITION

837 REQUIRED AK202 329

Health Care Claim M AN 4/9

Transaction Set Control Number

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
SEMANTIC:

AK202 is the transaction set control number found in the ST segment in the transaction set being acknowledged.

MAY 2000

B.19

004010X098 997 AK2/AK3 AK3 DATA SEGMENT NOTE

DATA SEGMENT NOTE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AK3

DATA SEGMENT NOTE 004010X098 997 AK2/AK3 AK3

IMPLEMENTATION

DATA SEGMENT NOTE

Loop: AK2/AK3 DATA SEGMENT NOTE Repeat: 999999 Usage: SITUATIONAL Repeat: 1

0 008 100 504

STANDARD

Notes:

1. Used when there are errors to report in a transaction.

Example: AK3VNM1V37V2010BBV7~

AK3 Data Segment Note

Level: Header Position: 040 Loop: AK2/AK3 Repeat: 999999 Requirement: Optional Max Use: 1 Purpose: To report errors in a data segment and identify the location of the data segment Set Notes: 1. The data segments of this standard are used to report the results of the syntactical analysis of the functional groups of transaction sets; they report the extent to which the syntax complies with the standards for transaction sets and functional groups. They do not report on the semantic meaning of the transaction sets (for example, on the ability of the receiver to comply with the request of the sender).

DIAGRAM

AK301

721

AK302

719

AK303

447

AK304

720

AK3 V

Segment ID Code
M ID 2/3

V Segment Pos V in TS
M N0 1/6 O

Loop ID Code
AN 1/6

V Segment Syn ~ Error Code

O ID 1/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AK301

721

Segment ID Code

ID

2/3

Code defining the segment ID of the data segment in error (See Appendix A Number 77)
CODE SOURCE 77:

X12 Directories

505
REQUIRED AK302 719

This is the two or three characters which occur at the beginning of a segment. Segment Position in Transaction Set M N0 1/6
The numerical count position of this data segment from the start of the transaction set: the transaction set header is count position 1

506

This is a data count, not a segment position in the standard description.

B.20

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 997 AK2/AK3 AK3 DATA SEGMENT NOTE

SITUATIONAL

AK303

447

Loop Identifier Code

AN

1/6

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

507

Use this code to identify a loop within the transaction set that is bounded by the related LS and LE segments (corresponding LS and LE segments must have the same value for loop identifier). (Note: The loop ID number given on the transaction set diagram is recommended as the value for this data element in the segments LS and LE.) AK304 720 Segment Syntax Error Code This code is required if an error exists.
CODE DEFINITION

SITUATIONAL

ID

1/3

Code indicating error found based on the syntax editing of a segment

520

1 2 3 4 5 6 7 8

Unrecognized segment ID Unexpected segment Mandatory segment missing Loop Occurs Over Maximum Times Segment Exceeds Maximum Use Segment Not in Defined Transaction Set Segment Not in Proper Sequence Segment Has Data Element Errors

MAY 2000

B.21

004010X098 997 AK2/AK3 AK4 DATA ELEMENT NOTE

DATA ELEMENT NOTE

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AK4

DATA ELEMENT NOTE 004010X098 997 AK2/AK3 AK4

IMPLEMENTATION

DATA ELEMENT NOTE

Loop: AK2/AK3 DATA SEGMENT NOTE Usage: SITUATIONAL Repeat: 99

1 008 100 509

STANDARD

Notes:

1. Used when there are errors to report in a data element or composite data structure.

Example: AK4V1V98V7~

AK4 Data Element Note

Level: Header Position: 050 Loop: AK2/AK3 Requirement: Optional Max Use: 99 Purpose: To report errors in a data element or composite data structure and identify the location of the data element
DIAGRAM

AK401

C030

AK402

725

AK403

723

AK404

724

AK4 V

Position in Segment
M

V Data Elemnt V Data Elemnt V Copy of Bad ~ Ref Number Error Code Data Elemnt
O N0 1/4 M ID 1/3 O AN 1/99

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AK401

C030

POSITION IN SEGMENT

Code indicating the relative position of a simple data element, or the relative position of a composite data structure combined with the relative position of the component data element within the composite data structure, in error; the count starts with 1 for the simple data element or composite data structure immediately following the segment ID

REQUIRED

AK401 - 1

722

Element Position in Segment

N0

1/2

This is used to indicate the relative position of a simple data element, or the relative position of a composite data structure with the relative position of the component within the composite data structure, in error; in the data segment the count starts with 1 for the simple data element or composite data structure immediately following the segment ID

SITUATIONAL

AK401 - 2

1528

Component Data Element Position in Composite

N0

1/2

To identify the component data element position within the composite that is in error

1000082

Used when an error occurs in a composite data element and the composite data element position can be determined.

B.22

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 997 AK2/AK3 AK4 DATA ELEMENT NOTE

SITUATIONAL

AK402

725

Data Element Reference Number

ADVISORY: Under CODE SOURCE 77:

N0

1/4

Reference number used to locate the data element in the Data Element Dictionary most circumstances, this element is expected to be sent. X12 Directories

510
REQUIRED

The Data Element Reference Number for this data element is 725. For example, all reference numbers are found with the segment descriptions in this guide. AK403 723 Data Element Syntax Error Code
CODE DEFINITION

ID

1/3

Code indicating the error found after syntax edits of a data element

1 2 3 4 5 6 7 8 9 10 SITUATIONAL AK404 724

Mandatory data element missing Conditional required data element missing. Too many data elements. Data element too short. Data element too long. Invalid character in data element. Invalid code value. Invalid Date Invalid Time Exclusion Condition Violated O AN 1/99

Copy of Bad Data Element

This is a copy of the data element in error
SEMANTIC:

In no case shall a value be used for AK404 that would generate a syntax error, e.g., an invalid character.

1000083

Used to provide copy of erroneous data to the original submitter, but this is not used if the error reported in an invalid character.

MAY 2000

B.23

004010X098 997 AK2 AK5 TRANSACTION SET RESPONSE TRAILER

TRANSACTION SET RESPONSE TRAILER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

AK5

004010X098 997 AK2 AK5 TRAILER TRANSACTION SET RESPONSE

IMPLEMENTATION

TRANSACTION SET RESPONSE TRAILER

Loop: AK2/AK3 DATA SEGMENT NOTE Usage: REQUIRED Repeat: 1

511
STANDARD

Example: AK5VEV5~

AK5 Transaction Set Response Trailer

Level: Header Position: 060 Loop: AK2 Requirement: Mandatory Max Use: 1 Purpose: To acknowledge acceptance or rejection and report errors in a transaction set
DIAGRAM

AK501

717

AK502

718

AK503

718

AK504

718

AK505

718

AK506

718

AK5 V
M

TS Ack Code
ID 1/1

TS Syntax Error Code

O ID 1/3

TS Syntax Error Code

O ID 1/3

TS Syntax Error Code

O ID 1/3

TS Syntax Error Code

O ID 1/3

TS Syntax Error Code

O ID 1/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AK501

717

Transaction Set Acknowledgment Code

ID

1/1

Code indicating accept or reject condition based on the syntax editing of the transaction set
CODE DEFINITION

Accepted ADVISED

E M

Accepted But Errors Were Noted Rejected, Message Authentication Code (MAC) Failed Rejected ADVISED

W X

Rejected, Assurance Failed Validity Tests Rejected, Content After Decryption Could Not Be Analyzed

B.24

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 997 AK2 AK5 TRANSACTION SET RESPONSE TRAILER

SITUATIONAL

AK502

718

Transaction Set Syntax Error Code This code is required if an error exists.
CODE DEFINITION

ID

1/3

Code indicating error found based on the syntax editing of a transaction set

520

1 2 3

Transaction Set Not Supported Transaction Set Trailer Missing Transaction Set Control Number in Header and Trailer Do Not Match Number of Included Segments Does Not Match Actual Count One or More Segments in Error Missing or Invalid Transaction Set Identifier Missing or Invalid Transaction Set Control Number Authentication Key Name Unknown Encryption Key Name Unknown Requested Service (Authentication or Encrypted) Not Available Unknown Security Recipient Incorrect Message Length (Encryption Only) Message Authentication Code Failed Unknown Security Originator Syntax Error in Decrypted Text Security Not Supported Transaction Set Control Number Not Unique within the Functional Group S3E Security End Segment Missing for S3S Security Start Segment S3S Security Start Segment Missing for S3E Security End Segment S4E Security End Segment Missing for S4S Security Start Segment S4S Security Start Segment Missing for S4E Security End Segment O ID 1/3

5 6 7 8 9 10

11 12 13 15 16 17 23

24

25

26

27 SITUATIONAL

AK503

718

Transaction Set Syntax Error Code Use the same codes indicated in AK502.

Code indicating error found based on the syntax editing of a transaction set

512

MAY 2000

B.25

004010X098 997 AK2 AK5 TRANSACTION SET RESPONSE TRAILER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SITUATIONAL

AK504

718

Transaction Set Syntax Error Code Use the same codes indicated in AK502.

ID

1/3

Code indicating error found based on the syntax editing of a transaction set

512
SITUATIONAL AK505 718

Transaction Set Syntax Error Code Use the same codes indicated in AK502.

ID

1/3

Code indicating error found based on the syntax editing of a transaction set

512
SITUATIONAL AK506 718

Transaction Set Syntax Error Code Use the same codes indicated in AK502.

ID

1/3

Code indicating error found based on the syntax editing of a transaction set

512

B.26

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

FUNCTIONAL GROUP RESPONSE TRAILER

004010X098 997 AK9 FUNCTIONAL GROUP RESPONSE TRAILER

AK9

FUNCTIONAL 997 AK9 004010X098 GROUP RESPONSE TRAILER

IMPLEMENTATION

FUNCTIONAL GROUP RESPONSE TRAILER

Usage: REQUIRED Repeat: 1

513
STANDARD

Example: AK9VAV1V1V1~

AK9 Functional Group Response Trailer

Level: Header Position: 070 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To acknowledge acceptance or rejection of a functional group and report the number of included transaction sets from the original trailer, the accepted sets, and the received sets in this functional group
DIAGRAM

AK901

715

AK902

97

AK903

123

AK904

AK905

716

AK906

716

AK9

V Funct Group V Ack Code

M ID 1/1

Number of TS Included
M N0 1/6

V Number of V Number of V Funct Group V Funct Group Received TS Accepted TS Error Code Error Code
M N0 1/6 M N0 1/6 O ID 1/3 O ID 1/3

AK907

716

AK908

716

AK909

716

V Funct Group V Funct Group V Funct Group ~ Error Code Error Code Error Code
O ID 1/3 O ID 1/3 O ID 1/3

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

AK901

715

Functional Group Acknowledge Code

ID

1/1

Code indicating accept or reject condition based on the syntax editing of the functional group
COMMENT: If AK901 contains the value A or E, then the transmitted functional group is accepted. CODE DEFINITION

Accepted ADVISED

E M

Accepted, But Errors Were Noted. Rejected, Message Authentication Code (MAC) Failed

MAY 2000

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004010X098 997 AK9 FUNCTIONAL GROUP RESPONSE TRAILER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Partially Accepted, At Least One Transaction Set Was Rejected ADVISED

Rejected ADVISED

W X REQUIRED

Rejected, Assurance Failed Validity Tests Rejected, Content After Decryption Could Not Be Analyzed M N0 1/6

AK902

97

Number of Transaction Sets Included

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

514
REQUIRED REQUIRED SITUATIONAL AK903 AK904 AK905 123 2 716

This is the value in the original GE01. Number of Received Transaction Sets
Number of Transaction Sets received

M M O

N0 N0 ID

1/6 1/6 1/3

Number of Accepted Transaction Sets

Number of accepted Transaction Sets in a Functional Group

Functional Group Syntax Error Code

Code indicating error found based on the syntax editing of the functional group header and/or trailer

520

This code is required if an error exists.

CODE DEFINITION

1 2 3 4

Functional Group Not Supported Functional Group Version Not Supported Functional Group Trailer Missing Group Control Number in the Functional Group Header and Trailer Do Not Agree Number of Included Transaction Sets Does Not Match Actual Count Group Control Number Violates Syntax Authentication Key Name Unknown Encryption Key Name Unknown Requested Service (Authentication or Encryption) Not Available Unknown Security Recipient Unknown Security Originator Syntax Error in Decrypted Text Security Not Supported Incorrect Message Length (Encryption Only) Message Authentication Code Failed

6 10 11 12

13 14 15 16 17 18

B.28

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 997 AK9 FUNCTIONAL GROUP RESPONSE TRAILER

23

S3E Security End Segment Missing for S3S Security Start Segment S3S Security Start Segment Missing for S3E End Segment S4E Security End Segment Missing for S4S Security Start Segment S4S Security Start Segment Missing for S4E Security End Segment O ID 1/3

24

25

26 SITUATIONAL

AK906

716

Functional Group Syntax Error Code

Code indicating error found based on the syntax editing of the functional group header and/or trailer

515
SITUATIONAL AK907 716

Use the same codes indicated in AK905. Functional Group Syntax Error Code O ID 1/3
Code indicating error found based on the syntax editing of the functional group header and/or trailer

515
SITUATIONAL AK908 716

Use the same codes indicated in AK905. Functional Group Syntax Error Code O ID 1/3
Code indicating error found based on the syntax editing of the functional group header and/or trailer

515
SITUATIONAL AK909 716

Use the same codes indicated in AK905. Functional Group Syntax Error Code O ID 1/3
Code indicating error found based on the syntax editing of the functional group header and/or trailer

515

Use the same codes indicated in AK905.

MAY 2000

B.29

004010X098 997 SE TRANSACTION SET TRAILER

TRANSACTION SET TRAILER

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

SE

TRANSACTION SET TRAILER 004010X098 997 SE

IMPLEMENTATION

TRANSACTION SET TRAILER

Usage: REQUIRED Repeat: 1

516
STANDARD

Example: SEV27V1234~

SE Transaction Set Trailer

Level: Header Position: 080 Loop: ____ Requirement: Mandatory Max Use: 1 Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
DIAGRAM

SE01

96

SE02

329

SE V

Number of Inc Segs

M N0 1/10

TS Control Number
M AN 4/9

ELEMENT SUMMARY
REF. DES. DATA ELEMENT

USAGE

NAME

ATTRIBUTES

REQUIRED

SE01

96

Number of Included Segments

N0

1/10

Total number of segments included in a transaction set including ST and SE segments

REQUIRED

SE02

329

Transaction Set Control Number

AN

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

501

The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). The number also aids in error resolution research. For example, start with the number 0001 and increment from there.

B.30

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

C External Code Sources

5 Countries, Currencies and Funds
SIMPLE DATA ELEMENT/CODE REFERENCES

235/CH, 26, 100

SOURCE

Codes for Representation of Names of Countries, ISO 3166-(Latest Release) Codes for Representation of Currencies and Funds, ISO 4217-(Latest Release)
AVAILABLE FROM

American National Standards Institute 11 West 42nd Street, 13th Floor New York, NY 10036
ABSTRACT

This international standard provides a two-letter alphabetic code for representing the names of countries, dependencies, and other areas of special geopolitical interest for purposes of international exchange and general directions for the maintenance of the code. The standard is intended for use in any application requiring expression of entitles in coded form. Most currencies are those of the geopolitical entities that are listed in ISO 3166, Codes for the Representation of Names of Countries. The code may be a three-character alphabetic or three-digit numeric. The two leftmost characters of the alphabetic code identify the currency authority to which the code is assigned (using the two character alphabetic code from ISO 3166, if applicable). The rightmost character is a mnemonic derived from the name of the major currency unit or fund. For currencies not associated with a single geographic entity, a specially-allocated two-character alphabetic code, in the range XA to XZ identifies the currency authority. The rightmost character is derived from the name of the geographic area concerned, and is mnemonic to the extent possible. The numeric codes are identical to those assigned to the geographic entities listed in ISO 3166. The range 950-998 is reserved for identification of funds and currencies not associated with a single entity listed in ISO 3166.

22

States and Outlying Areas of the U.S.

SIMPLE DATA ELEMENT/CODE REFERENCES

66/SJ, 771/009, 235/A5, 156

SOURCE

National Zip Code and Post Office Directory

AVAILABLE FROM

U.S. Postal Service National Information Data Center P.O. Box 2977 Washington, DC 20013
ABSTRACT

Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The entities listed are considered to be the first order divisions of the U.S.

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Microfiche available from NTIS (same as address above). The Canadian Post Office lists the following as official codes for Canadian Provinces: AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NF - Newfoundland NS - Nova Scotia NT - North West Territories ON - Ontario PE - Prince Edward Island PQ - Quebec SK - Saskatchewan YT - Yukon

41

Universal Product Code

SIMPLE DATA ELEMENT/CODE REFERENCES

66/8, 235/UA, 235/UB, 235/UC, 235/UD, 235/UE, 235/UI, 235/UN, 235/UP, 559/FD, 88/UP, 438, 766
SOURCE

Publication series on Universal Product Code numbering system and usage.

AVAILABLE FROM

Uniform Code Council, Inc. 8163 Old Yankee Road, Suite J Dayton, OH 45458
ABSTRACT

U.P.C. is a system of coding products whereby each item/multipack/case is uniquely identified. Codes are formated as an optional digit which identifies the packing variations, one or two high order digit(s) identifying the system (grocery, drug, general merchandise, coupons), 5 digits which identify the manufacturer, 5 digits which identity the item and an optional 1 character check digit.

51

ZIP Code
SIMPLE DATA ELEMENT/CODE REFERENCES

66/16, 309/PQ, 309/PR, 309/PS, 771/010, 116

SOURCE

National ZIP Code and Post Office Directory, Publication 65 The USPS Domestic Mail Manual
AVAILABLE FROM

U.S Postal Service Washington, DC 20260 New Orders Superintendent of Documents

C.2

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

P.O. Box 371954 Pittsburgh, PA 15250-7954

ABSTRACT

The ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two rightmost digits identify a local delivery area. In the nine-digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery area. The two leftmost digits identify a sector which may consist of several large buildings, blocks or groups of streets. The rightmost digits divide the sector into segments such as a street, a block, a floor of a building, or a cluster of mailboxes. The USPS Domestics Mail Manual includes information on the use of the new 11digit zip code.

77

X12 Directories
SIMPLE DATA ELEMENT/CODE REFERENCES

721, 725
SOURCE

X12.3 Data Element Dictionary X12.22 Segment Directory

AVAILABLE FROM

Data Interchange Standards Association, Inc. (DISA) Suite 200 1800 Diagonal Road Alexandria, VA 22314-2852
ABSTRACT

The data element dictionary contains the format and descriptions of data elements used to construct X12 segments. It also contains code lists associated with these data elements. The segment directory contains the format and definitions of the data segments used to construct X12 transaction sets.

121

Health Industry Identification Number

SIMPLE DATA ELEMENT/CODE REFERENCES

128/HI, 66/21, I05/20, 1270/HI

SOURCE

Health Industry Number Database

AVAILABLE FROM

Health Industry Business Communications Council 5110 North 40th Street Phoenix, AZ 85018
ABSTRACT

The HIN is a coding system, developed and administered by the Health Industry Business Communications Council, that assigns a unique code number to hospi-

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

tals and other provider organizations - the customers of health industry manufacturers and distributors.

130

Health Care Financing Administration Common Procedural Coding System

SIMPLE DATA ELEMENT/CODE REFERENCES

235/HC, 1270/BO, 1270/BP

SOURCE

Health Care Finance Administration Common Procedural Coding System

AVAILABLE FROM

www.hcfa.gov/medicare/hcpcs.htm Health Care Financing Administration Center for Health Plans and Providers CCPP/DCPC C5-08-27 7500 Security Boulevard Baltimore, MD 21244-1850
ABSTRACT

HCPCS is Health Care Finance Administrations (HFCA) coding scheme to group procedures performed for payment to providers.

131

International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

SIMPLE DATA ELEMENT/CODE REFERENCES

235/ID, 235/DX, 1270/BF, 1270/BJ, 1270/BK, 1270/BN, 1270/BQ, 1270/BR, 1270/SD, 1270/TD, 1270/DD, 128/ICD
SOURCE

International Classification of Diseases, 9th Revision, Clincal Modification (ICD-9CM)

AVAILABLE FROM

U.S. National Center for Health Statistics Commission of Professional and Hospital Activities 1968 Green Road Ann Arbor, MI 48105
ABSTRACT

The International Classification of Diseases, 9th Revision, Clinical Modification, describes the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations.

C.4

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

139

Claim Adjustment Reason Code

SIMPLE DATA ELEMENT/CODE REFERENCES

1034
SOURCE

National Health Care Claim Payment/Advice Committee Bulletins

AVAILABLE FROM

www.wpc-edi.com Washington Publishing Company PMB 161 5284 Randolph Road Rockville, MD 20852-2116
ABSTRACT

Bulletins describe standard codes and messages that detail the reason why an adjustment was made to a health care claim payment by the payer.

235

Claim Frequency Type Code

SIMPLE DATA ELEMENT/CODE REFERENCES

1325
SOURCE

National Uniform Billing Data Element Specifications Type of Bill Position 3

AVAILABLE FROM

National Uniform Billing Committee American Hospitial Association 840 Lake Shore Drive Chicago, IL 60697
ABSTRACT

A variety of codes explaining the frequency of the bill submission.

237

Place of Service from Health Care Financing Administration Claim Form

SIMPLE DATA ELEMENT/CODE REFERENCES

1332/B
SOURCE

Electronic Media Claims National Standard Format

AVAILABLE FROM

www.hcfa.gov/medicare/poscode.htm Health Care Financing Administration Center for Health Plans and Providers 7500 Security Blvd. Baltimore, MD 21244-1850 Contact: Patricia Gill
ABSTRACT

A variety of codes indicating place where service was rendered.

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

240

National Drug Code by Format

SIMPLE DATA ELEMENT/CODE REFERENCES

235/N1, 235/N2, 235/N3, 235/N4, 1270/NDC, 235/N5, 235/N6

SOURCE

Drug Establishment Registration and Listing Instruction Booklet

AVAILABLE FROM

Federal Drug Listing Branch HFN-315 5600 Fishers Lane Rockville, MD 20857
ABSTRACT

Publication includes manufacturing and labeling information as well as drug packaging sizes.

245

National Association of Insurance Commissioners (NAIC) Code

SIMPLE DATA ELEMENT/CODE REFERENCES

128/NF
SOURCE

National Association of Insurance Commissioners Company Code List Manual

AVAILABLE FROM

National Association of Insurance Commission Publications Department 12th Street, Suite 1100 Kansas City, MO 64105-1925
ABSTRACT

Codes that uniquely identify each insurance company.

411

Remittance Remark Codes

SIMPLE DATA ELEMENT/CODE REFERENCES

1270/HE, 1271
SOURCE

Medicare Part A Specification for the ASC X12 835 (7/1/94) or Medicare Part B Specification for the ASC X12 835 (7/1/94) or National Standard Format Electronic Remittance Advice (Version 001.04)
AVAILABLE FROM

Washington Publishing Company http://www.wpc-edi.com or Health Care Financing Administration (HCFA) http://www.hcfa.gov/medicare/edi/edi.htm
ABSTRACT

These codes represent non-financial information critical to understanding the adjudication of a health insurance claim.

C.6

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

513

Home Infusion EDI Coalition (HIEC) Product/Service Code List

SIMPLE DATA ELEMENT/CODE REFERENCES

235/IV
SOURCE

Home Infusion EDI Coalition (HIEC) Coding System

AVAILABLE FROM

Home Infusion EDI Coalition affiliated with National Home Infusion Association 205 Daingerfield Road Alexandria, Virginia 22314 Telephone: 703-549-3740 FAX: 703-683-1484
ABSTRACT

This list contains codes identifying home infusion therapy products/services.

522

Health Industry Labeler Identification Code

SIMPLE DATA ELEMENT/CODE REFERENCES

128/LIC
SOURCE

AVAILABLE FROM

Health Industry Business Communications Council 5110 North 40th Street, Suite 240 Phoenix, AZ 85018
ABSTRACT

The HIBCC Labeler Identification Code (LIC) is assigned and maintained by HIBCC. The first character of the code is always alphabetic. The LIC may, at the option of the labeler, identify a labeler to the point of separate subsidiaries and divisions within a parent organization. The LIC is also a key component of the HIBCC LIC Primary Data Symbologies Code 128 and Code 39.

540

Health Care Financing Administration National PlanID

SIMPLE DATA ELEMENT/CODE REFERENCES

66/XV
SOURCE

PlanID Database
AVAILABLE FROM

Health Care Financing Administration Center for Beneficiary Services Administration Group Division of Membership Operations S1-05-06 7500 Security Boulevard Baltimore, MD 21244-1850
MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL ABSTRACT

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

The Health care Financing Administration is developing the PlanID, which will be proposed as the standard unique identifier for each health plan under the Health Insurance Portability and Accountability Act of 1996.

C.8

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

D Change Summary
The ASC X12N 4010 Implementation Guide for the 837 Professional Health Care Claim is based on the 3070 Tutorial. As such, all changes from the 3060 version to the 3070 version are contained in the 3070 Tutorial.

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

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D.2

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

E Data Element Name Index

This appendix contains an alphabetic listing of data elements used in this implementation guide. Consult the Data Element Dictionary for the complete list. Data element names in normal type are generic ASC X12 names. Italic type indicates a health care industry defined name.
Name Definition Transaction Set ID Locator Key H=Header, D=Detail, S=Summary Loop ID Segment ID/Reference Designator Composite ID-Sequence Data Element Number Page Number

Payment Date
Date of payment. 277
D | 2200D | SPA12 | C001-2 | 373 .............. 156

Accident Date
Date of the accident related to charges or to the patients current condition, diagnosis, or treatment referenced in the transaction.
ACUTE MANIFESTATION DATE

Adjustment Amount
Adjustment amount for the associated reason code.
D D D D D D D D D D D D | | | | | | | | | | | | 2320 2320 2320 2320 2320 2320 2430 2430 2430 2430 2430 2430 | | | | | | | | | | | | CAS03 CAS06 CAS09 CAS12 CAS15 CAS18 CAS03 CAS06 CAS09 CAS12 CAS15 CAS18 | | | | | | | | | | | | | 782 .............. 327 | 782 .............. 327 | 782 .............. 328 | 782 .............. 329 | 782 .............. 330 | 782 .............. 330 | 782 .............. 560 | 782 .............. 561 | 782 .............. 562 | 782 .............. 563 | 782 .............. 564 | 782 .............. 565

D |

2300

| DTP03 |

| 1251 .............195

Acute Manifestation Date

Date of acute manifestation of patients condition.
ADDITIONAL SUBMITTER NAME

D | D |

2300 2400

| DTP03 | | DTP03 |

| 1251 .............191 | 1251 .............457

Additional Submitter Name

Additional name information for the receiver or submitter of the transaction.
ADJUDICATION OR PAYMENT DATE

ADJUSTMENT QUANTITY

Adjustment Quantity
Numeric quantity associated with the related reason code for coordination of benefits.
D D D D D D D D D D D D | | | | | | | | | | | | 2320 2320 2320 2320 2320 2320 2430 2430 2430 2430 2430 2430 | | | | | | | | | | | | CAS04 CAS07 CAS10 CAS13 CAS16 CAS19 CAS04 CAS07 CAS10 CAS13 CAS16 CAS19 | | | | | | | | | | | | | 380 .............. 327 | 380 .............. 328 | 380 .............. 328 | 380 .............. 329 | 380 .............. 330 | 380 .............. 331 | 380 .............. 560 | 380 .............. 561 | 380 .............. 562 | 380 .............. 563 | 380 .............. 564 | 380 .............. 565

H | 1000A |

N201

| 93 ...................70

Adjudication or Payment Date

Date of payment or denial determination by previous payer.
ADJUSTED REPRICED CLAIM REFERENCE NUMBER

D | 2330B | DTP03 | D | 2430 | DTP03 |

| 1251 .............367 | 1251 .............566

Adjusted Repriced Claim Reference Number

Identification number, assigned by a repricing organization, to identify an adjusted claim.
ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER

ADJUSTMENT REASON CODE

D |

2300

| REF02 |

| 127 ...............235

Adjustment Reason Code

Code that indicates the reason for the adjustment.
D D D D D D D | | | | | | | 2320 2320 2320 2320 2320 2320 2430 | | | | | | | CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 CAS02 | | | | | | | | 1034 ............ 326 | 1034 ............ 327 | 1034 ............ 328 | 1034 ............ 329 | 1034 ............ 329 | 1034 ............ 330 | 1034 ............ 560

Adjusted Repriced Line Item Reference Number

Identification number of an adjusted repriced line item adjusted from an original amount.
ADJUSTMENT AMOUNT

D |

2400

| REF02 |

| 127 ...............469

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

D D D D D | | | | | 2430 2430 2430 2430 2430 | | | | | CAS05 CAS08 CAS11 CAS14 CAS17 | | | | | | 1034 ............ 561 | 1034 ............ 562 | 1034 ............ 563 | 1034 ............ 564 | 1034 ............ 565

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Arterial Blood Gas Quantity

The Arterial Blood Gas test results breathing room air (furnish results of recent hospital tests).
ASSIGNED NUMBER

D |

2400

| CR510 |

| 380 .............. 424

ALLOWED AMOUNT

Allowed Amount
The maximum amount determined by the payer as being allowable under the provisions of the contract prior to the determination of actual payment.
AMBULANCE TRANSPORT CODE

Assigned Number
Number assigned for differentiation within a transaction set.
ASSUMED OR RELINQUISHED CARE DATE

D |

2400

LX01

| 554 .............. 399

D |

2320

| AMT02 |

| 782 .............. 334

Ambulance Transport Code

Code indicating the type of ambulance transport.
AMBULANCE TRANSPORT REASON CODE

Assumed or Relinquished Care Date

Date post-operative care was assumed by another provider, or date provider ceased post-operative care.
ATTACHMENT CONTROL NUMBER

D | D |

2300 2400

| CR103 | | CR103 |

| 1316 ............ 249 | 1316 ............ 413

D |

2300

| DTP03 |

| 1251 ............ 213

Ambulance Transport Reason Code

Code indicating the reason for ambulance transport.
AMBULATORY PATIENT GROUP NUMBER

Attachment Control Number

Identification number of attachment related to the claim.
ATTACHMENT REPORT TYPE CODE

D |

2300

| PWK06 |

| 67 ................ 216

D | D |

2300 2400

| CR104 | | CR104 |

| 1317 ............ 249 | 1317 ............ 413

Attachment Report Type Code

Code to specify the type of attachment that is related to the claim.
ATTACHMENT TRANSMISSION CODE

Ambulatory Patient Group Number

Identifier for Ambulatory Patient Group assigned to the claim.
AMOUNT QUALIFIER CODE

D | D |

2300 2400

| PWK01 | | PWK01 |

| 755 .............. 215 | 755 .............. 410

D | D |

2300 2400

| REF02 | | REF02 |

| 127 .............. 240 | 127 .............. 479

Attachment Transmission Code

Code defining timing, transmission method or format by which an attachment report is to be sent or has been sent.

Amount Qualifier Code

Code to qualify amount.
D D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | | 2300 2300 2300 2320 2320 2320 2320 2320 2320 2320 2320 2320 2320 2400 2400 2400 | | | | | | | | | | | | | | | | AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 AMT01 | | | | | | | | | | | | | | | | | 522 .............. 219 | 522 .............. 220 | 522 .............. 221 | 522 .............. 332 | 522 .............. 333 | 522 .............. 334 | 522 .............. 335 | 522 .............. 336 | 522 .............. 337 | 522 .............. 338 | 522 .............. 339 | 522 .............. 340 | 522 .............. 341 | 522 .............. 484 | 522 .............. 485 | 522 .............. 486

AUTO ACCIDENT STATE OR PROVINCE CODE

D | D |

2300 2400

| PWK02 | | PWK02 |

| 756 .............. 216 | 756 ...............411

Auto Accident State or Province Code

State or Province where auto accident occurred.
BEGIN THERAPY DATE

D |

2300

| CLM11 | C024-4 | 156 .............. 177

Begin Therapy Date

Date therapy begins.
BENEFITS ASSIGNMENT CERTIFICATION INDICATOR

D |

2400

| DTP03 |

| 1251 ............ 441

ANESTHESIA MODIFYING UNITS

Benefits Assignment Certification Indicator

A code showing whether the provider has a signed form authorizing the third party payer to pay the provider.
BILLING PROVIDER ADDITIONAL IDENTIFIER

Anesthesia Modifying Units

Unit quantity for qualifying extenuating circumstances at time of service.
APPROVED AMOUNT

D |

2400

| QTY02 |

| 380 .............. 463

D | D |

2300 2320

| CLM08 | | OI03 |

| 1073 ............ 175 | 1073 ............ 345

Approved Amount
Amount approved.
ARTERIAL BLOOD GAS QUANTITY

D | D |

2320 2400

| AMT02 | | AMT02 |

| 782 .............. 333 | 782 .............. 485

Billing Provider Additional Identifier

Identifies another or additional distinguishing code number associated with the billing provider.
BILLING PROVIDER ADDITIONAL NAME

D | 2010AA | REF02 |

| 127 ................ 92

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Billing Provider Additional Name

Additional names or characters for the billing provider or billing entity for the transaction.
BILLING PROVIDER ADDRESS LINE

Billing Provider Postal Zone or ZIP Code

Postal zone code or ZIP code for the provider or billing entity billing for services.
BILLING PROVIDER STATE OR PROVINCE CODE

D | 2010AA |

N201

| 93 .................. 87

D | 2010AA |

N403

| 116................. 90

Billing Provider Address Line

Address line of the billing provider or billing entity address.
BILLING PROVIDER CITY NAME

Billing Provider State or Province Code

State or province for provider or billing entity billing for services.
BUNDLED OR UNBUNDLED LINE NUMBER

D | 2010AA | D | 2010AA |

N301 N302

| |

| 166 ................ 88 | 166 ................ 88

D | 2010AA |

N402

| 156 ................ 90

Billing Provider City Name

City of the billing provider or billing entity
BILLING PROVIDER CONTACT NAME

D | 2010AA |

N401

| 19 .................. 89

Bundled or Unbundled Line Number

Identification of line item bundled or unbundled by non-destination (COB) payer in payment of benefits.
CERTIFICATION CONDITION INDICATOR

Billing Provider Contact Name

Person at billing organization to contact regarding the billing transaction.
BILLING PROVIDER CREDIT CARD IDENTIFIER

D |

2430

| SVD06 |

| 554 .............. 557

D | 2010AA | PER02 |

| 93 .................. 97

Certification Condition Indicator

Code indicating whether or not the condition codes apply to the patient or another entity.
D D D D D | | | | | 2300 2300 2300 2400 2400 | | | | | CRC02 CRC02 CRC02 CRC02 CRC02 | | | | | | 1073 ............ 258 | 1073 ............ 261 | 1073 ............ 264 | 1073 ............ 428 | 1073 ............ 433

Billing Provider Credit Card Identifier

Identification number for credit card processing for the billing provider or billing entity
BILLING PROVIDER FIRST NAME

D | 2010AA | REF02 |

| 127 ................ 95

CERTIFICATION PERIOD PROJECTED VISIT COUNT

Billing Provider First Name

First name of the billing provider or billing entity
BILLING PROVIDER IDENTIFIER

Certification Period Projected Visit Count

Total visits projected during this certification period.
CERTIFICATION REVISION DATE

D | 2010AA | NM104 |

| 1036 .............. 85

D |

2305

| CR703 |

| 1470 ............ 277

Billing Provider Identifier

Identification number for the provider or organization in whose name the bill is submitted and to whom payment should be made.
BILLING PROVIDER LAST OR ORGANIZATIONAL NAME

Certification Revision Date

Date the certification was revised.
CERTIFICATION TYPE CODE

D | 2010AA | NM109 |

| 67 .................. 86

D |

2400

| DTP03 |

| 1251 ............ 438

Billing Provider Last or Organizational Name

Last name or organization name of the provider billing or billing entity for services.
BILLING PROVIDER MIDDLE NAME

Certification Type Code

Code indicating the type of certification
CLAIM ADJUSTMENT GROUP CODE

D | D |

2400 2400

| CR301 | | CR501 |

| 1322 ............ 421 | 1322 ............ 424

D | 2010AA | NM103 |

| 1035 .............. 85

Claim Adjustment Group Code

Billing Provider Middle Name

The middle name of the billing provider or billing entity
BILLING PROVIDER NAME SUFFIX

Code identifying the general category of payment adjustment.

CLAIM FILING INDICATOR CODE

D | 2010AA | NM105 |

| 1037 .............. 85

D | D |

2320 2430

| CAS01 | | CAS01 |

| 1033 ............ 326 | 1033 ............ 560

Billing Provider Name Suffix

Suffix, including generation, for the name of the provider or billing entity submitting the claim.
BILLING PROVIDER POSTAL ZONE OR ZIP CODE

Claim Filing Indicator Code

Code identifying type of claim or expected adjudication process.
CLAIM FREQUENCY CODE

D | 2010AA | NM107 |

| 1039 .............. 86

D | 2000B | SBR09 | D | 2320 | SBR09 |

| 1032 .............112 | 1032 ............ 321

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

Claim Frequency Code

Code specifying the frequency of the claim. This is the third position of the Uniform Billing Claim Form Bill Type.
CLAIM NOTE TEXT

Communication Number
Complete communications number including country or area code when applicable
H H H D D D D D D D D D | | | | | | | | | | | | 1000A 1000A 1000A 2010AA 2010AA 2010AA 2330B 2330B 2330B 2420E 2420E 2420E | | | | | | | | | | | | PER04 PER06 PER08 PER04 PER06 PER08 PER04 PER06 PER08 PER04 PER06 PER08 | | | | | | | | | | | | | 364 ................ 72 | 364 ................ 73 | 364 ................ 73 | 364 ................ 97 | 364 ................ 98 | 364 ................ 98 | 364 .............. 364 | 364 .............. 365 | 364 .............. 365 | 364 .............. 539 | 364 .............. 540 | 364 .............. 540

D |

2300

| CLM05 | C023-3 | 1325 ............ 173

Claim Note Text

Narrative text providing additional information related to the claim.
CLAIM ORIGINAL REFERENCE NUMBER

D |

2300

| NTE02 |

| 352 .............. 247

Claim Original Reference Number

Number assigned by a processor to identify a claim.
CLAIM OR ENCOUNTER IDENTIFIER

COMMUNICATION NUMBER QUALIFIER

D |

2300

| REF02 |

| 127 .............. 230

Communication Number Qualifier

Code identifying the type of communication number
H H H D D D D D D D D D | | | | | | | | | | | | 1000A 1000A 1000A 2010AA 2010AA 2010AA 2330B 2330B 2330B 2420E 2420E 2420E | | | | | | | | | | | | PER03 PER05 PER07 PER03 PER05 PER07 PER03 PER05 PER07 PER03 PER05 PER07 | | | | | | | | | | | | | 365 ................ 72 | 365 ................ 73 | 365 ................ 73 | 365 ................ 97 | 365 ................ 97 | 365 ................ 98 | 365 .............. 364 | 365 .............. 364 | 365 .............. 365 | 365 .............. 539 | 365 .............. 539 | 365 .............. 540

Claim or Encounter Identifier

Code indicating whether the transaction is a claim or reporting encounter information.
CLEARINGHOUSE TRACE NUMBER

H |

| BHT06 |

| 640 ................ 65

Clearinghouse Trace Number

Unique tracking number for the transaction assigned by a clearinghouse.
CLINICAL LABORATORY IMPROVEMENT AMENDMENT NUMBER

D |

2300

| REF02 |

| 127 .............. 239

COMPLICATION INDICATOR

Clinical Laboratory Improvement Amendment Number

The CLIA Certificate of Waiver or the CLIA Certificate of Registration Identification Number assigned to the laboratory testing site that rendered the services on this claim.
CO-PAY STATUS CODE

Complication Indicator
A code to indicate whether the Patients condition is Complicated or Uncomplicated.
CONDITION CODE

D | D |

2300 2400

| CR209 | | CR209 |

| 1073 ............ 255 | 1073 ............ 419

D | D |

2300 2400

| REF02 | | REF02 |

| 127 .............. 232 | 127 .............. 476

Condition Code
Code(s) used to identify condition(s) relating to this bill or relating to the patient.
D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | 2300 2300 2300 2300 2300 2300 2300 2300 2300 2300 2400 2400 2400 2400 2400 | | | | | | | | | | | | | | | CRC03 CRC04 CRC05 CRC06 CRC07 CRC03 CRC04 CRC05 CRC06 CRC07 CRC03 CRC04 CRC05 CRC06 CRC07 | | | | | | | | | | | | | | | | 1321 ............ 258 | 1321 ............ 259 | 1321 ............ 259 | 1321 ............ 259 | 1321 ............ 259 | 1321 ............ 261 | 1321 ............ 261 | 1321 ............ 261 | 1321 ............ 261 | 1321 ............ 262 | 1321 ............ 428 | 1321 ............ 429 | 1321 ............ 429 | 1321 ............ 429 | 1321 ............ 429

Co-Pay Status Code

A code indicating the status of the co-payment requirements for this service.
CODE CATEGORY

D |

2400

| SV115 |

| 1327 ............ 407

Code Category
Specifies the situation or category to which the code applies.
D D D D D D | | | | | | 2300 2300 2300 2400 2400 2400 | | | | | | CRC01 CRC01 CRC01 CRC01 CRC01 CRC01 | | | | | | | 1136............. 257 | 1136............. 260 | 1136............. 263 | 1136............. 427 | 1136............. 431 | 1136............. 433

CONDITION INDICATOR

CODE LIST QUALIFIER CODE

Condition Indicator Code List Qualifier Code

Code identifying a specific industry code list.
COMMUNICATION NUMBER

Code indicating a condition

| 1270 ............ 568 D D D D D D | | | | | | 2400 2400 2400 2400 2400 2400 | | | | | | CRC03 CRC03 CRC04 CRC05 CRC06 CRC07 | | | | | | | 1321 ............ 431 | 1321 ............ 433 | 1321 ............ 434 | 1321 ............ 434 | 1321 ............ 434 | 1321 ............ 434

D |

2440

LQ01

CONTACT FUNCTION CODE

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

Contact Function Code

Code identifying the major duty or responsibility of the person or group named.
H D D D | | | | 1000A 2010AA 2330B 2420E | | | | PER01 PER01 PER01 PER01 | | | | | 366 ................ 72 | 366 ................ 97 | 366 .............. 364 | 366 .............. 539

Credit or Debit Card Holder Additional Name

Additional name information for the person or entity who has a credit card that could be used as payment for the billed charges.
CREDIT OR DEBIT CARD HOLDER FIRST NAME

D | 2010BD |

N201

| 93 ................ 149

CONTRACT AMOUNT

Contract Amount
Fixed monetary amount pertaining to the contract
CONTRACT CODE

Credit or Debit Card Holder First Name

First name of the person or entity who has a credit card that could be used as payment for the billed charges.
CREDIT OR DEBIT CARD HOLDER LAST OR ORGANIZATIONAL NAME

D | D |

2300 2400

| CN102 | | CN102 |

| 782 .............. 218 | 782 .............. 467

D | 2010BD | NM104 |

| 1036 ............ 147

Contract Code
Code identifying the specific contract, established by the payer.
CONTRACT PERCENTAGE

Credit or Debit Card Holder Last or Organizational Name

Last name or organization name of the person or entity who has a credit card that could be used as payment for the billed charges.
CREDIT OR DEBIT CARD HOLDER MIDDLE NAME

D | D |

2300 2400

| CN104 | | CN104 |

| 127 .............. 218 | 127 .............. 467

Contract Percentage
Percent of charges payable under the contract
CONTRACT TYPE CODE

D | 2010BD | NM103 |

| 1035 ............ 147

D | D |

2300 2400

| CN103 | | CN103 |

| 332 .............. 218 | 332 .............. 467

Credit or Debit Card Holder Middle Name

Middle name of the person or entity who has a credit card that could be used as payment for the billed charges.

Contract Type Code

Code identifying a contract type
CONTRACT VERSION IDENTIFIER

D | D |

2300 2400

| CN101 | | CN101 |

| 1166............. 217 | 1166............. 466

CREDIT OR DEBIT CARD HOLDER NAME SUFFIX

D | 2010BD | NM105 |

| 1037 ............ 147

Contract Version Identifier

Identification of additional or supplemental contract provisions, or identification of a particular version or modification of contract.
COUNTRY CODE

Credit or Debit Card Holder Name Suffix

Name suffix of the person or entity who has a credit card that could be used as payment for the billed charges.
CREDIT OR DEBIT CARD MAXIMUM AMOUNT

D | D |

2300 2400

| CN106 | | CN106 |

| 799 .............. 218 | 799 .............. 467

D | 2010BD | NM107 |

| 1039 ............ 147

Country Code
Code indicating the geographic location.
D D D D D D D D D D D | | | | | | | | | | | 2010AA 2010AB 2010BA 2010BB 2010BC 2010CA 2300 2310D 2330A 2420C 2420E | N404 | | 26 .................. 90 | N404 | | 26 ................ 105 | N404 | | 26 ................ 123 | N404 | | 26 ................ 136 | N404 | | 26 ................ 145 | N404 | | 26 ................ 163 | CLM11 | C024-5 | 26 ................ 178 | N404 | | 26 ................ 309 | N404 | | 26 ................ 356 | N404 | | 26 ................ 520 | N404 | | 26 ................ 535

Credit or Debit Card Maximum Amount

Dollar limit for a credit or debit card
CREDIT OR DEBIT CARD NUMBER

D |

2300

| AMT02 |

| 782 .............. 219

Credit or Debit Card Number

Credit/Debit card number that may be used to pay for billed charges.
CURRENCY CODE

D | 2010BD | NM109 |

| 67 ................ 148

CREDIT OR DEBIT CARD AUTHORIZATION NUMBER

Currency Code
Code for country in whose currency the charges are specified.
DATE TIME PERIOD FORMAT QUALIFIER

Credit or Debit Card Authorization Number

Credit/Debit card authorization number used to authorize use of card for payment for billed charges.
CREDIT OR DEBIT CARD HOLDER ADDITIONAL NAME

D | 2000A | CUR02 |

| 100 ................ 82

Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format
D | 2000B | PAT05 | D | 2010BA | DMG01 | D | 2000C | PAT05 | | 1250 .............115 | 1250 ............ 124 | 1250 ............ 155

D | 2010BD | REF02 |

| 127 .............. 150

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D | 2010CA | DMG01 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2300 | DTP02 | | 2320 | DMG01 | | 2330B | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2400 | DTP02 | | 2430 | DTP02 | | 1250 ............ 164 | 1250 ............ 180 | 1250 ............ 182 | 1250 ............ 184 | 1250 ............ 186 | 1250 ............ 189 | 1250 ............ 190 | 1250 ............ 192 | 1250 ............ 194 | 1250 ............ 196 | 1250 ............ 197 | 1250 ............ 199 | 1250 ............ 200 | 1250 ............ 201 | 1250 ............ 203 | 1250 ............ 205 | 1250 ............ 206 | 1250 ............ 208 | 1250 ............ 210 | 1250 ............ 213 | 1250 ............ 342 | 1250 ............ 366 | 1250 ............ 436 | 1250 ............ 437 | 1250 ............ 439 | 1250 ............ 440 | 1250 ............ 443 | 1250 ............ 444 | 1250 ............ 445 | 1250 ............ 447 | 1250 ............ 450 | 1250 ............ 451 | 1250 ............ 452 | 1250 ............ 454 | 1250 ............ 456 | 1250 ............ 458 | 1250 ............ 460 | 1250 ............ 566 D D D D D

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

| | | | | 2400 2400 2400 2400 2430 | | | | | DTP01 DTP01 DTP01 DTP01 DTP01 | | | | | | 374 .............. 454 | 374 .............. 456 | 374 .............. 458 | 374 .............. 460 | 374 .............. 566

DELAY REASON CODE

Delay Reason Code

Code indicating the reason why a request was delayed.
DELIVERY PATTERN TIME CODE

D |

2300

| CLM20 |

| 1514 ............ 179

Delivery Pattern Time Code

Code which specifies the time delivery pattern of the services..
DEMONSTRATION PROJECT IDENTIFIER

D | D |

2305 2400

| HSD08 | | HSD08 |

| 679 .............. 281 | 679 .............. 494

Demonstration Project Identifier

Identification number for a Medicare demonstration project.
DIAGNOSIS CODE

D |

2300

| REF02 |

| 127 .............. 243

Diagnosis Code
An ICD-9-CM Diagnosis Code identifying a diagnosed medical condition.
D D D D D D D D | | | | | | | | 2300 2300 2300 2300 2300 2300 2300 2300 | | | | | | | | HI01 HI02 HI03 HI04 HI05 HI06 HI07 HI08 | | | | | | | | C022-2 C022-2 C022-2 C022-2 C022-2 C022-2 C022-2 C022-2 | 1271 ............ 266 | 1271 ............ 266 | 1271 ............ 267 | 1271 ............ 268 | 1271 ............ 268 | 1271 ............ 269 | 1271 ............ 269 | 1271 ............ 270

DATE TIME QUALIFIER

DIAGNOSIS CODE POINTER

Date Time Qualifier

Code specifying the type of date or time or both date and time.
D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2300 | DTP01 | | 2330B | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 2400 | DTP01 | | 374 .............. 180 | 374 .............. 182 | 374 .............. 184 | 374 .............. 186 | 374 .............. 188 | 374 .............. 190 | 374 .............. 192 | 374 .............. 194 | 374 .............. 196 | 374 .............. 197 | 374 .............. 199 | 374 .............. 200 | 374 .............. 201 | 374 .............. 203 | 374 .............. 205 | 374 .............. 206 | 374 .............. 208 | 374 .............. 210 | 374 .............. 213 | 374 .............. 366 | 374 .............. 435 | 374 .............. 437 | 374 .............. 439 | 374 .............. 440 | 374 .............. 442 | 374 .............. 444 | 374 .............. 445 | 374 .............. 447 | 374 .............. 449 | 374 .............. 451 | 374 .............. 452

Diagnosis Code Pointer

A pointer to the claim diagnosis code in the order of importance to this service
D D D D | | | | 2400 2400 2400 2400 | | | | SV107 SV107 SV107 SV107 | | | | C004-1 C004-2 C004-3 C004-4 | 1328 ............ 405 | 1328 ............ 405 | 1328 ............ 405 | 1328 ............ 405

DIAGNOSIS TYPE CODE

Diagnosis Type Code

Code identifying the type of diagnosis.
D D D D D D D D | | | | | | | | 2300 2300 2300 2300 2300 2300 2300 2300 | | | | | | | | HI01 HI02 HI03 HI04 HI05 HI06 HI07 HI08 | | | | | | | | C022-1 C022-1 C022-1 C022-1 C022-1 C022-1 C022-1 C022-1 | 1270 ............ 266 | 1270 ............ 266 | 1270 ............ 267 | 1270 ............ 268 | 1270 ............ 268 | 1270 ............ 269 | 1270 ............ 269 | 1270 ............ 270

DISABILITY FROM DATE

Disability From Date

The beginning date the patient, in the providers opinion, was or will be unable to perform the duties normally associated with his/her work.
DISABILITY TO DATE

D |

2300

| DTP03 |

| 1251 ............ 202

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Disability To Date
The ending date the patient, in the providers opinion, will be able to perform the duties normally associated with his/her work.
DISCIPLINE TYPE CODE

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual
H H D D D D D D D D D D D D D D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 1000A 1000B 2000A 2010AA 2010AB 2010BA 2010BB 2010BC 2010BD 2010CA 2310A 2310B 2310C 2310D 2310E 2330A 2330B 2330C 2330D 2330E 2330F 2330G 2330H 2420A 2420B 2420C 2420D 2420E 2420F 2420G | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | NM101 NM101 CUR01 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 NM101 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 98 .................. 68 | 98 .................. 75 | 98 .................. 82 | 98 .................. 85 | 98 ................ 100 | 98 .................118 | 98 ................ 131 | 98 ................ 140 | 98 ................ 147 | 98 ................ 157 | 98 ................ 283 | 98 ................ 291 | 98 ................ 299 | 98 ................ 304 | 98 ................ 313 | 98 ................ 351 | 98 ................ 360 | 98 ................ 375 | 98 ................ 379 | 98 ................ 383 | 98 ................ 387 | 98 ................ 391 | 98 ................ 395 | 98 ................ 502 | 98 ................ 510 | 98 ................ 515 | 98 ................ 524 | 98 ................ 530 | 98 ................ 542 | 98 ................ 550

D |

2300

| DTP03 |

| 1251 ............ 204

Discipline Type Code

Code indicating discipline(s) ordered by the physician.
DURABLE MEDICAL EQUIPMENT DURATION

D |

2305

| CR701 |

| 921 .............. 276

Durable Medical Equipment Duration

Length of time durable medical equipment (DME) is needed.
DURATION OF VISITS UNITS

D |

2400

| CR303 |

| 380 .............. 422

Duration of Visits Units

The unit (month, week, etc.) over which home health visits occur. Example: One visit every three days for 21 days. This element qualifies that the data is communicating that the one visit every three days occurs over a duration of days.
DURATION OF VISITS,, NUMBER OF UNITS

D | D |

2305 2400

| HSD05 | | HSD05 |

| 615 .............. 280 | 615 .............. 493

Duration of Visits, Number of Units

The number of units (month, week, etc.) over which home health visits occur. Example: One visit every three days for 21 days. This element indicates that the data is communicating that the one visit every three days occurs over a duration of 21 days.
EPSDT INDICATOR

ENTITY TYPE QUALIFIER

Entity Type Qualifier

Code qualifying the type of entity
H H D D D D D D D D D D D D D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 1000A 1000B 2010AA 2010AB 2010BA 2010BB 2010BC 2010BD 2010CA 2310A 2310B 2310C 2310D 2310E 2330A 2330B 2330C 2330D 2330E 2330F 2330G 2330H 2420A 2420B 2420C 2420D 2420E 2420F 2420G | | | | | | | | | | | | | | | | | | | | | | | | | | | | | NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 NM102 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 1065 .............. 68 | 1065 .............. 75 | 1065 .............. 85 | 1065 ............ 100 | 1065 .............118 | 1065 ............ 131 | 1065 ............ 140 | 1065 ............ 147 | 1065 ............ 158 | 1065 ............ 283 | 1065 ............ 291 | 1065 ............ 299 | 1065 ............ 304 | 1065 ............ 313 | 1065 ............ 351 | 1065 ............ 360 | 1065 ............ 375 | 1065 ............ 379 | 1065 ............ 383 | 1065 ............ 387 | 1065 ............ 391 | 1065 ............ 395 | 1065 ............ 502 | 1065 ............ 510 | 1065 ............ 515 | 1065 ............ 524 | 1065 ............ 530 | 1065 ............ 542 | 1065 ............ 550

D | D |

2305 2400

| HSD06 | | HSD06 |

| 616 .............. 280 | 616 .............. 493

EPSDT Indicator
An indicator of whether or not Early and Periodic Screening for Diagnosis and Treatment of children services are involved with this detail line.
EMERGENCY INDICATOR

D |

2400

| SV111 |

| 1073 ............ 406

Emergency Indicator
An indicator of whether or not emergency care was rendered in response to the sudden and unexpected onset of a medical condition, a severe injury, or an acute exacerbation of a chronic condition which was threatening to life, limb or sight, and which req
END STAGE RENAL DISEASE PAYMENT AMOUNT

D |

2400

| SV109 |

| 1073 ............ 406

End Stage Renal Disease Payment Amount

Amount of payment under End Stage Renal Disease benefit.
ENTITY IDENTIFIER CODE

ESTIMATED BIRTH DATE

Estimated Birth Date

Date delivery is expected.
EXCEPTION CODE

D |

2320

| MOA08 |

| 782 .............. 349

D |

2300

| DTP03 |

| 1251 ............ 199

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Exception Code
Exception code generated by the Third Party Organization.
FACILITY TYPE CODE

Hierarchical ID Number
| 1527 ............ 275 | 1527 ............ 500

D | D |

2300 2400

| HCP15 | | HCP15 |

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure.
D | 2000A | D | 2000B | D | 2000C | HL01 HL01 HL01 | | | | 628 ................ 78 | 628 .............. 109 | 628 .............. 153

HIERARCHICAL LEVEL CODE

Facility Type Code

Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format.
FAMILY PLANNING INDICATOR

Hierarchical Level Code

Code defining the characteristic of a level in a hierarchical structure.
D | 2000A | D | 2000B | D | 2000C | HL03 HL03 HL03 | | | | 735 ................ 78 | 735 .............. 109 | 735 .............. 153

D |

2300

| CLM05 | C023-1 | 1331 ............ 173

HIERARCHICAL PARENT ID NUMBER

Family Planning Indicator

An indicator of whether or not Family Planning Services are involved with this detail line.
FIXED FORMAT INFORMATION

Hierarchical Parent ID Number

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to.
HIERARCHICAL STRUCTURE CODE

D |

2400

| SV112 |

| 1073 ............ 406

Fixed Format Information

Data in fixed format agreed upon by sender and receiver
FORM IDENTIFIER

D | 2000B | D | 2000C |

HL02 HL02

| |

| 734 .............. 109 | 734 .............. 153

D | D |

2300 2400

| |

K301 K301

| |

| 449 .............. 245 | 449 .............. 487

Hierarchical Structure Code

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
HOMEBOUND INDICATOR

Form Identifier
Letter or number identifying a specific form.
FREQUENCY COUNT

H |

| BHT01 |

| 1005 .............. 63

D |

2440

LQ02

| 1271 ............ 568

Homebound Indicator Frequency Count

The count of the frequency units of home health visits. Example: One visit every three days for 21 days. This element indicates that the data is communicating that the one visit occurs at three day intervals.
FREQUENCY PERIOD

A code indicating whether a patient is homebound.

HOSPICE EMPLOYED PROVIDER INDICATOR

D |

2300

| CRC03 |

| 1321 ............ 264

D | D |

2305 2400

| HSD04 | | HSD04 |

| 1167............. 280 | 1167............. 493

Hospice Employed Provider Indicator

An indicator of whether or not the treatment in the Hospice was rendered by a Hospice employed provider.
IDENTIFICATION CODE QUALIFIER

Frequency Period
The units specifying the frequency of home health visits (e.g., days, months, etc.) Example: One visit every three days for 21 days. This element qualifies that the data is communicating that the the one visit occurs at a frequency of days.
HCPCS PAYABLE AMOUNT

D |

2400

| CRC02 |

| 1073 ............ 431

Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)
H H D D D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | | | | | 1000A 1000B 2010AA 2010AB 2010BA 2010BB 2010BD 2010CA 2300 2310A 2310B 2310C 2310D 2310E 2330A 2330B 2330C 2420A 2420B | | | | | | | | | | | | | | | | | | | NM108 NM108 NM108 NM108 NM108 NM108 NM108 NM108 PWK05 NM108 NM108 NM108 NM108 NM108 NM108 NM108 NM108 NM108 NM108 | | | | | | | | | | | | | | | | | | | | 66 .................. 68 | 66 .................. 75 | 66 .................. 86 | 66 ................ 101 | 66 .................119 | 66 ................ 131 | 66 ................ 147 | 66 ................ 159 | 66 ................ 216 | 66 ................ 284 | 66 ................ 292 | 66 ................ 299 | 66 ................ 305 | 66 ................ 314 | 66 ................ 352 | 66 ................ 360 | 66 ................ 375 | 66 ................ 503 | 66 ................ 510

D | D |

2305 2400

| HSD03 | | HSD03 |

| 355 .............. 279 | 355 .............. 492

HCPCS Payable Amount

Amount due under Medicare HCPCS system.
HIERARCHICAL CHILD CODE

D |

2320

| MOA02 |

| 782 .............. 348

Hierarchical Child Code

Code indicating if there are hierarchical child data segments subordinate to the level being described.
D | 2000A | D | 2000B | D | 2000C | HL04 HL04 HL04 | | | | 736 ................ 78 | 736 .............. 109 | 736 .............. 153

HIERARCHICAL ID NUMBER

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D D D D D | | | | | 2420C 2420D 2420E 2420F 2420G | | | | | NM108 NM108 NM108 NM108 NM108 | | | | | | 66 ................ 515 | 66 ................ 525 | 66 ................ 531 | 66 ................ 543 | 66 ................ 550

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

Laboratory or Facility Address Line

Address line of the laboratory or facility performing tests billed on the claim where the health care service was performed/rendered.
D D D D | | | | 2310D 2310D 2420C 2420C | | | | N301 N302 N301 N302 | | | | | 166 .............. 307 | 166 .............. 307 | 166 .............. 518 | 166 .............. 518

IMMUNIZATION BATCH NUMBER

Immunization Batch Number

The manufacturers lot number for vaccine used in immunization.
INDIVIDUAL RELATIONSHIP CODE

LABORATORY OR FACILITY CITY NAME

D |

2400

| REF02 |

| 127 .............. 478

Individual Relationship Code

Code indicating the relationship between two individuals or entities
D | 2000B | SBR02 | D | 2000C | PAT01 | D | 2320 | SBR02 | | 1069 ............. 111 | 1069 ............ 154 | 1069 ............ 319

Laboratory or Facility City Name

City of the laboratory or facility performing tests billed on the claim where the health care service was performed/rendered.
LABORATORY OR FACILITY NAME

D | 2310D | D | 2420C |

N401 N401

| |

| 19 ................ 308 | 19 ................ 519

INITIAL TREATMENT DATE

Initial Treatment Date

Date that the patient initially sought treatment for this condition.
INSURANCE TYPE CODE

Laboratory or Facility Name

| 1251 ............ 183 | 1251 ............ 459

D | D |

2300 2400

| DTP03 | | DTP03 |

Name of laboratory or other facility performing Laboratory testing on the claim where the health care service was performed/rendered.
LABORATORY OR FACILITY NAME ADDITIONAL TEXT

D | 2310D | NM103 | D | 2420C | NM103 |

| 1035 ............ 304 | 1035 ............ 515

Insurance Type Code

Code identifying the type of insurance.
INSURED GROUP NAME

D | 2000B | SBR05 | D | 2320 | SBR05 |

| 1336 ............. 111 | 1336 ............ 321

Laboratory or Facility Name Additional Text

Additional name information identifying the laboratory or facility performing tests billed on the claim where the health care service was performed/rendered.
LABORATORY OR FACILITY POSTAL ZONE OR ZIP CODE

Insured Group Name

Name of the group or plan through which the insurance is provided to the insured.
INSURED GROUP OR POLICY NUMBER

D | 2310D | D | 2420C |

N201 N201

| |

| 93 ................ 306 | 93 ................ 517

D | 2000B | SBR04 |

| 93 ................. 111

Insured Group or Policy Number

The identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered.
INSURED INDIVIDUAL DEATH DATE

Laboratory or Facility Postal Zone or ZIP Code

Postal ZIP or zonal code of the laboratory or facility performing tests billed on the claim where the health care service was performed/rendered.
LABORATORY OR FACILITY PRIMARY IDENTIFIER

D | 2000B | SBR03 | D | 2320 | SBR03 |

| 127 ............... 111 | 127 .............. 320

D | 2310D | D | 2420C |

N403 N403

| |

| 116............... 309 | 116............... 520

Insured Individual Death Date

Date of death for subscriber or dependent.
INVESTIGATIONAL DEVICE EXEMPTION IDENTIFIER

Laboratory or Facility Primary Identifier

Identification number of laboratory or other facility performing laboratory testing on the claim where the health care service was performed/rendered.
LABORATORY OR FACILITY SECONDARY IDENTIFIER

D | 2000B | PAT06 |

| 1251 .............115

Investigational Device Exemption Identifier

Number or reference identifying exemption assigned to an ivestigational device referenced in the claim.
LABORATORY OR FACILITY ADDRESS LINE

D | 2310D | NM109 | D | 2420C | NM109 |

| 67 ................ 305 | 67 ................ 516

D |

2300

| REF02 |

| 127 .............. 236

Laboratory or Facility Secondary Identifier

Additional identifier for the laboratory or facility performing tests billed on the claim where the health care service was performed/rendered.
LABORATORY OR FACILITY STATE OR PROVINCE CODE

D | 2310D | REF02 |

| 127 ...............311

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Laboratory or Facility State or Province Code

State or province of the laboratory or facility performing tests billed on the claim where the health care service was performed/rendered.
LAST CERTIFICATION DATE

Measurement Qualifier
Code identifying a specific product or process characteristic to which a measurement applies
MEASUREMENT REFERENCE IDENTIFICATION CODE

D |

2400

| MEA02 |

| 738 .............. 465

D | 2310D | D | 2420C |

N402 N402

| |

| 156 .............. 309 | 156 .............. 520

Measurement Reference Identification Code

Code identifying the broad category to which a measurement applies
MEDICAL RECORD NUMBER

Last Certification Date

The date of the last certification.
LAST MENSTRUAL PERIOD DATE

D |

2400

| MEA01 |

| 737 .............. 465

D |

2400

| DTP03 |

| 1251 ............ 443

Last Menstrual Period Date

The date of the last menstrual period (LMP).
LAST SEEN DATE

Medical Record Number

A unique number assigned to patient by the provider to assist in retrieval of medical records.
MEDICARE ASSIGNMENT CODE

D |

2300

| DTP03 |

| 1251 ............ 196

D |

2300

| REF02 |

| 127 .............. 241

Last Seen Date

Date the patient was last seen by the referring or ordering physician for a claim billed by a provider whose services require physician certification.
LAST WORKED DATE

Medicare Assignment Code

An indication, used by Medicare or other government programs, that the provider accepted assignment.
MEDICARE SECTION 4081 INDICATOR

D |

2300

| CLM07 |

| 1359 ............ 174

D | D |

2300 2400

| DTP03 | | DTP03 |

| 1251 ............ 187 | 1251 ............ 446

Medicare Section 4081 Indicator Last Worked Date

Date patient last worked at the patients current occupation
LAST X-RAY DATE

Code indicating Medicare Section 4081 applies.

MONTHLY TREATMENT COUNT

D |

2300

| REF02 |

| 127 .............. 225

D |

2300

| DTP03 |

| 1251 ............ 205

Monthly Treatment Count

Number of treatments rendered in the month of service.
NON-PAYABLE PROFESSIONAL COMPONENT BILLED AMOUNT

Last X-Ray Date

Date patient received last X-Ray.
LINE ITEM CHARGE AMOUNT

D | D |

2300 2400

| CR207 | | CR207 |

| 380 .............. 255 | 380 .............. 419

D | D |

2300 2400

| DTP03 | | DTP03 |

| 1251 ............ 198 | 1251 ............ 455

Line Item Charge Amount

Charges related to this service.
LINE ITEM CONTROL NUMBER

Non-Payable Professional Component Billed Amount

Amount of non-payable charges included in the bill related to professional services.
NOTE REFERENCE CODE

D |

2400

| SV102 |

| 782 .............. 402

D |

2320

| MOA09 |

| 782 .............. 349

Line Item Control Number

Identifier assigned by the submitter/provider to this line item.
LINE NOTE TEXT

Note Reference Code

Code identifying the functional area or purpose for which the note applies.
NUMBER OF VISITS

D |

2400

| REF02 |

| 127 .............. 473

D | D |

2300 2400

| NTE01 | | NTE01 |

| 363 .............. 247 | 363 .............. 488

Line Note Text

Narrative text providing additional information related to the service line.
MAMMOGRAPHY CERTIFICATION NUMBER

Number of Visits
The number of home health visits. Example: One visit every three days for 21 days. This element indicates that the data is communicating the number of visits, i.e., one.
ONSET DATE

D |

2400

| NTE02 |

| 352 .............. 488

Mammography Certification Number

HCFA assigned Certification Number of the certified mammography screening center
MEASUREMENT QUALIFIER

D | D |

2305 2400

| HSD02 | | HSD02 |

| 380 .............. 279 | 380 .............. 492

D | D |

2300 2400

| REF02 | | REF02 |

| 127 .............. 226 | 127 .............. 474

Onset Date
Date of onset of indicated patient condition.
ONSET OF CURRENT ILLNESS OR INJURY DATE

D |

2400

| DTP03 |

| 1251 ............ 453

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Onset of Current Illness or Injury Date

Date of onset of indicated patient condition.
ORDER DATE

Ordering Provider Name Suffix

Suffix to the name of the provider ordering services for the patient.
ORDERING PROVIDER POSTAL ZONE OR ZIP CODE

D |

2300

| DTP03 |

| 1251 ............ 189

D | 2420E | NM107 |

| 1039 ............ 530

Order Date
Date the service(s) was ordered.
ORDERING PROVIDER ADDRESS LINE

Ordering Provider Postal Zone or ZIP Code

| 1251 ............ 181 | 1251 ............ 444

D | D |

2300 2400

| DTP03 | | DTP03 |

Postal ZIP code of the provider ordering services for the patient.
ORDERING PROVIDER SECONDARY IDENTIFIER

D | 2420E |

N403

| 116............... 535

Ordering Provider Address Line

Address line of the provider ordering services for the patient.
ORDERING PROVIDER CITY NAME

Ordering Provider Secondary Identifier

Additional identifier for the provider ordering services for the patient.
ORDERING PROVIDER STATE CODE

D | 2420E | D | 2420E |

N301 N302

| |

| 166 .............. 533 | 166 .............. 533

D | 2420E | REF02 |

| 127 .............. 537

Ordering Provider City Name

City of provider ordering services for the patient
ORDERING PROVIDER CONTACT NAME

Ordering Provider State Code

The State Postal Code of the provider who ordered / prescribed this service.
ORIGINATOR APPLICATION TRANSACTION IDENTIFIER

D | 2420E |

N401

| 19 ................ 534

Ordering Provider Contact Name

Contact person to whom inquiries should be directed at the provider ordering services for the patient.
ORDERING PROVIDER FIRST NAME

D | 2420E |

N402

| 156 .............. 535

Originator Application Transaction Identifier

An identification number that identifies a transaction within the originators applications system.
OTHER INSURED ADDITIONAL IDENTIFIER

D | 2420E | PER02 |

| 93 ................ 539

Ordering Provider First Name

The first name of the provider who ordered or prescribed this service.
ORDERING PROVIDER IDENTIFIER

H |

| BHT03 |

| 127 ................ 64

D | 2420E | NM104 |

| 1036 ............ 530

Other Insured Additional Identifier

Number providing additional identification of the other insured.
OTHER INSURED ADDITIONAL NAME

Ordering Provider Identifier

The identifier assigned by the Payer to the provider who ordered or prescribed this service.
ORDERING PROVIDER LAST NAME

D | 2330A | REF02 |

| 127 .............. 358

D | 2420E | NM109 |

| 67 ................ 531

Other Insured Additional Name

Additional name information for the other insured.
OTHER INSURED ADDRESS LINE

Ordering Provider Last Name

The last name of the provider who ordered or prescribed this service.
ORDERING PROVIDER MIDDLE NAME

D | 2330A |

N201

| 93 ................ 353

D | 2420E | NM103 |

| 1035 ............ 530

Other Insured Address Line

Address line of the additional insured individuals mailing address.
OTHER INSURED BIRTH DATE

Ordering Provider Middle Name

Middle name of the provider ordering services for the patient.
ORDERING PROVIDER NAME ADDITIONAL TEXT

D | 2330A | D | 2330A |

N301 N302

| |

| 166 .............. 354 | 166 .............. 354

D | 2420E | NM105 |

| 1037 ............ 530

Other Insured Birth Date Ordering Provider Name Additional Text

Additional name infromation for the provider ordering services for the patient.
ORDERING PROVIDER NAME SUFFIX

The birth date of the additional insured individual.

OTHER INSURED CITY NAME

D |

2320

| DMG02 |

| 1251 ............ 343

D | 2420E |

N201

| 93 ................ 532

Other Insured City Name

The city name of the additional insured individual.
OTHER INSURED FIRST NAME

D | 2330A |

N401

| 19 ................ 355

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Other Insured First Name

The first name of the additional insured individual.
OTHER INSURED GENDER CODE

Other Payer Claim Adjustment Indicator

Indicates the other payer has made a previous claim adjustment to this claim.
OTHER PAYER CONTACT NAME

D | 2330A | NM104 |

| 1036 ............ 351

D | 2330B | REF02 |

| 127 .............. 373

Other Insured Gender Code

A code to specify the sex of the additional insured individual.
OTHER INSURED GROUP NAME

Other Payer Contact Name

Name of other payer contact.
OTHER PAYER COVERED AMOUNT

D |

2320

| DMG03 |

| 1068 ............ 343

D | 2330B | PER02 |

| 93 ................ 364

Other Insured Group Name

Name of the group or plan through which the insurance is provided to the other insured.
OTHER INSURED IDENTIFIER

Other Payer Covered Amount

Amount determined by other payer to be covered for the claim for coordination of benefits.
OTHER PAYER DISCOUNT AMOUNT

D |

2320

| SBR04 |

| 93 ................ 320

D |

2320

| AMT02 |

| 782 .............. 336

Other Insured Identifier

An identification number, assigned by the third party payer, to identify the additional insured individual.
OTHER INSURED LAST NAME

Other Payer Discount Amount

Amount determined by other payer to be subject to discount provisions.
OTHER PAYER IDENTIFICATION NUMBER

D | 2330A | NM109 |

| 67 ................ 352

D |

2320

| AMT02 |

| 782 .............. 337

Other Insured Last Name

The last name of the additional insured individual.
OTHER INSURED MIDDLE NAME

Other Payer Identification Number

The non-destination (COB) payers identification number.
OTHER PAYER LAST OR ORGANIZATION NAME

D | 2330A | NM103 |

| 1035 ............ 351

D | 2420G | NM109 |

| 67 ................ 551

Other Insured Middle Name

The middle name of the additional insured individual.
OTHER INSURED NAME SUFFIX

D | 2330A | NM105 |

| 1037 ............ 351

Other Payer Last or Organization Name

The name of the other payer organization.
OTHER PAYER PATIENT PAID AMOUNT

D | 2330B | NM103 |

| 1035 ............ 360

Other Insured Name Suffix

The suffix to the name of the additional insured individual.
OTHER INSURED POSTAL ZONE OR ZIP CODE

D | 2330A | NM107 |

| 1039 ............ 352

Other Payer Patient Paid Amount

Amount reported by other payer as paid by the patient
OTHER PAYER PATIENT PRIMARY IDENTIFIER

Other Insured Postal Zone or ZIP Code

The Postal ZIP code of the additional insured individuals mailing address.
OTHER INSURED STATE CODE

D |

2320

| AMT02 |

| 782 .............. 339

D | 2330A |

N403

| 116............... 356

Other Payer Patient Primary Identifier

The non-destination (COB) payers patients primary identification number.
OTHER PAYER PATIENT RESPONSIBILITY AMOUNT

Other Insured State Code

The state code of the additional insured individuals mailing address.
OTHER PAYER ADDITIONAL NAME TEXT

D | 2330C | NM109 |

| 67 ................ 375

D | 2330A |

N402

| 156 .............. 356

Other Payer Patient Responsibility Amount

Amount determined by other payer to be the amount owed by the patient.
OTHER PAYER PATIENT SECONDARY IDENTIFIER

Other Payer Additional Name Text

Additional name information for the other payer organization.
OTHER PAYER CLAIM ADJUSTMENT INDICATOR

D |

2320

| AMT02 |

| 782 .............. 335

D | 2330B |

N201

| 93 ................ 362

Other Payer Patient Secondary Identifier

The non-destination (COB) payers patients secondary identification number(s).
OTHER PAYER PER DAY LIMIT AMOUNT

D | 2330C | REF02 |

| 127 .............. 377

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Other Payer Per Day Limit Amount

Amount determined by other payer to be the maximum payable per day under the contract.
OTHER PAYER PRE-TAX CLAIM TOTAL AMOUNT

Other Payer Supervising Provider Identifier

The non-destination (COB) payers supervising provider identifier.
OTHER PAYER TAX AMOUNT

D |

2320

| AMT02 |

| 782 .............. 338

D | 2330H | REF02 |

| 127 .............. 397

Other Payer Pre-Tax Claim Total Amount

Total claim amount before applying taxes as reported by other payer.
OTHER PAYER PRIMARY IDENTIFIER

Other Payer Tax Amount

Amount of taxes related to the claim as determined By other payer.
OXYGEN FLOW RATE

D |

2320

| AMT02 |

| 782 .............. 340

D |

2320

| AMT02 |

| 782 .............. 341

Oxygen Flow Rate Other Payer Primary Identifier

An identification number for the other payer.
OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

The oxygen flow rate in liters per minute.

OXYGEN SATURATION QUANTITY

D |

2400

| REF02 |

| 127 .............. 481

D | 2330B | NM109 | D | 2430 | SVD01 |

| 67 ................ 361 | 67 ................ 555

Oxygen Saturation Quantity

The oxygen saturation (oximetry) test results.
OXYGEN SATURATION TEST DATE

Other Payer Prior Authorization or Referral Number

The non-destination (COB) payers prior authorization or referral number.
OTHER PAYER PURCHASED SERVICE PROVIDER IDENTIFIER

D |

2400

| CR511 |

| 380 .............. 425

Oxygen Saturation Test Date

Date patient received oxygen saturation test.
OXYGEN TEST CONDITION CODE

D | 2330B | REF02 | D | 2420G | REF02 |

| 127 .............. 371 | 127 .............. 552

D |

2400

| DTP03 |

| 1251 ............ 450

Other Payer Purchased Service Provider Identifier

The non-destination (COB) payers purchased service provider identifier.
OTHER PAYER REFERRING PROVIDER IDENTIFIER

Oxygen Test Condition Code

Code indicating the conditions under which a patient was tested.
OXYGEN TEST FINDINGS CODE

D |

2400

| CR512 |

| 1349 ............ 425

D | 2330F | REF02 |

| 127 .............. 389

Oxygen Test Findings Code

Other Payer Referring Provider Identifier

The non-destination (COB) payers referring provider identifier.
OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFIER

Code indicating the findings of oxygen tests performed on a patient.

D | D | D | 2400 2400 2400 | CR513 | | CR514 | | CR515 | | 1350 ............ 425 | 1350 ............ 425 | 1350 ............ 426

D | 2330D | REF02 |

| 127 .............. 381

PAID SERVICE UNIT COUNT

Other Payer Rendering Provider Secondary Identifier

The non-destination (COB) payers rendering provider identifier.
OTHER PAYER SECONDARY IDENTIFIER

Paid Service Unit Count

Units of service paid by the payer for coordination of benefits.
PARTICIPATION AGREEMENT

D |

2430

| SVD05 |

| 380 .............. 557

D | 2330E | REF02 |

| 127 .............. 385

Participation Agreement
Code indicating a participating claim submitted by a non-participating provider.
PATIENT ACCOUNT NUMBER

Other Payer Secondary Identifier

Additional identifier for the other payer organization
OTHER PAYER SERVICE FACILITY LOCATION IDENTIFIER

D |

2300

| CLM16 |

| 1360 ............ 178

D | 2330B | REF02 |

| 127 .............. 369

Patient Account Number

Unique identification number assigned by the provider to the claim patient to facilitate posting of payment information and identification of the billed claim.
PATIENT ADDITIONAL NAME

Other Payer Service Facility Location Identifier

The non-destination (COB) payers service facility location identifier.
OTHER PAYER SUPERVISING PROVIDER IDENTIFIER

D |

2300

| CLM01 |

| 1028 ............ 171

D | 2330G | REF02 |

| 127 .............. 393

Patient Additional Name

Additional name information for the patient.
PATIENT ADDRESS LINE

D | 2010CA |

N201

| 93 ................ 160

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Patient Address Line

Address line of the street mailing address of the patient.
PATIENT AMOUNT PAID

Patient Name Suffix

Suffix to the name of the individual to whom the services were provided.
PATIENT POSTAL ZONE OR ZIP CODE

D | 2010CA | D | 2010CA |

N301 N302

| |

| 166 .............. 161 | 166 .............. 161

D | 2010CA | NM107 |

| 1039 ............ 158

Patient Amount Paid

The amount the provider has received from the patient (or insured) toward payment of this claim.
PATIENT BIRTH DATE

Patient Postal Zone or ZIP Code

The ZIP Code of the patient.
PATIENT PRIMARY IDENTIFIER

D | 2010CA |

N403

| 116............... 163

D |

2300

| AMT02 |

| 782 .............. 220

Patient Primary Identifier

Identifier assigned by the payer to identify the patient
PATIENT SECONDARY IDENTIFIER

Patient Birth Date

Date of birth of the patient.
PATIENT CITY NAME

D | 2010CA | NM109 |

| 67 ................ 159

D | 2010CA | DMG02 |

| 1251 ............ 165

Patient Secondary Identifier Patient City Name

The city name of the patient.
PATIENT CONDITION CODE

Additional identifier assigned to the patient by the payer.

PATIENT SIGNATURE SOURCE CODE

D | 2010CA | REF02 |

| 127 .............. 167

D | 2010CA |

N401

| 19 ................ 162

Patient Condition Code

Code indicating the condition of the patient.
PATIENT CONDITION DESCRIPTION

Patient Signature Source Code

| 1342 ............ 255 | 1342 ............ 419

D | D |

2300 2400

| CR208 | | CR208 |

Code indication how the patient/subscriber authorization signatures were obtained and how they are being retained by the provider.
PATIENT STATE CODE

D | D |

2300 2320

| CLM10 | | OI04 |

| 1351 ............ 176 | 1351 ............ 345

Patient Condition Description

Free-form description of the patients condition.
D D D D | | | | 2300 2300 2400 2400 | | | | CR210 CR211 CR210 CR211 | | | | | 352 .............. 256 | 352 .............. 256 | 352 .............. 420 | 352 .............. 420

Patient State Code

The State Postal Code of the patient.
PATIENT WEIGHT

D | 2010CA |

N402

| 156 .............. 162

PATIENT DEATH DATE

Patient Weight Patient Death Date

Date of the patients death.
PATIENT FIRST NAME

Weight of the patient at time of treatment or transport.

| 1251 ............ 156 D D D D | 2000B | PAT08 | | 2000C | PAT08 | | 2300 | CR102 | | 2400 | CR102 | | 81 .................115 | 81 ................ 156 | 81 ................ 249 | 81 ................ 413

D | 2000C | PAT06 |

Patient First Name

The first name of the individual to whom the services were provided.
PATIENT GENDER CODE

PAY-TO PROVIDER ADDITIONAL NAME

D | 2010CA | NM104 |

| 1036 ............ 158

Pay-to Provider Additional Name

Additional name information for the provider to receive payment.
PAY-TO PROVIDER ADDRESS LINE

Patient Gender Code

A code indicating the sex of the patient.
PATIENT LAST NAME

D | 2010AB |

N201

| 93 ................ 102

D | 2010CA | DMG03 |

| 1068 ............ 165

Pay-to Provider Address Line

Address line of the provider to receive payment
PAY-TO PROVIDER CITY NAME

Patient Last Name

The last name of the individual to whom the services were provided.
PATIENT MIDDLE NAME

D | 2010AB | D | 2010AB |

N301 N302

| |

| 166 .............. 103 | 166 .............. 103

D | 2010CA | NM103 | D | 2330C | NM103 |

| 1035 ............ 158 | 1035 ............ 375

Pay-to Provider City Name

City name of the provider to receive payment.
PAY-TO PROVIDER FIRST NAME

Patient Middle Name

The middle name of the individual to whom the services were provided.
PATIENT NAME SUFFIX

D | 2010AB |

N401

| 19 ................ 104

Pay-to Provider First Name

First name of the provider to receive payment.
PAY-TO PROVIDER IDENTIFIER

D | 2010CA | NM105 |

| 1037 ............ 158

D | 2010AB | NM104 |

| 1036 ............ 100

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Pay-to Provider Identifier

Identification number for the provider or organization that will receive payment.
PAY-TO PROVIDER LAST OR ORGANIZATIONAL NAME

Payer Name
Name identifying the payer organization.
PAYER PAID AMOUNT

D | 2010AB | NM109 | D | 2010AB | REF02 |

| 67 ................ 101 | 127 .............. 107

D | 2010BB | NM103 | D | 2420G | NM103 |

| 1035 ............ 131 | 1035 ............ 550

Pay-to Provider Last or Organizational Name

Last or organizational name of the provider to receive payment.
PAY-TO PROVIDER MIDDLE NAME

Payer Paid Amount

The amount paid by the payer on this claim.
PAYER POSTAL ZONE OR ZIP CODE

D |

2320

| AMT02 |

| 782 .............. 332

D | 2010AB | NM103 |

| 1035 ............ 100

Payer Postal Zone or ZIP Code

The ZIP Code of the Payers claim mailing address for this particular payer organization identification and claim office.
PAYER RESPONSIBILITY SEQUENCE NUMBER CODE

Pay-to Provider Middle Name

The middle name of the pay-to provider.
PAY-TO PROVIDER NAME SUFFIX

D | 2010BB |

N403

| 116............... 136

D | 2010AB | NM105 |

| 1037 ............ 100

Pay-to Provider Name Suffix

The suffix, including generation, of the provider that will receive payment.
PAY-TO PROVIDER POSTAL ZONE OR ZIP CODE

Payer Responsibility Sequence Number Code

Code identifying the insurance carriers level of responsibility for a payment of a claim
PAYER STATE CODE

D | 2010AB | NM107 |

| 1039 ............ 101

D | 2000B | SBR01 | D | 2320 | SBR01 |

| 1138..............110 | 1138............. 319

Pay-to Provider Postal Zone or ZIP Code

Postal ZIP code of the provider to receive payment
PAY-TO PROVIDER STATE CODE

Payer State Code

State Postal Code of the Payers claim mailing address for this particular payor organization identification and claim office.
PLACE OF SERVICE CODE

D | 2010AB |

N403

| 116............... 105

D | 2010BB |

N402

| 156 .............. 136

Pay-to Provider State Code

State of the provider to receive payment.
PAYER ADDITIONAL IDENTIFIER

Place of Service Code

The code that identifies where the service was performed.
POLICY COMPLIANCE CODE

D | 2010AB |

N402

| 156 .............. 104

D |

2400

| SV105 |

| 1331 ............ 404

Payer Additional Identifier

Additional identifier for the payer.
PAYER ADDITIONAL NAME

D | 2010BB | REF02 |

| 127 .............. 138

Policy Compliance Code

The code that specifies policy compliance.
POSTAGE CLAIMED AMOUNT

Payer Additional Name

Additional name information for the payer.
PAYER ADDRESS LINE

D | D |

2300 2400

| HCP14 | | HCP14 |

| 1526 ............ 274 | 1526 ............ 499

D | 2010BB |

N201

| 93 ................ 133

Postage Claimed Amount

Cost of postage used to provide service or to process associated paper work.
PREGNANCY INDICATOR

Payer Address Line

Address line of the Payers claim mailing address for this particular payer organization identification and claim office.
PAYER CITY NAME

D |

2400

| AMT02 |

| 782 .............. 486

D | 2010BB | D | 2010BB |

N301 N302

| |

| 166 .............. 134 | 166 .............. 134

Pregnancy Indicator
A yes/no code indicating whether a patient is pregnant.
PRESCRIPTION DATE

Payer City Name

The City Name of the Payers claim mailing address for this particular payer ID and claim office.
PAYER IDENTIFIER

D | 2000B | PAT09 | D | 2000C | PAT09 |

| 1073 .............116 | 1073 ............ 156

Prescription Date
The date the prescription was issued by the referring physician.
PRESCRIPTION NUMBER

D | 2010BB |

N401

| 19 ................ 135

D |

2300

| DTP03 |

| 1251 ............ 200

Payer Identifier
Number identifying the payer organization.
PAYER NAME

D | 2010BB | NM109 |

| 67 ................ 131

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Prescription Number
The unique identification number assigned by the pharmacy or supplier to the prescription.
PRICING METHODOLOGY

Provider Code
Code identifying the type of provider.
D D D D D | | | | | 2000A 2310A 2310B 2420A 2420F | | | | | PRV01 PRV01 PRV01 PRV01 PRV01 | | | | | | 1221 .............. 79 | 1221 ............ 285 | 1221 ............ 293 | 1221 ............ 504 | 1221 ............ 544 | 127 .............. 409

D |

2400

| SV401 |

Pricing Methodology
Pricing methodology at which the claim or line item has been priced or repriced.
PRIOR AUTHORIZATION OR REFERRAL NUMBER

PROVIDER TAXONOMY CODE

D | D |

2300 2400

| HCP01 | | HCP01 |

| 1473 ............ 272 | 1473 ............ 496

Provider Taxonomy Code

Code designating the provider type, classification, and specialization.
D D D D D | | | | | 2000A 2310A 2310B 2420A 2420F | | | | | PRV03 PRV03 PRV03 PRV03 PRV03 | | | | | | 127 ................ 80 | 127 .............. 286 | 127 .............. 294 | 127 .............. 505 | 127 .............. 545

Prior Authorization or Referral Number

A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved.
PROCEDURE CODE

PROVIDER OR SUPPLIER SIGNATURE INDICATOR

D | D |

2300 2400

| REF02 | | REF02 |

| 127 .............. 228 | 127 .............. 470

Provider or Supplier Signature Indicator

An indicater that the provider of service reported on this claim acknowledges the performance of the service and authorizes payment, and that a signature is on file in the providers office.
PURCHASED SERVICE CHARGE AMOUNT

Procedure Code
Code identifying the procedure, product or service.
D | D | D | 2400 2400 2430 | SV101 | C003-2 | 234 .............. 401 | HCP10 | | 234 .............. 498 | SVD03 | C003-2 | 234 .............. 556

D |

2300

| CLM06 |

| 1073 ............ 174

PROCEDURE CODE DESCRIPTION

Purchased Service Charge Amount

The charge for the purchased service.
PURCHASED SERVICE PROVIDER IDENTIFIER

Procedure Code Description

Description clarifying the Product/Service Procedure Code and related data elements.
PROCEDURE MODIFIER

D |

2400

| PS102 |

| 782 .............. 490

D |

2430

| SVD03 | C003-7 | 352 .............. 557

Purchased Service Provider Identifier

The provider number of the entity from which service was purchased.
D | 2310C | NM109 | D | 2400 | PS101 | D | 2420B | NM109 | | 67 ................ 300 | 127 .............. 489 | 67 .................511

Procedure Modifier
This identifies special circumstances related to the performance of the service.
D D D D D D D D | | | | | | | | 2400 2400 2400 2400 2430 2430 2430 2430 | | | | | | | | SV101 SV101 SV101 SV101 SVD03 SVD03 SVD03 SVD03 | | | | | | | | C003-3 C003-4 C003-5 C003-6 C003-3 C003-4 C003-5 C003-6 | 1339 ............ 401 | 1339 ............ 402 | 1339 ............ 402 | 1339 ............ 402 | 1339 ............ 556 | 1339 ............ 556 | 1339 ............ 556 | 1339 ............ 556

PURCHASED SERVICE PROVIDER NAME

Purchased Service Provider Name

The name of the provider of the purchased service.
PURCHASED SERVICE PROVIDER SECONDARY IDENTIFIER

PRODUCT OR SERVICE ID QUALIFIER

D | 2330F | NM103 |

| 1035 ............ 387

Product or Service ID Qualifier

Code identifying the type/source of the descriptive number used in Product/Service ID (234).
D | D | D | 2400 2400 2430 | SV101 | C003-1 | 235 .............. 401 | HCP09 | | 235 .............. 498 | SVD03 | C003-1 | 235 .............. 555

Purchased Service Provider Secondary Identifier

Additional identifier for the provider of purchased services.
QUANTITY QUALIFIER

PROPERTY CASUALTY CLAIM NUMBER

D | 2310C | REF02 | D | 2420B | REF02 |

| 127 .............. 302 | 127 .............. 513

Property Casualty Claim Number

Identification number for property casualty claim associated with the services identified on the bill.
PROVIDER CODE

Quantity Qualifier
Code specifying the type of quantity
QUESTION NUMBER/LETTER

D |

2400

| QTY01 |

| 673 .............. 462

D | 2010BA | REF02 | D | 2010CA | REF02 |

| 127 .............. 129 | 127 .............. 169

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D D D D D D D D D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | | | | | | | | | 2330F 2330G 2330H 2400 2400 2400 2400 2400 2400 2400 2400 2400 2400 2400 2420A 2420A 2420B 2420C 2420D 2420E 2420F 2420F 2420G | | | | | | | | | | | | | | | | | | | | | | | REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 PRV02 REF01 REF01 REF01 REF01 REF01 PRV02 REF01 REF01 | | | | | | | | | | | | | | | | | | | | | | | | 128 .............. 388 | 128 .............. 392 | 128 .............. 396 | 128 .............. 468 | 128 .............. 469 | 128 .............. 470 | 128 .............. 472 | 128 .............. 474 | 128 .............. 475 | 128 .............. 477 | 128 .............. 478 | 128 .............. 479 | 128 .............. 480 | 128 .............. 483 | 128 .............. 504 | 128 .............. 507 | 128 .............. 512 | 128 .............. 521 | 128 .............. 527 | 128 .............. 536 | 128 .............. 545 | 128 .............. 547 | 128 .............. 552

Question Number/Letter
Identifies the question or letter number.
QUESTION RESPONSE

D |

2440

| FRM01 |

| 350 .............. 570

Question Response
A yes/no question response.
D D D D | | | | 2440 2440 2440 2440 | | | | FRM02 FRM03 FRM04 FRM05 | | | | | 1073 ............ 570 | 127 .............. 571 | 373 .............. 571 | 332 .............. 571

RECEIVER ADDITIONAL NAME

Receiver Additional Name

Additional name information for the receiver.
RECEIVER NAME

H | 1000B |

N201

| 93 .................. 76

Receiver Name
Name of organization receiving the transaction.
RECEIVER PRIMARY IDENTIFIER

H | 1000B | NM103 |

| 1035 .............. 75

REFERRAL DATE

Receiver Primary Identifier

Primary identification number for the receiver of the transaction.
REFERENCE IDENTIFICATION QUALIFIER

Referral Date
Date of referral.
REFERRING CLIA NUMBER

H | 1000B | NM109 |

| 67 .................. 75

D | D |

2300 2400

| DTP03 | | DTP03 |

| 1251 ............ 185 | 1251 ............ 439

Reference Identification Qualifier

Code qualifying the reference identification
H D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 2000A 2010AA 2010AA 2010AB 2010BA 2010BA 2010BB 2010BD 2010CA 2010CA 2300 2300 2300 2300 2300 2300 2300 2300 2300 2300 2300 2300 2300 2310A 2310A 2310B 2310B 2310C 2310D 2310E 2330A 2330B 2330B 2330B 2330C 2330D 2330E | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | REF01 PRV02 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 PRV02 REF01 PRV02 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 REF01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 128 ................ 66 | 128 ................ 80 | 128 ................ 92 | 128 ................ 94 | 128 .............. 106 | 128 .............. 126 | 128 .............. 128 | 128 .............. 137 | 128 .............. 150 | 128 .............. 166 | 128 .............. 168 | 128 .............. 222 | 128 .............. 224 | 128 .............. 226 | 128 .............. 228 | 128 .............. 230 | 128 .............. 232 | 128 .............. 233 | 128 .............. 235 | 128 .............. 236 | 128 .............. 239 | 128 .............. 240 | 128 .............. 241 | 128 .............. 242 | 128 .............. 286 | 128 .............. 288 | 128 .............. 294 | 128 .............. 296 | 128 .............. 301 | 128 .............. 310 | 128 .............. 316 | 128 .............. 357 | 128 .............. 368 | 128 .............. 370 | 128 .............. 373 | 128 .............. 376 | 128 .............. 380 | 128 .............. 384

Referring CLIA Number

Referring Clinical Laboratory Improvement Amendment (CLIA) facility identification.
REFERRING PROVIDER FIRST NAME

D |

2400

| REF02 |

| 127 .............. 477

Referring Provider First Name

The first name of provider who referred the patient to the provider of service on this claim.
REFERRING PROVIDER IDENTIFIER

D | 2310A | NM104 | D | 2420F | NM104 |

| 1036 ............ 283 | 1036 ............ 542

Referring Provider Identifier

The identification number for the referring physician.
REFERRING PROVIDER LAST NAME

D | 2310A | NM109 | D | 2420F | NM109 |

| 67 ................ 284 | 67 ................ 543

Referring Provider Last Name

The Last Name of Provider who referred the patient to the provider of service on this claim.
D | 2310A | NM103 | D | 2330D | NM103 | D | 2420F | NM103 | | 1035 ............ 283 | 1035 ............ 379 | 1035 ............ 542

REFERRING PROVIDER MIDDLE NAME

Referring Provider Middle Name

Middle name of the provider who is referring patient for care.
REFERRING PROVIDER NAME ADDITIONAL TEXT

D | 2310A | NM105 | D | 2420F | NM105 |

| 1037 ............ 284 | 1037 ............ 543

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Referring Provider Name Additional Text

Additional name information identifying the referring provider.
REFERRING PROVIDER NAME SUFFIX

Remark Code
Code indicating a code from a specific industry code list, such as the Health Care Claim Status Code list.
D D D D D | | | | | 2320 2320 2320 2320 2320 | | | | | MOA03 MOA04 MOA05 MOA06 MOA07 | | | | | | 127 .............. 348 | 127 .............. 348 | 127 .............. 348 | 127 .............. 348 | 127 .............. 349

D | 2310A | D | 2420F |

N201 N201

| |

| 93 ................ 287 | 93 ................ 546

Referring Provider Name Suffix

Suffix to the name of the provider referring the patient for care.
REFERRING PROVIDER SECONDARY IDENTIFIER

RENDERING PROVIDER FIRST NAME

D | 2310A | NM107 | D | 2420F | NM107 |

| 1039 ............ 284 | 1039 ............ 543

Rendering Provider First Name

The first name of the provider who performed the service.
RENDERING PROVIDER IDENTIFIER

Referring Provider Secondary Identifier

Additional identification number for the provider referring the patient for service.
REIMBURSEMENT RATE

D | 2310B | NM104 | D | 2420A | NM104 |

| 1036 ............ 291 | 1036 ............ 502

Rendering Provider Identifier

The identifier assigned by the Payor to the provider who performed the service.
RENDERING PROVIDER LAST OR ORGANIZATION NAME

D | 2310A | REF02 | D | 2420F | REF02 |

| 127 .............. 289 | 127 .............. 548

D | 2310B | NM109 | D | 2420A | NM109 |

| 67 ................ 292 | 67 ................ 503

Reimbursement Rate
Rate used when payment is based upon a percentage of applicable charges.
REJECT REASON CODE

D |

2320

| MOA01 |

| 954 .............. 347

Rendering Provider Last or Organization Name

The last name or organization of the provider who performed the service
D | 2310B | NM103 | D | 2330E | NM103 | D | 2420A | NM103 | | 1035 ............ 291 | 1035 ............ 383 | 1035 ............ 502

Reject Reason Code

Code assigned by issuer to identify reason for rejection
RELATED CAUSES CODE

RENDERING PROVIDER MIDDLE NAME

D | D |

2300 2400

| HCP13 | | HCP13 |

| 901 .............. 274 | 901 .............. 499

Rendering Provider Middle Name

Middle name of the provider who has provided the services to the patient.
RENDERING PROVIDER NAME ADDITIONAL TEXT

Related Causes Code

Code identifying an accompanying cause of an illness, injury, or an accident.
D | D | D | 2300 2300 2300 | CLM11 | C024-1 | 1362 ............ 176 | CLM11 | C024-2 | 1362 ............ 177 | CLM11 | C024-3 | 1362 ............ 177

D | 2310B | NM105 | D | 2420A | NM105 |

| 1037 ............ 292 | 1037 ............ 503

RELATED HOSPITALIZATION ADMISSION DATE

Rendering Provider Name Additional Text

Additional name information identifying the rendering provider.
RENDERING PROVIDER NAME SUFFIX

Related Hospitalization Admission Date

The date the patient was admitted for inpatient care related to current service.
RELATED HOSPITALIZATION DISCHARGE DATE

D | 2310B | D | 2420A |

N201 N201

| |

| 93 ................ 295 | 93 ................ 506

D |

2300

| DTP03 |

| 1251 ............ 209

Rendering Provider Name Suffix Related Hospitalization Discharge Date

The date the patient was discharged from the inpatient care referenced in the applicable hospitalization or hospice date.
RELEASE OF INFORMATION CODE

Name suffix of the provider who has provided the services to the patient.
RENDERING PROVIDER SECONDARY IDENTIFIER

D | 2310B | NM107 | D | 2420A | NM107 |

| 1039 ............ 292 | 1039 ............ 503

D |

2300

| DTP03 |

| 1251 .............211

Rendering Provider Secondary Identifier

Additional identifier for the provider providing care to the patient.
REPRICED ALLOWED AMOUNT

Release of Information Code

Code indicating whether the provider has on file a signed statement permitting the release of medical data to other organizations.
REMARK CODE

D | 2310B | REF02 | D | 2420A | REF02 |

| 127 .............. 297 | 127 .............. 508

D | D |

2300 2320

| CLM09 | | OI06 |

| 1363 ............ 175 | 1363 ............ 345

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Repriced Allowed Amount

The maximum amount determined by the repricer as being allowable under the provisions of the contract prior to the determination of the actual payment.
REPRICED APPROVED AMBULATORY PATIENT GROUP AMOUNT

Repricing Per Diem or Flat Rate Amount

Amount used to determine the flat rate or per diem price by the repricing organization.
RESPONSIBLE PARTY ADDITIONAL NAME

D | D |

2300 2400

| HCP02 | | HCP02 |

| 782 .............. 272 | 782 .............. 496

D | D |

2300 2400

| HCP05 | | HCP05 |

| 118............... 273 | 118............... 497

Repriced Approved Ambulatory Patient Group Amount

Amount of payment by the repricer for the referenced Ambulatory Patient Group.
REPRICED APPROVED AMBULATORY PATIENT GROUP CODE

Responsible Party Additional Name

Additional name of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY ADDRESS LINE

D | D |

2300 2400

| HCP07 | | HCP07 |

| 782 .............. 273 | 782 .............. 497

D | 2010BC |

N201

| 93 ................ 142

Repriced Approved Ambulatory Patient Group Code

Identifier for Ambulatory Patient Group assigned to the claim by the repricer.
REPRICED APPROVED SERVICE UNIT COUNT

Responsible Party Address Line

Address line of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY CITY NAME

D | D |

2300 2400

| HCP06 | | HCP06 |

| 127 .............. 273 | 127 .............. 497

D | 2010BC | D | 2010BC |

N301 N302

| |

| 166 .............. 143 | 166 .............. 143

Repriced Approved Service Unit Count

Number of service units approved by pricing or repricing entity.
REPRICED CLAIM REFERENCE NUMBER

Responsible Party City Name

City name of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY FIRST NAME

D |

2400

| HCP12 |

| 380 .............. 499

D | 2010BC |

N401

| 19 ................ 144

Repriced Claim Reference Number

Identification number, assigned by a repricing organization, to identify the claim.
REPRICED LINE ITEM REFERENCE NUMBER

Responsible Party First Name

First name of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY LAST OR ORGANIZATION NAME

D |

2300

| REF02 |

| 127 .............. 233

Repriced Line Item Reference Number

Identification number of a line item repriced by a third party or prior payer.
REPRICED SAVING AMOUNT

D | 2010BC | NM104 |

| 1036 ............ 140

Responsible Party Last or Organization Name

Last name or organization name of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY MIDDLE NAME

D |

2400

| REF02 |

| 127 .............. 468

Repriced Saving Amount

The amount of savings related to Third Party Organization claims.
REPRICING ORGANIZATION IDENTIFIER

D | 2010BC | NM103 |

| 1035 ............ 140

D | D |

2300 2400

| HCP03 | | HCP03 |

| 782 .............. 273 | 782 .............. 497

Responsible Party Middle Name

Middle name of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY POSTAL ZONE OR ZIP CODE

Repricing Organization Identifier

Reference or identification number of the repricing organization.
REPRICING PER DIEM OR FLAT RATE AMOUNT

D | 2010BC | NM105 |

| 1037 ............ 141

D | D |

2300 2400

| HCP04 | | HCP04 |

| 127 .............. 273 | 127 .............. 497

Responsible Party Postal Zone or ZIP Code

Postal ZIP code of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
RESPONSIBLE PARTY STATE CODE

D | 2010BC |

N403

| 116............... 145

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Responsible Party State Code

State or province of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations.
RESPONSIBLE PARTY SUFFIX NAME

Service Unit Count

The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS codes, revenue code or procedure code.
SHIP,, DELIVERY OR CALENDAR PATTERN CODE

D | 2010BC |

N402

| 156 .............. 144

D |

2400

| SV104 |

| 380 .............. 403

Responsible Party Suffix Name

Suffix for name of the person or entity responsible for payment of balance of bill after applicable processing by other parties, insurers, or organizations..
ROUND TRIP PURPOSE DESCRIPTION

Ship, Delivery or Calendar Pattern Code

The time delivery pattern for the services.
SHIPPED DATE

D | 2010BC | NM107 |

| 1039 ............ 141

D | D |

2305 2400

| HSD07 | | HSD07 |

| 678 .............. 280 | 678 .............. 493

Round Trip Purpose Description

Free-form description of the purpose of the ambulance transport round trip.
SALES TAX AMOUNT

Shipped Date
Date product shipped.
SIMILAR ILLNESS OR SYMPTOM DATE

D |

2400

| DTP03 |

| 1251 ............ 451

D | D |

2300 2400

| CR109 | | CR109 |

| 352 .............. 250 | 352 .............. 414

Similar Illness or Symptom Date

Date of onset of a similar illness or symptom.
SPECIAL PROGRAM INDICATOR

Sales Tax Amount

Amount of sales tax attributable to the referenced Service.
SERVICE AUTHORIZATION EXCEPTION CODE

D | D |

2300 2400

| DTP03 | | DTP03 |

| 1251 ............ 193 | 1251 ............ 461

Special Program Indicator

A code indicating the Special Program under which the services rendered to the patient were performed.
STRETCHER PURPOSE DESCRIPTION

D |

2400

| AMT02 |

| 782 .............. 484

Service Authorization Exception Code

Code identifying the service authorization exception.
SERVICE DATE

D |

2300

| CLM12 |

| 1366 ............ 178

Stretcher Purpose Description

Free-form description of the purpose of the use of a stretcher during ambulance service.
SUBLUXATION LEVEL CODE

D |

2300

| REF02 |

| 127 .............. 223

Service Date
Date of service, such as the start date of the service, the end date of the service, or the single day date of the service.
SERVICE FACILITY LOCATION SECONDARY IDENTIFIER

D | D |

2300 2400

| CR110 | | CR110 |

| 352 .............. 250 | 352 .............. 414

Subluxation Level Code

Code identifying the specific level of subluxation.
D D D D | | | | 2300 2300 2400 2400 | | | | CR203 CR204 CR203 CR204 | | | | | 1367 ............ 252 | 1367 ............ 253 | 1367 ............ 416 | 1367 ............ 417

D |

2400

| DTP03 |

| 1251 ............ 436

Service Facility Location Secondary Identifier

Secondary identifier for service facility location.
SERVICE FACILITY NAME

SUBMITTER CONTACT NAME

D | 2420C | REF02 |

| 127 .............. 522

Submitter Contact Name

Name of the person at the submitter organization to whom inquiries about the transaction should be directed.

Service Facility Name

Name of the service facility.
SERVICE LINE PAID AMOUNT

D | 2330G | NM103 |

| 1035 ............ 391

SUBMITTER FIRST NAME

H | 1000A | PER02 |

| 93 .................. 72

Service Line Paid Amount

Amount paid by the indicated payer for a service line
SERVICE UNIT COUNT

Submitter First Name

The first name of the person submitting the transaction or receiving the transaction, as identified by the preceding identification code.
SUBMITTER IDENTIFIER

D |

2430

| SVD02 |

| 782 .............. 555

H | 1000A | NM104 |

| 1036 .............. 68

Submitter Identifier
Code or number identifying the entity submitting the claim.
SUBMITTER LAST OR ORGANIZATION NAME

H | 1000A | NM109 |

| 67 .................. 69

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Submitter Last or Organization Name

The last name or the organizational name of the entity submitting the transaction
SUBMITTER MIDDLE NAME

Subscriber Postal Zone or ZIP Code

The ZIP Code of the insured individual or subscriber to the coverage
SUBSCRIBER PRIMARY IDENTIFIER

H | 1000A | NM103 |

| 1035 .............. 68

D | 2010BA |

N403

| 116............... 123

Submitter Middle Name

The middle name of the person submitting the transaction
SUBSCRIBER ADDRESS LINE

Subscriber Primary Identifier

Primary identification number of the subscriber to the coverage.
SUBSCRIBER STATE CODE

H | 1000A | NM105 |

| 1037 .............. 68

D | 2010BA | NM109 |

| 67 .................119

Subscriber Address Line

Address line of the current mailing address of the insured individual or subscriber to the coverage.
SUBSCRIBER BIRTH DATE

Subscriber State Code

The State Postal Code of the insured individual or subscriber to the coverage
SUBSCRIBER SUPPLEMENTAL DESCRIPTION

D | 2010BA |

N402

| 156 .............. 123

D | 2010BA | D | 2010BA |

N301 N302

| |

| 166 .............. 121 | 166 .............. 121

Subscriber Birth Date

The date of birth of the subscriber to the indicated coverage or policy.
SUBSCRIBER CITY NAME

Subscriber Supplemental Description

Text information clarifying subscriber additional information
SUBSCRIBER SUPPLEMENTAL IDENTIFIER

D | 2010BA | DMG02 |

| 1251 ............ 125

D | 2010BA |

N201

| 93 ................ 120

Subscriber City Name

The City Name of the insured individual or subscriber to the coverage
SUBSCRIBER FIRST NAME

Subscriber Supplemental Identifier

Identifies another or additional distinguishing code number associated with the subscriber.
SUPERVISING PROVIDER FIRST NAME

D | 2010BA |

N401

| 19 ................ 122

D | 2010BA | REF02 |

| 127 .............. 127

Subscriber First Name

The first name of the insured individual or subscriber to the coverage
SUBSCRIBER GENDER CODE

Supervising Provider First Name

The First Name of the Provider who supervised the rendering of a service on this claim.
SUPERVISING PROVIDER IDENTIFIER

D | 2010BA | NM104 |

| 1036 .............118

Subscriber Gender Code

Code indicating the sex of the subscriber to the indicated coverage or policy.
SUBSCRIBER LAST NAME

D | 2310E | NM104 | D | 2420D | NM104 |

| 1036 ............ 313 | 1036 ............ 524

D | 2010BA | DMG03 |

| 1068 ............ 125

Supervising Provider Identifier

The Identification Number for the Supervising Provider.
D | 2310E | NM109 | D | 2420D | NM109 | | 67 ................ 314 | 67 ................ 525

Subscriber Last Name

The surname of the insured individual or subscriber to the coverage
SUBSCRIBER MIDDLE NAME

SUPERVISING PROVIDER LAST NAME

D | 2010BA | NM103 |

| 1035 .............118

Supervising Provider Last Name

The Last Name of the Provider who supervised the rendering of a service on this claim.
D | 2310E | NM103 | D | 2330H | NM103 | D | 2420D | NM103 | | 1035 ............ 313 | 1035 ............ 395 | 1035 ............ 524

Subscriber Middle Name

The middle name of the subscriber to the indicated coverage or policy.
SUBSCRIBER NAME SUFFIX

D | 2010BA | NM105 |

| 1037 .............118

SUPERVISING PROVIDER MIDDLE NAME

Subscriber Name Suffix

Suffix of the insured individual or subscriber to the coverage.
SUBSCRIBER POSTAL ZONE OR ZIP CODE

Supervising Provider Middle Name

Middle name of the provider supervising care rendered to the patient.
SUPERVISING PROVIDER NAME ADDITIONAL TEXT

D | 2010BA | NM107 |

| 1039 .............118

D | 2310E | NM105 | D | 2420D | NM105 |

| 1037 ............ 313 | 1037 ............ 524

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Supervising Provider Name Additional Text

Additional name information of the provider supervising care rendered to the patient.
SUPERVISING PROVIDER NAME SUFFIX

Transaction Segment Count

A tally of all segments between the ST and the SE segments including the ST and SE segments.
TRANSACTION SET CONTROL NUMBER

D | 2310E | D | 2420D |

N201 N201

| |

| 93 ................ 315 | 93 ................ 526

D |

SE01

| 96 ................ 572

Supervising Provider Name Suffix

Suffix to the name of the provider supervising care rendered to the patient.
SUPERVISING PROVIDER SECONDARY IDENTIFIER

Transaction Set Control Number

The unique identification number within a transaction set.
TRANSACTION SET CREATION DATE

D | 2310E | NM107 | D | 2420D | NM107 |

| 1039 ............ 313 | 1039 ............ 524

H | D |

| |

ST02 SE02

| |

| 329 ................ 62 | 329 .............. 572

Transaction Set Creation Date Supervising Provider Secondary Identifier

Additional identifier for the provider supervising care rendered to the patient.
TERMS DISCOUNT PERCENTAGE

Identifies the date the submitter created the transaction

TRANSACTION SET CREATION TIME

H |

| BHT04 |

| 373 ................ 64

D | 2310E | REF02 | D | 2420D | REF02 |

| 127 .............. 317 | 127 .............. 528

Transaction Set Creation Time

Time file is created for transmission.
TRANSACTION SET IDENTIFIER CODE

H |

| BHT05 |

| 337 ................ 65

Terms Discount Percentage

Discount percentage available to the payer for payment within a specific time period.
TEST PERFORMED DATE

Transaction Set Identifier Code

Code uniquely identifying a Transaction Set.
TRANSACTION SET PURPOSE CODE

D | D |

2300 2400

| CN105 | | CN105 |

| 338 .............. 218 | 338 .............. 467

H |

ST01

| 143 ................ 62

Test Performed Date

The date the patient was tested for arterial blood. gas and/or oxygen saturation on room air.
TEST RESULTS

Transaction Set Purpose Code

Code identifying purpose of transaction set.
TRANSMISSION TYPE CODE

H |

| BHT02 |

| 353 ................ 64

D |

2400

| DTP03 |

| 1251 ............ 448

Transmission Type Code Test Results

If tests are performed under other conditions such as oxygen, give test results and information necessary for interpreting the tests and why performed under these conditions.
TOTAL CLAIM CHARGE AMOUNT

Code identifying the type of transaction or transmission included in the transaction set.
TRANSPORT DISTANCE

H |

| REF02 |

| 127 ................ 66

D |

2400

| MEA03 |

| 739 .............. 465

Transport Distance
Distance traveled during the ambulance transport.
TREATMENT COUNT

Total Claim Charge Amount

The sum of all charges included within this claim.
TOTAL PURCHASED SERVICE AMOUNT

D | D |

2300 2400

| CR106 | | CR106 |

| 380 .............. 250 | 380 .............. 414

D |

2300

| CLM02 |

| 782 .............. 172

Treatment Count
Total number of treatments in the series.
TREATMENT PERIOD COUNT

Total Purchased Service Amount

Amount of charges associated with the claim attributable to purchased services
TOTAL VISITS RENDERED COUNT

D | D |

2300 2400

| CR202 | | CR202 |

| 380 .............. 252 | 380 .............. 416

D |

2300

| AMT02 |

| 782 .............. 221

Treatment Period Count

The number of time periods during which treatment will be provided to patient.
D | D | D | 2300 2400 2400 | CR206 | | CR206 | | CR502 | | 380 .............. 255 | 380 .............. 419 | 380 .............. 424

Total Visits Rendered Count

Total visits on this billl rendered prior to re-certification date.
TRANSACTION SEGMENT COUNT

TREATMENT SERIES NUMBER

D |

2305

| CR702 |

| 1470 ............ 277

Treatment Series Number

Number this treatment is in the series of services.
D | 2300 | CR201 | | 609 .............. 252

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

UNIT OR BASIS FOR MEASUREMENT CODE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

| 609 .............. 416

D |

2400

| CR201 |

Visits
The unit for home health visitations. Example: One visit every three days for 21 days. This element qualifies that the data is communicating visits.
WORK RETURN DATE

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken.
D D D D D D D D D D D | 2000B | PAT07 | | 2000C | PAT07 | | 2300 | CR101 | | 2300 | CR105 | | 2300 | CR205 | | 2400 | SV103 | | 2400 | CR101 | | 2400 | CR105 | | 2400 | CR205 | | 2400 | CR302 | | 2400 | HCP11 | | 355 ...............115 | 355 .............. 156 | 355 .............. 249 | 355 .............. 250 | 355 .............. 254 | 355 .............. 403 | 355 .............. 413 | 355 .............. 414 | 355 .............. 418 | 355 .............. 422 | 355 .............. 498

D | D |

2305 2400

| HSD01 | | HSD01 |

| 673 .............. 279 | 673 .............. 492

Work Return Date

Date patient was or is able to return to the patients normal occupation or to a similar or substitute occupation.
X-RAY AVAILABILITY INDICATOR

D |

2300

| DTP03 |

| 1251 ............ 207

X-ray Availability Indicator

Indicates if X-Rays are on file for chiropractor spinal manipulation.
D | D | 2300 2400 | CR212 | | CR212 | | 1073 ............ 256 | 1073 ............ 420

UNIVERSAL PRODUCT NUMBER

Universal Product Number

Industry standard code identifying supplies and materials.
VISITS

D |

2400

| REF02 |

| 127 .............. 483

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

F NSF Mapping
Truncation: Because payer processing is often predicated on flat file data content and field lengths, payers will accept the maximum ANSI ASC X12 field lengths established by the implementation guide, but may only process the maximum flat file field lengths, thus resulting in some truncation. Mappings: The 837 is a variable length record designed for wire transmissions and is not suitable for use in an application program. Therefore mappings to and from the national standard format flat file have been provided to assist users in the translation of the 837 for applications system processing. The requirement to engage in this standard flat file translation step may vary by payer.

F.1

X12N-NSF Map
This is a list of all the NSF 3.01 fields referred to in the body of the 837 professional implementation guide listed by: Loop ID | Reference Designator | Composite ID-Composite Sequence | Data Element Number / Code Value
AA0-02.0 1000A | NM109. . . . . . . . . . . . . . . . . . . . . . . . . 69 AA0-05.0 BHT03 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 AA0-06.0 1000A | NM103. . . . . . . . . . . . . . . . . . . . . . . . . 68 AA0-13.0 1000A | PER02 . . . . . . . . . . . . . . . . . . . . . . . . . 72 AA0-14.0 1000A | PER04 . . . . . . . . . . . . . . . . . . . . . . . . . 72 AA0-15.0 BHT04 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 AA0-16.0 BHT05 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 AA0-17.0 1000B | NM109. . . . . . . . . . . . . . . . . . . . . . . . . 75 AA0-23.0 BHT02 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 BA0-02.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-02.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-02.0 2010AB | REF02. . . . . . . . . . . . . . . . . . . . . . . 107 BA0-02.0 2010AA | REF02. . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-06.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-06.0 2010AA | REF02. . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-06.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-06.0 2010AB | REF02. . . . . . . . . . . . . . . . . . . . . . . 107 BA0-08.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-09.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-09.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-09.0 2010AB | REF02. . . . . . . . . . . . . . . . . . . . . . . 107 BA0-10.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-10.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-10.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-10.0 2010AB | REF02. . . . . . . . . . . . . . . . . . . . . . . 107 BA0-12.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-12.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-12.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-12.0 2010AB | REF02. . . . . . . . . . . . . . . . . . . . . . . 107 BA0-13.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-13.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-13.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101

MAY 2000

F.1

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL BA0-13.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA0-14.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-14.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-14.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-14.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA0-15.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-15.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-15.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-15.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA0-16.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-16.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-16.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-16.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA0-17.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-17.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-17.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA0-17.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA0-18.0 or BA0-19.0 2010AA | NM103 . . . . . . . . . . . . . . . . . . . . . . . 85 BA0-18.0 or BA0-19.0 2010AB | NM103 . . . . . . . . . . . . . . . . . . . . . . 100 BA0-20.0 2010AA | NM104 . . . . . . . . . . . . . . . . . . . . . . . 85 BA0-20.0 2010AB | NM104 . . . . . . . . . . . . . . . . . . . . . . 100 BA0-21.0 2010AA | NM105 . . . . . . . . . . . . . . . . . . . . . . . 85 BA0-21.0 2010AB | NM105 . . . . . . . . . . . . . . . . . . . . . . 100 BA0-22.0 2000A | PRV03 . . . . . . . . . . . . . . . . . . . . . . . . 80 BA0-24.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA0-24.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 BA0-24.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE BA0-24.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA1-02.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 BA1-02.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 BA1-02.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 BA1-02.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 BA1-07.0 2010AA | N301 . . . . . . . . . . . . . . . . . . . . . . . . . 88 BA1-07.0 2010AB | N301. . . . . . . . . . . . . . . . . . . . . . . . 103 BA1-08.0 2010AA | N302 . . . . . . . . . . . . . . . . . . . . . . . . . 88 BA1-08.0 2010AB | N302. . . . . . . . . . . . . . . . . . . . . . . . 103 BA1-09.0 2010AA | N401 . . . . . . . . . . . . . . . . . . . . . . . . . 89 BA1-09.0 2010AB | N401. . . . . . . . . . . . . . . . . . . . . . . . 104 BA1-10.0 2010AA | N402 . . . . . . . . . . . . . . . . . . . . . . . . . 90 BA1-10.0 2010AB | N402. . . . . . . . . . . . . . . . . . . . . . . . 104 BA1-11.0 2010AA | N403 . . . . . . . . . . . . . . . . . . . . . . . . . 90 BA1-11.0 2010AB | N403. . . . . . . . . . . . . . . . . . . . . . . . 105 BA1-12.0 2010AA | PER04 . . . . . . . . . . . . . . . . . . . . . . . 97 BA1-13.0 2010AB | N301. . . . . . . . . . . . . . . . . . . . . . . . 103 BA1-13.0 2010AA | N301 . . . . . . . . . . . . . . . . . . . . . . . . . 88 BA1-14.0 2010AB | N302. . . . . . . . . . . . . . . . . . . . . . . . 103 BA1-14.0 2010AA | N302 . . . . . . . . . . . . . . . . . . . . . . . . . 88 BA1-15.0 2010AB | N401. . . . . . . . . . . . . . . . . . . . . . . . 104 BA1-15.0 2010AA | N401 . . . . . . . . . . . . . . . . . . . . . . . . . 89 BA1-16.0 2010AB | N402. . . . . . . . . . . . . . . . . . . . . . . . 104 BA1-16.0 2010AA | N402 . . . . . . . . . . . . . . . . . . . . . . . . . 90 BA1-17.0 2010AB | N403. . . . . . . . . . . . . . . . . . . . . . . . 105 BA1-17.0 2010AA | N403 . . . . . . . . . . . . . . . . . . . . . . . . . 90 BA1-18.0 2010AA | PER04 . . . . . . . . . . . . . . . . . . . . . . . 97

F.2

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE CA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 CA0-04.0 2010BA | NM103 . . . . . . . . . . . . . . . . . . . . . . 118 CA0-04.0 2010CA | NM103 . . . . . . . . . . . . . . . . . . . . . . 158 CA0-05.0 2010BA | NM104 . . . . . . . . . . . . . . . . . . . . . . 118 CA0-05.0 2010CA | NM104 . . . . . . . . . . . . . . . . . . . . . . 158 CA0-06.0 2010BA | NM105 . . . . . . . . . . . . . . . . . . . . . . 118 CA0-06.0 2010CA | NM105 . . . . . . . . . . . . . . . . . . . . . . 158 CA0-07.0 2010BA | NM107 . . . . . . . . . . . . . . . . . . . . . . 118 CA0-07.0 2010CA | NM107 . . . . . . . . . . . . . . . . . . . . . . 158 CA0-08.0 2010BA | DMG02 . . . . . . . . . . . . . . . . . . . . . 125 CA0-08.0 2010CA | DMG02 . . . . . . . . . . . . . . . . . . . . . 165 CA0-09.0 2010BA | DMG03 . . . . . . . . . . . . . . . . . . . . . 125 CA0-09.0 2010CA | DMG03 . . . . . . . . . . . . . . . . . . . . . 165 CA0-11.0 2010BA | N301 . . . . . . . . . . . . . . . . . . . . . . . 121 CA0-11.0 2010CA | N301 . . . . . . . . . . . . . . . . . . . . . . . 161 CA0-12.0 2010BA | N302 . . . . . . . . . . . . . . . . . . . . . . . 121 CA0-12.0 2010CA | N302 . . . . . . . . . . . . . . . . . . . . . . . 161 CA0-13.0 2010BA | N401 . . . . . . . . . . . . . . . . . . . . . . . 122 CA0-13.0 2010CA | N401 . . . . . . . . . . . . . . . . . . . . . . . 162 CA0-14.0 2010BA | N402 . . . . . . . . . . . . . . . . . . . . . . . 123 CA0-14.0 2010CA | N402 . . . . . . . . . . . . . . . . . . . . . . . 162 CA0-15.0 2010BA | N403 . . . . . . . . . . . . . . . . . . . . . . . 123 CA0-15.0 2010CA | N403 . . . . . . . . . . . . . . . . . . . . . . . 163 CA0-21.0 2000B | PAT06 . . . . . . . . . . . . . . . . . . . . . . . 115 CA0-21.0 2000C | PAT06 . . . . . . . . . . . . . . . . . . . . . . . 156 CA0-23.0 (B) 2000B | SBR09 | 1032/WC . . . . . . . . . . . . . . 113 CA0-23.0 (C) 2000B | SBR09 | 1032/MB . . . . . . . . . . . . . . 113

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL CA0-23.0 (D) 2000B | SBR09 | 1032/MC. . . . . . . . . . . . . . . 113 CA0-23.0 (E) 2000B | SBR09 | 1032/OF . . . . . . . . . . . . . . . 113 CA0-23.0 (F) 2000B | SBR09 | 1032/CI. . . . . . . . . . . . . . . . 113 CA0-23.0 (G) 2000B | SBR09 | 1032/BL . . . . . . . . . . . . . . . 112 CA0-23.0 (H) 2000B | SBR09 | 1032/CH . . . . . . . . . . . . . . . 113 CA0-23.0 (I) 2000B | SBR09 | 1032/HM. . . . . . . . . . . . . . . 113 CA0-23.0 (K) 2000B | SBR09 | 1032/10 . . . . . . . . . . . . . . . 112 CA0-23.0 (K) 2320 | SBR09 | 1032/10. . . . . . . . . . . . . . . . . 321 CA0-23.0 (P) 2000B | SBR09 | 1032/BL . . . . . . . . . . . . . . . 112 CA0-23.0 (Z) 2000B | SBR09 | 1032/ZZ . . . . . . . . . . . . . . . 113 CA0-25.0 2010BC | NM101 . . . . . . . . . . . . . . . . . . . . . . 140 CA0-28.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 CA0-28.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 CA0-28.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 CA0-28.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 CA1-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 CA1-05.0 2010BA | NM109 . . . . . . . . . . . . . . . . . . . . . . 119 CA1-06.0 2010BA | NM109 . . . . . . . . . . . . . . . . . . . . . . 119 CB0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 CB0-04.0 2010BC | NM103 . . . . . . . . . . . . . . . . . . . . . . 140 CB0-05.0 2010BC | NM104 . . . . . . . . . . . . . . . . . . . . . . 140 CB0-06.0 2010BC | NM105 . . . . . . . . . . . . . . . . . . . . . . 141 CB0-07.0 2010BC | N301 . . . . . . . . . . . . . . . . . . . . . . . 143 CB0-08.0 2010BC | N302 . . . . . . . . . . . . . . . . . . . . . . . 143 CB0-09.0 2010BC | N401 . . . . . . . . . . . . . . . . . . . . . . . 144 CB0-10.0 2010BC | N402 . . . . . . . . . . . . . . . . . . . . . . . 144 CB0-11.0 2010BC | N403 . . . . . . . . . . . . . . . . . . . . . . . 145

MAY 2000

F.3

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL DA0-02.0 2000B | SBR01 . . . . . . . . . . . . . . . . . . . . . . . 110 DA0-02.0 2320 | SBR01 . . . . . . . . . . . . . . . . . . . . . . . . 319 DA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 DA0-05.0 2320 | SBR09 . . . . . . . . . . . . . . . . . . . . . . . . 321 DA0-05.0 (B) 2000B | SBR09 | 1032/WC . . . . . . . . . . . . . . 113 DA0-05.0 (C) 2000B | SBR09 | 1032/MB . . . . . . . . . . . . . . 113 DA0-05.0 (D) 2000B | SBR09 | 1032/MC . . . . . . . . . . . . . . 113 DA0-05.0 (E) 2000B | SBR09 | 1032/OF. . . . . . . . . . . . . . . 113 DA0-05.0 (F) 2000B | SBR09 | 1032/CI . . . . . . . . . . . . . . . 113 DA0-05.0 (G) 2000B | SBR09 | 1032/BL . . . . . . . . . . . . . . . 112 DA0-05.0 (H) 2000B | SBR09 | 1032/CH . . . . . . . . . . . . . . 113 DA0-05.0 (I) 2000B | SBR09 | 1032/HM . . . . . . . . . . . . . . 113 DA0-05.0 (K) 2000B | SBR09 | 1032/10 . . . . . . . . . . . . . . . 112 DA0-05.0 (K) 2320 | SBR09 | 1032/10 . . . . . . . . . . . . . . . . 321 DA0-05.0 (P) 2000B | SBR09 | 1032/BL . . . . . . . . . . . . . . . 112 DA0-05.0 (T) 2000B | SBR09 | 1032/TV . . . . . . . . . . . . . . . 113 DA0-05.0 (V) 2000B | SBR09 | 1032/VA . . . . . . . . . . . . . . . 113 DA0-05.0 (Z) 2000B | SBR09 | 1032/ZZ . . . . . . . . . . . . . . . 113 DA0-06.0 2000B | SBR05 . . . . . . . . . . . . . . . . . . . . . . . . 111 DA0-06.0 2320 | SBR05 . . . . . . . . . . . . . . . . . . . . . . . . 321 DA0-07.0 2330B | NM109 . . . . . . . . . . . . . . . . . . . . . . . 361 DA0-07.0 2010BB | NM109 . . . . . . . . . . . . . . . . . . . . . . 131 DA0-08.0 2010BB | REF02 . . . . . . . . . . . . . . . . . . . . . . 138 DA0-09.0 2010BB | NM103 . . . . . . . . . . . . . . . . . . . . . . 131 DA0-09.0 2330B | NM103 . . . . . . . . . . . . . . . . . . . . . . . 360 DA0-10.0 2320 | SBR03 . . . . . . . . . . . . . . . . . . . . . . . . 320 DA0-10.0 2000B | SBR03 . . . . . . . . . . . . . . . . . . . . . . . . 111

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DA0-11.0 2320 | SBR04. . . . . . . . . . . . . . . . . . . . . . . . . 320 DA0-11.0 2000B | SBR04 . . . . . . . . . . . . . . . . . . . . . . . 111 DA0-14.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 228 DA0-15.0 2300 | CLM08 . . . . . . . . . . . . . . . . . . . . . . . . 175 DA0-15.0 2320 | OI03 . . . . . . . . . . . . . . . . . . . . . . . . . . 345 DA0-16.0 2300 | CLM10 . . . . . . . . . . . . . . . . . . . . . . . . 176 DA0-16.0 2320 | OI04 . . . . . . . . . . . . . . . . . . . . . . . . . . 345 DA0-17.0 2000B | SBR02 . . . . . . . . . . . . . . . . . . . . . . . 111 DA0-17.0 2000C | PAT01 . . . . . . . . . . . . . . . . . . . . . . . . 154 DA0-17.0 2320 | SBR02. . . . . . . . . . . . . . . . . . . . . . . . . 319 DA0-18.0 2010BA | NM109 . . . . . . . . . . . . . . . . . . . . . . 119 DA0-18.0 2010CA | NM109 . . . . . . . . . . . . . . . . . . . . . . 159 DA0-18.0 2330A | NM109 . . . . . . . . . . . . . . . . . . . . . . . 352 DA0-19.0 2010BA | NM103 . . . . . . . . . . . . . . . . . . . . . . 118 DA0-19.0 2330A | NM103 . . . . . . . . . . . . . . . . . . . . . . . 351 DA0-20.0 2010BA | NM104 . . . . . . . . . . . . . . . . . . . . . . 118 DA0-20.0 2330A | NM104 . . . . . . . . . . . . . . . . . . . . . . . 351 DA0-21.0 2010BA | NM105 . . . . . . . . . . . . . . . . . . . . . . 118 DA0-21.0 2330A | NM105 . . . . . . . . . . . . . . . . . . . . . . . 351 DA0-22.0 2010BA | NM107 . . . . . . . . . . . . . . . . . . . . . . 118 DA0-22.0 2330A | NM107 . . . . . . . . . . . . . . . . . . . . . . . 352 DA0-23.0 2010BA | DMG03 . . . . . . . . . . . . . . . . . . . . . . 125 DA0-23.0 2320 | DMG03 . . . . . . . . . . . . . . . . . . . . . . . . 343 DA0-24.0 2320 | DMG02 . . . . . . . . . . . . . . . . . . . . . . . . 343 DA0-24.0 2010BA | DMG02 . . . . . . . . . . . . . . . . . . . . . . 125 DA0-30.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 225 DA1-02.0 2000B | SBR01 . . . . . . . . . . . . . . . . . . . . . . . 110

F.4

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DA1-02.0 2320 | SBR01 . . . . . . . . . . . . . . . . . . . . . . . . 319 DA1-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 DA1-04.0 2010BB | N301 . . . . . . . . . . . . . . . . . . . . . . . 134 DA1-05.0 2010BB | N302 . . . . . . . . . . . . . . . . . . . . . . . 134 DA1-06.0 2010BB | N401 . . . . . . . . . . . . . . . . . . . . . . . 135 DA1-07.0 2010BB | N402 . . . . . . . . . . . . . . . . . . . . . . . 136 DA1-08.0 2010BB | N403 . . . . . . . . . . . . . . . . . . . . . . . 136 DA1-09.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-10.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-11.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-12.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-13.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-16.0 2320 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . 326 DA1-17.0 2320 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-18.0 2320 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA1-27.0 2330B | DTP03 . . . . . . . . . . . . . . . . . . . . . . . 367 DA1-30.0 2320 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . 326 DA1-30.0 2320 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-30.0 2320 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA1-30.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA1-30.0 2320 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA1-30.0 2320 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA1-30.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-30.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-30.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA1-30.0 2320 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA1-30.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL DA1-30.0 2320 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA1-33.0 2320 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-33.0 2320 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA1-33.0 2320 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA1-33.0 2320 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA1-33.0 2320 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA1-33.0 2320 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA1-37.0 2320 | AMT02. . . . . . . . . . . . . . . . . . . . . . . . . 333 DA2-02.0 2000B | SBR01 . . . . . . . . . . . . . . . . . . . . . . . 110 DA2-02.0 2320 | SBR01. . . . . . . . . . . . . . . . . . . . . . . . . 319 DA2-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 DA2-04.0 2010BA | N301 . . . . . . . . . . . . . . . . . . . . . . . . 121 DA2-04.0 2330A | N301 . . . . . . . . . . . . . . . . . . . . . . . . . 354 DA2-05.0 2010BA | N302 . . . . . . . . . . . . . . . . . . . . . . . . 121 DA2-05.0 2330A | N302 . . . . . . . . . . . . . . . . . . . . . . . . . 354 DA2-06.0 2010BA | N401 . . . . . . . . . . . . . . . . . . . . . . . . 122 DA2-06.0 2330A | N401 . . . . . . . . . . . . . . . . . . . . . . . . . 355 DA2-07.0 2010BA | N402 . . . . . . . . . . . . . . . . . . . . . . . . 123 DA2-07.0 2330A | N402 . . . . . . . . . . . . . . . . . . . . . . . . . 356 DA2-08.0 2010BA | N403 . . . . . . . . . . . . . . . . . . . . . . . . 123 DA2-08.0 2330A | N403 . . . . . . . . . . . . . . . . . . . . . . . . . 356 DA3-04.0 2320 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-04.0 2320 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-04.0 2320 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-04.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-04.0 2320 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-04.0 2320 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 330

MAY 2000

F.5

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL DA3-05.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-05.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-05.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-05.0 2320 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-05.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-05.0 2320 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-06.0 2320 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-06.0 2320 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-06.0 2320 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-06.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-06.0 2320 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-06.0 2320 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-07.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-07.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-07.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-07.0 2320 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-07.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-07.0 2320 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-08.0 2320 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-08.0 2320 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-08.0 2320 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-08.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-08.0 2320 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-08.0 2320 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-09.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-09.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-09.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DA3-09.0 2320 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-09.0 2320 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-09.0 2320 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-10.0 2320 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-10.0 2320 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-10.0 2320 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-10.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-10.0 2320 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-10.0 2320 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-11.0 2320 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-11.0 2320 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-11.0 2320 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-11.0 2320 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-11.0 2320 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-11.0 2320 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-12.0 2320 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-12.0 2320 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-12.0 2320 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-12.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-12.0 2320 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-12.0 2320 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-13.0 2320 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-13.0 2320 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-13.0 2320 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-13.0 2320 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-13.0 2320 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-13.0 2320 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 330

F.6

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE DA3-14.0 2320 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-14.0 2320 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-14.0 2320 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-14.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-14.0 2320 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-14.0 2320 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-15.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-15.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-15.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-15.0 2320 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-15.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-15.0 2320 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-16.0 2320 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . 326 DA3-16.0 2320 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-16.0 2320 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-16.0 2320 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-16.0 2320 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-16.0 2320 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-17.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-17.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-17.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-17.0 2320 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-17.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-17.0 2320 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-18.0 2320 | MOA03 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-18.0 2320 | MOA04 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-18.0 2320 | MOA05 . . . . . . . . . . . . . . . . . . . . . . . . 348

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL DA3-18.0 2320 | MOA06 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-18.0 2320 | MOA07 . . . . . . . . . . . . . . . . . . . . . . . . 349 DA3-19.0 2320 | MOA03 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-19.0 2320 | MOA04 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-19.0 2320 | MOA05 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-19.0 2320 | MOA06 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-19.0 2320 | MOA07 . . . . . . . . . . . . . . . . . . . . . . . . 349 DA3-20.0 2320 | MOA03 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-20.0 2320 | MOA04 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-20.0 2320 | MOA05 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-20.0 2320 | MOA06 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-20.0 2320 | MOA07 . . . . . . . . . . . . . . . . . . . . . . . . 349 DA3-21.0 2320 | MOA03 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-21.0 2320 | MOA04 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-21.0 2320 | MOA05 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-21.0 2320 | MOA06 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-21.0 2320 | MOA07 . . . . . . . . . . . . . . . . . . . . . . . . 349 DA3-22.0 2320 | MOA03 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-22.0 2320 | MOA04 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-22.0 2320 | MOA05 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-22.0 2320 | MOA06 . . . . . . . . . . . . . . . . . . . . . . . . 348 DA3-22.0 2320 | MOA07 . . . . . . . . . . . . . . . . . . . . . . . . 349 DA3-24.0 2330B | REF02 . . . . . . . . . . . . . . . . . . . . . . . 373 DA3-25.0 2320 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-25.0 2320 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-25.0 2320 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-25.0 2320 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 329

MAY 2000

F.7

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL DA3-25.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-25.0 2320 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-26.0 2320 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-26.0 2320 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 327 DA3-26.0 2320 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 328 DA3-26.0 2320 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 329 DA3-26.0 2320 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-26.0 2320 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 330 DA3-29.0 2330B | REF02 . . . . . . . . . . . . . . . . . . . . . . . 369 EA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 EA0-04.0 - Employment 2300 | CLM11 | C024-01 . . . . . . . . . . . . . . . . 176 EA0-04.0 - Employment 2300 | CLM11 | C024-02 . . . . . . . . . . . . . . . . 177 EA0-04.0 - Employment 2300 | CLM11 | C024-03 . . . . . . . . . . . . . . . . 177 EA0-05.0 - Auto Accident or Other Accident 2300 | CLM11 | C024-01 . . . . . . . . . . . . . . . . 176 EA0-05.0 - Auto Accident or Other Accident 2300 | CLM11 | C024-02 . . . . . . . . . . . . . . . . 177 EA0-05.0 - Auto Accident or Other Accident 2300 | CLM11 | C024-03 . . . . . . . . . . . . . . . . 177 EA0-07.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 189 EA0-07.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 196 EA0-07.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 453 EA0-07.0 - Accident Date 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 195 EA0-09.0 - Responsibility Indicator 2300 | CLM11 | C024-01 . . . . . . . . . . . . . . . . 176 EA0-09.0 - Responsibility Indicator 2300 | CLM11 | C024-02 . . . . . . . . . . . . . . . . 177 EA0-09.0 - Responsibility Indicator 2300 | CLM11 | C024-03 . . . . . . . . . . . . . . . . 177 EA0-10.0 2300 | CLM11 | C024-04 . . . . . . . . . . . . . . . . 177 EA0-11.0 Accident Hour (no minutes) 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 195

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE EA0-13.0 2300 | CLM09 . . . . . . . . . . . . . . . . . . . . . . . . 175 EA0-16.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 193 EA0-16.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 453 EA0-18.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 202 EA0-19.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 204 EA0-20.0 2310A | NM109 . . . . . . . . . . . . . . . . . . . . . . . 284 EA0-20.0 2310A | REF02. . . . . . . . . . . . . . . . . . . . . . . . 289 EA0-24.0 2310A | NM103 . . . . . . . . . . . . . . . . . . . . . . . 283 EA0-25.0 2310A | NM104 . . . . . . . . . . . . . . . . . . . . . . . 283 EA0-26.0 2310A | NM105 . . . . . . . . . . . . . . . . . . . . . . . 284 EA0-28.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 209 EA0-29.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 211 EA0-31.0 2300 | AMT02. . . . . . . . . . . . . . . . . . . . . . . . . 221 EA0-32.0 2300 | HI01 | C022-02 . . . . . . . . . . . . . . . . . . 266 EA0-33.0 2300 | HI02 | C022-02 . . . . . . . . . . . . . . . . . . 266 EA0-34.0 2300 | HI03 | C022-02 . . . . . . . . . . . . . . . . . . 267 EA0-35.0 2300 | HI04 | C022-02 . . . . . . . . . . . . . . . . . . 268 EA0-36.0 2300 | CLM07 . . . . . . . . . . . . . . . . . . . . . . . . 174 EA0-37.0 2300 | CLM06 . . . . . . . . . . . . . . . . . . . . . . . . 174 EA0-39.0 2310D | NM103 . . . . . . . . . . . . . . . . . . . . . . . 304 EA0-40.0 2300 | PWK02 . . . . . . . . . . . . . . . . . . . . . . . . 216 EA0-40.0 2400 | PWK02 . . . . . . . . . . . . . . . . . . . . . . . . 411 EA0-41.0 2300 | PWK01 . . . . . . . . . . . . . . . . . . . . . . . . 215 EA0-43.0 2300 | CLM12 . . . . . . . . . . . . . . . . . . . . . . . . 178 EA0-43.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 243 EA0-47.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 230 EA0-48.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 187

F.8

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE EA0-48.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 446 EA0-50.0 2300 | CRC03 | 1321/IH . . . . . . . . . . . . . . . . 264 EA0-53.0 2310D | NM109 . . . . . . . . . . . . . . . . . . . . . . . 305 EA0-53.0 2310D | REF02 . . . . . . . . . . . . . . . . . . . . . . . 311 EA0-54.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 236 EA1-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 EA1-04.0 2310D | NM109 . . . . . . . . . . . . . . . . . . . . . . . 305 EA1-04.0 2310D | REF02 . . . . . . . . . . . . . . . . . . . . . . . 311 EA1-06.0 2310D | N301 . . . . . . . . . . . . . . . . . . . . . . . . 307 EA1-07.0 2310D | N302 . . . . . . . . . . . . . . . . . . . . . . . . 307 EA1-08.0 2310D | N401 . . . . . . . . . . . . . . . . . . . . . . . . 308 EA1-09.0 2310D | N402 . . . . . . . . . . . . . . . . . . . . . . . . 309 EA1-10.0 2310D | N403 . . . . . . . . . . . . . . . . . . . . . . . . 309 EA1-12.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 207 EA1-16.0 2310E | NM109 . . . . . . . . . . . . . . . . . . . . . . . 314 EA1-16.0 2310E | REF02 . . . . . . . . . . . . . . . . . . . . . . . 317 EA1-18.0 2310E | NM103 . . . . . . . . . . . . . . . . . . . . . . . 313 EA1-19.0 2310E | NM104 . . . . . . . . . . . . . . . . . . . . . . . 313 EA1-20.0 2310E | NM105 . . . . . . . . . . . . . . . . . . . . . . . 313 EA1-25.0 - Provider Assumed Care Date 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 213 EA2-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 FA0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 FA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 FA0-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 473 FA0-05.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 436 FA0-06.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 436 FA0-07.0 2300 | CLM05 | C023 . . . . . . . . . . . . . . . . . . 172

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL FA0-07.0 2400 | SV105 . . . . . . . . . . . . . . . . . . . . . . . . . 404 FA0-09.0 2400 | SV101 | C003-02. . . . . . . . . . . . . . . . . 401 FA0-10.0 2400 | SV101 | C003-03. . . . . . . . . . . . . . . . . 401 FA0-11.0 2400 | SV101 | C003-04. . . . . . . . . . . . . . . . . 402 FA0-12.0 2400 | SV101 | C003-05. . . . . . . . . . . . . . . . . 402 FA0-13.0 2400 | SV102 . . . . . . . . . . . . . . . . . . . . . . . . . 402 FA0-14.0 2400 | SV107 | C004-01. . . . . . . . . . . . . . . . . 405 FA0-15.0 2400 | SV107 | C004-02. . . . . . . . . . . . . . . . . 405 FA0-16.0 2400 | SV107 | C004-03. . . . . . . . . . . . . . . . . 405 FA0-17.0 2400 | SV107 | C004-04. . . . . . . . . . . . . . . . . 405 FA0-18.0 2400 | SV104 . . . . . . . . . . . . . . . . . . . . . . . . . 403 FA0-19.0 2400 | SV104 . . . . . . . . . . . . . . . . . . . . . . . . . 403 FA0-20.0 2400 | SV109 . . . . . . . . . . . . . . . . . . . . . . . . . 406 FA0-23.0 2310B | NM109 . . . . . . . . . . . . . . . . . . . . . . . 292 FA0-23.0 2420A | NM109 . . . . . . . . . . . . . . . . . . . . . . . 503 FA0-24.0 2420F | NM109 . . . . . . . . . . . . . . . . . . . . . . . 543 FA0-27.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FA0-28.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FA0-31.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 226 FA0-31.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 474 FA0-34.0 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 232 FA0-34.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 476 FA0-35.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FA0-36.0 2400 | SV101 | C003-06. . . . . . . . . . . . . . . . . 402 FA0-37.0 2310B | PRV03 . . . . . . . . . . . . . . . . . . . . . . . 294 FA0-37.0 2420A | PRV03. . . . . . . . . . . . . . . . . . . . . . . . 505 FA0-40.0 2400 | CRC02 . . . . . . . . . . . . . . . . . . . . . . . . 431

MAY 2000

F.9

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL FA0-41.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 448 FA0-42.0 - Hemoglobin 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 FA0-43.0 - Hematocrit 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 FA0-44.0 2000B | PAT08 . . . . . . . . . . . . . . . . . . . . . . . 115 FA0-44.0 2000C | PAT08 . . . . . . . . . . . . . . . . . . . . . . . 156 FA0-45.0 - Epoetin Starting Dosage 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 FA0-46.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . 448 FA0-47.0 - Creatin 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 FA0-48.0 2430 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 560 FA0-50.0 2300 | CR106 . . . . . . . . . . . . . . . . . . . . . . . . 250 FA0-50.0 2400 | SV103 . . . . . . . . . . . . . . . . . . . . . . . . 403 FA0-50.0 2400 | CR106 . . . . . . . . . . . . . . . . . . . . . . . . 414 FA0-51.0 2400 | AMT02 . . . . . . . . . . . . . . . . . . . . . . . . 485 FA0-52.0 2430 | SVD02 . . . . . . . . . . . . . . . . . . . . . . . . 555 FA0-53.0 2430 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 560 FA0-53.0 2430 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 561 FA0-53.0 2430 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 562 FA0-53.0 2430 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 563 FA0-53.0 2430 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 564 FA0-53.0 2430 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 565 FA0-54.0 2430 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . 560 FA0-54.0 2430 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . 561 FA0-54.0 2430 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . 562 FA0-54.0 2430 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . 563 FA0-54.0 2430 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . 564 FA0-54.0 2430 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . 565 FA0-57.0 2310B | NM108 . . . . . . . . . . . . . . . . . . . . . . . 292

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE FA0-57.0 2310B | REF01 . . . . . . . . . . . . . . . . . . . . . . . 296 FA0-57.0 2420A | NM108 . . . . . . . . . . . . . . . . . . . . . . . 503 FA0-58.0 2310B | NM109 . . . . . . . . . . . . . . . . . . . . . . . 292 FA0-58.0 2310B | REF02 . . . . . . . . . . . . . . . . . . . . . . . 297 FA0-58.0 2420A | NM109 . . . . . . . . . . . . . . . . . . . . . . . 503 FA0-59.0 2300 | CLM07 . . . . . . . . . . . . . . . . . . . . . . . . 174 FA0-62.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 483 FB0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 FB0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 FB0-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 473 FB0-05.0 2400 | PS102 . . . . . . . . . . . . . . . . . . . . . . . . . 490 FB0-06.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB0-07.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB0-08.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB0-09.0 2420E | NM109 . . . . . . . . . . . . . . . . . . . . . . . 531 FB0-10.0 2420E | N402 . . . . . . . . . . . . . . . . . . . . . . . . . 535 FB0-11.0 2310C | REF02 . . . . . . . . . . . . . . . . . . . . . . . 302 FB0-11.0 2400 | PS101 . . . . . . . . . . . . . . . . . . . . . . . . . 489 FB0-11.0 2420B | REF02 . . . . . . . . . . . . . . . . . . . . . . . 513 FB0-11.0 2310C | NM109 . . . . . . . . . . . . . . . . . . . . . . . 300 FB0-11.0 2420B | NM109 . . . . . . . . . . . . . . . . . . . . . . . 511 FB0-15.0 2400 | SV101 | C003-02. . . . . . . . . . . . . . . . . 401 FB0-16.0 2400 | SV104 . . . . . . . . . . . . . . . . . . . . . . . . . 403 FB0-21.0 2400 | SV115 . . . . . . . . . . . . . . . . . . . . . . . . . 407 FB0-22.0 2400 | SV111 . . . . . . . . . . . . . . . . . . . . . . . . . 406 FB0-23.0 2400 | SV112 . . . . . . . . . . . . . . . . . . . . . . . . . 406 FB1-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399

F.10

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE FB1-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 FB1-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 473 FB1-06.0 2420E | NM103. . . . . . . . . . . . . . . . . . . . . . . . 530 FB1-07.0 2420E | NM104. . . . . . . . . . . . . . . . . . . . . . . . 530 FB1-08.0 2420E | NM105. . . . . . . . . . . . . . . . . . . . . . . . 530 FB1-09.0 2420E | NM109. . . . . . . . . . . . . . . . . . . . . . . . 531 FB1-10.0 2420F | NM103 . . . . . . . . . . . . . . . . . . . . . . . . 542 FB1-11.0 2420F | NM104 . . . . . . . . . . . . . . . . . . . . . . . . 542 FB1-12.0 2420F | NM105 . . . . . . . . . . . . . . . . . . . . . . . . 543 FB1-13.0 2420F | NM109 . . . . . . . . . . . . . . . . . . . . . . . . 543 FB1-14.0 2310B | NM103. . . . . . . . . . . . . . . . . . . . . . . . 291 FB1-14.0 2420A | NM103 . . . . . . . . . . . . . . . . . . . . . . . . 502 FB1-15.0 2310B | NM104. . . . . . . . . . . . . . . . . . . . . . . . 291 FB1-15.0 2420A | NM104 . . . . . . . . . . . . . . . . . . . . . . . . 502 FB1-16.0 2310B | NM105. . . . . . . . . . . . . . . . . . . . . . . . 292 FB1-16.0 2420A | NM105 . . . . . . . . . . . . . . . . . . . . . . . . 503 FB1-18.0 2420D | NM103 . . . . . . . . . . . . . . . . . . . . . . . 524 FB1-19.0 2420D | NM104 . . . . . . . . . . . . . . . . . . . . . . . 524 FB1-20.0 2420D | NM105 . . . . . . . . . . . . . . . . . . . . . . . 524 FB1-21.0 2420D | NM109 . . . . . . . . . . . . . . . . . . . . . . . 525 FB1-21.0 2420D | REF02 . . . . . . . . . . . . . . . . . . . . . . . . 528 FB2-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 FB2-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 FB2-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 473 FB2-06.0 2420E | N301 . . . . . . . . . . . . . . . . . . . . . . . . . 533 FB2-07.0 2420E | N302 . . . . . . . . . . . . . . . . . . . . . . . . . 533 FB2-08.0 2420E | N401 . . . . . . . . . . . . . . . . . . . . . . . . . 534

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL FB2-09.0 2420E | N402 . . . . . . . . . . . . . . . . . . . . . . . . . 535 FB2-10.0 2420E | N403 . . . . . . . . . . . . . . . . . . . . . . . . . 535 FB3-05.0 2430 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-05.0 2430 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-05.0 2430 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-05.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-05.0 2430 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-05.0 2430 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-06.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-06.0 2430 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-06.0 2430 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-06.0 2430 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-06.0 2430 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-06.0 2430 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-07.0 2430 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-07.0 2430 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-07.0 2430 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-07.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-07.0 2430 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-07.0 2430 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-08.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-08.0 2430 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-08.0 2430 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-08.0 2430 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-08.0 2430 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-08.0 2430 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-09.0 2430 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 560

MAY 2000

F.11

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL FB3-09.0 2430 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-09.0 2430 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-09.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-09.0 2430 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-09.0 2430 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-10.0 2430 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-10.0 2430 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-10.0 2430 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-10.0 2430 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-10.0 2430 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-10.0 2430 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-11.0 2430 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-11.0 2430 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-11.0 2430 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-11.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-11.0 2430 | CAS14 . . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-11.0 2430 | CAS17 . . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-12.0 2430 | CAS03 . . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-12.0 2430 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-12.0 2430 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-12.0 2430 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-12.0 2430 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-12.0 2430 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-13.0 2430 | CAS02 . . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-13.0 2430 | CAS05 . . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-13.0 2430 | CAS08 . . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-13.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE FB3-13.0 2430 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-13.0 2430 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-14.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-14.0 2430 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-14.0 2430 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-14.0 2430 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-14.0 2430 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-14.0 2430 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-15.0 2430 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-15.0 2430 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-15.0 2430 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-15.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-15.0 2430 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-15.0 2430 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-16.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-16.0 2430 | CAS06. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-16.0 2430 | CAS09. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-16.0 2430 | CAS12. . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-16.0 2430 | CAS15. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-16.0 2430 | CAS18. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-17.0 2430 | CAS02. . . . . . . . . . . . . . . . . . . . . . . . . 560 FB3-17.0 2430 | CAS05. . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-17.0 2430 | CAS08. . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-17.0 2430 | CAS11 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-17.0 2430 | CAS14. . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-17.0 2430 | CAS17. . . . . . . . . . . . . . . . . . . . . . . . . 565 FB3-18.0 2430 | CAS03. . . . . . . . . . . . . . . . . . . . . . . . . 560

F.12

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE FB3-18.0 2430 | CAS06 . . . . . . . . . . . . . . . . . . . . . . . . . 561 FB3-18.0 2430 | CAS09 . . . . . . . . . . . . . . . . . . . . . . . . . 562 FB3-18.0 2430 | CAS12 . . . . . . . . . . . . . . . . . . . . . . . . . 563 FB3-18.0 2430 | CAS15 . . . . . . . . . . . . . . . . . . . . . . . . . 564 FB3-18.0 2430 | CAS18 . . . . . . . . . . . . . . . . . . . . . . . . . 565 FD0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 FD0-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 473 FE0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 FE0-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 473 FE0-06.0 (TPO Reference Number) 2300 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 233 GA0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 GA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 GA0-05.0 2300 | CR102 . . . . . . . . . . . . . . . . . . . . . . . . . 249 GA0-05.0 2400 | CR102 . . . . . . . . . . . . . . . . . . . . . . . . . 413 GA0-06.0 2300 | CRC03 | 1321/01 . . . . . . . . . . . . . . . . . 258 GA0-06.0 2400 | CRC03 | 1321/01 . . . . . . . . . . . . . . . . . 428 GA0-07.0 2300 | CR103 . . . . . . . . . . . . . . . . . . . . . . . . . 249 GA0-07.0 2400 | CR103 . . . . . . . . . . . . . . . . . . . . . . . . . 413 GA0-08.0 2300 | CRC03 | 1321/02 . . . . . . . . . . . . . . . . . 258 GA0-08.0 2400 | CRC03 | 1321/02 . . . . . . . . . . . . . . . . . 428 GA0-09.0 2300 | CRC03 | 1321/03 . . . . . . . . . . . . . . . . . 258 GA0-09.0 2400 | CRC03 | 1321/03 . . . . . . . . . . . . . . . . . 428 GA0-10.0 2300 | CRC03 | 1321/04 . . . . . . . . . . . . . . . . . 258 GA0-10.0 2400 | CRC03 | 1321/04 . . . . . . . . . . . . . . . . . 428 GA0-11.0 2300 | CRC03 | 1321/05 . . . . . . . . . . . . . . . . . 258 GA0-11.0 2400 | CRC03 | 1321/05 . . . . . . . . . . . . . . . . . 428 GA0-12.0 2300 | CRC03 | 1321/06 . . . . . . . . . . . . . . . . . 258

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL GA0-12.0 2400 | CRC03 | 1321/06 . . . . . . . . . . . . . . . . 428 GA0-13.0 2300 | CRC03 | 1321/07 . . . . . . . . . . . . . . . . 258 GA0-13.0 2400 | CRC03 | 1321/07 . . . . . . . . . . . . . . . . 428 GA0-14.0 2300 | CRC03 | 1321/08 . . . . . . . . . . . . . . . . 258 GA0-14.0 2400 | CRC03 | 1321/08 . . . . . . . . . . . . . . . . 428 GA0-15.0 2300 | CR104 . . . . . . . . . . . . . . . . . . . . . . . . . 249 GA0-15.0 2400 | CR104 . . . . . . . . . . . . . . . . . . . . . . . . . 413 GA0-16.0 2300 | CRC03 | 1321/09 . . . . . . . . . . . . . . . . 259 GA0-16.0 2400 | CRC03 | 1321/09 . . . . . . . . . . . . . . . . 429 GA0-17.0 2300 | CR106 . . . . . . . . . . . . . . . . . . . . . . . . . 250 GA0-17.0 2400 | CR106 . . . . . . . . . . . . . . . . . . . . . . . . . 414 GA0-20.0 2300 | CR109 . . . . . . . . . . . . . . . . . . . . . . . . . 250 GA0-20.0 2400 | CR109 . . . . . . . . . . . . . . . . . . . . . . . . . 414 GA0-21.0 2300 | CR110 . . . . . . . . . . . . . . . . . . . . . . . . . 250 GA0-21.0 2400 | CR110 . . . . . . . . . . . . . . . . . . . . . . . . . 414 GA0-22.0 (for Ambulance Claims only) 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 211 GA0-23.0 (for ambulance claims only) 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 209 GA0-24.0 2300 | CRC03 | 1321/60 . . . . . . . . . . . . . . . . 259 GA0-24.0 2400 | CRC03 | 1321/60 . . . . . . . . . . . . . . . . 429 GC0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 GC0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 GC0-05.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 459 GC0-05.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 183 GC0-06.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 198 GC0-06.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 455 GC0-07.0 2300 | CR201 . . . . . . . . . . . . . . . . . . . . . . . . . 252 GC0-07.0 2300 | CR202 . . . . . . . . . . . . . . . . . . . . . . . . . 252

MAY 2000

F.13

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL GC0-07.0 2400 | CR201 . . . . . . . . . . . . . . . . . . . . . . . . . 416 GC0-07.0 2400 | CR202 . . . . . . . . . . . . . . . . . . . . . . . . . 416 GC0-08.0 2300 | CR203 . . . . . . . . . . . . . . . . . . . . . . . . . 252 GC0-08.0 2300 | CR204 . . . . . . . . . . . . . . . . . . . . . . . . . 253 GC0-08.0 2400 | CR203 . . . . . . . . . . . . . . . . . . . . . . . . . 416 GC0-08.0 2400 | CR204 . . . . . . . . . . . . . . . . . . . . . . . . . 417 GC0-09.0 2300 | CR206 . . . . . . . . . . . . . . . . . . . . . . . . . 255 GC0-09.0 2400 | CR206 . . . . . . . . . . . . . . . . . . . . . . . . . 419 GC0-10.0 2300 | CR207 . . . . . . . . . . . . . . . . . . . . . . . . . 255 GC0-10.0 2400 | CR207 . . . . . . . . . . . . . . . . . . . . . . . . . 419 GC0-11.0 2300 | CR208 . . . . . . . . . . . . . . . . . . . . . . . . . 255 GC0-11.0 2400 | CR208 . . . . . . . . . . . . . . . . . . . . . . . . . 419 GC0-12.0 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 191 GC0-12.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 457 GC0-13.0 2300 | CR209 . . . . . . . . . . . . . . . . . . . . . . . . . 255 GC0-13.0 2400 | CR209 . . . . . . . . . . . . . . . . . . . . . . . . . 419 GC0-14.0 2300 | CR210 . . . . . . . . . . . . . . . . . . . . . . . . . 256 GC0-14.0 2300 | CR211 . . . . . . . . . . . . . . . . . . . . . . . . . 256 GC0-14.0 2400 | CR210 . . . . . . . . . . . . . . . . . . . . . . . . . 420 GC0-14.0 2400 | CR211 . . . . . . . . . . . . . . . . . . . . . . . . . 420 GC0-15.0 2300 | CR212 . . . . . . . . . . . . . . . . . . . . . . . . . 256 GC0-15.0 2400 | CR212 . . . . . . . . . . . . . . . . . . . . . . . . . 420 GU0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 GU0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 GU0-04.0 2400 | CR301 . . . . . . . . . . . . . . . . . . . . . . . . . 421 GU0-05.0 2400 | SV105 . . . . . . . . . . . . . . . . . . . . . . . . . 404 GU0-06.0 2400 | CRC03 | 1321/ZV . . . . . . . . . . . . . . . . 434

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE GU0-07.0 2400 | SV101 | C003-02. . . . . . . . . . . . . . . . . 401 GU0-08.0 2400 | SV101 | C003-03. . . . . . . . . . . . . . . . . 401 GU0-12.0 2300 | HI01 | C022-02 . . . . . . . . . . . . . . . . . . 266 GU0-13.0 2300 | HI02 | C022-02 . . . . . . . . . . . . . . . . . . 266 GU0-14.0 2300 | HI03 | C022-02 . . . . . . . . . . . . . . . . . . 267 GU0-15.0 2300 | HI04 | C022-02 . . . . . . . . . . . . . . . . . . 268 GU0-16.0 - Patient Height 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 GU0-17.0 2000B | PAT08 . . . . . . . . . . . . . . . . . . . . . . . . 115 GU0-17.0 2000C | PAT08 . . . . . . . . . . . . . . . . . . . . . . . . 156 GU0-19.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 441 GU0-20.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 438 GU0-21.0 2400 | CR303 . . . . . . . . . . . . . . . . . . . . . . . . . 422 GU0-22.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 443 GU0-23.0 2420E | PER04 . . . . . . . . . . . . . . . . . . . . . . . 539 GU0-24.0 2400 | CRC03 | 1321/38 . . . . . . . . . . . . . . . . 433 GU0-25.0 2440 | LQ02 . . . . . . . . . . . . . . . . . . . . . . . . . . 568 GU0-26.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-27.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-28.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-28.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-29.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-30.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-31.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-31.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-32.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-33.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-33.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571

F.14

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE GU0-34.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-35.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-36.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-37.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-38.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-39.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-40.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-43.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-44.0 2440 | FRM02 . . . . . . . . . . . . . . . . . . . . . . . . . 570 GU0-45.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-46.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-47.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-48.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-49.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-50.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-51.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-53.0 2440 | FRM04 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-54.0 2440 | FRM04 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-55.0 2440 | FRM04 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-56.0 2440 | FRM04 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-57.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-58.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-59.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-60.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-61.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-62.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-63.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . . 571

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL GU0-64.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-65.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-66.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-67.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-68.0 2440 | FRM03 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-69.0 2440 | FRM05 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-70.0 2440 | FRM05 . . . . . . . . . . . . . . . . . . . . . . . . 571 GU0-71.0 2440 | FRM05 . . . . . . . . . . . . . . . . . . . . . . . . 571 GX0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 GX0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 GX0-04.0 2400 | CR501 . . . . . . . . . . . . . . . . . . . . . . . . . 424 GX0-05.0 2400 | CRC03 | 1321/37 . . . . . . . . . . . . . . . . 433 GX0-05.0 2400 | CRC03 | 1321/AL . . . . . . . . . . . . . . . . 433 GX0-06.0 2400 | CR502 . . . . . . . . . . . . . . . . . . . . . . . . . 424 GX0-10.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 441 GX0-11.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 438 GX0-11.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 443 GX0-14.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 481 GX0-17.0 - Arterial Blood Gas on 4 liters/minute 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 GX0-18.0 - Oxygen Saturation on 4 liters/minute 2400 | MEA03 . . . . . . . . . . . . . . . . . . . . . . . . 465 GX0-19.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 450 GX0-20.0 2400 | CRC03 | 1321/P1 . . . . . . . . . . . . . . . . 434 GX0-22.0 2400 | CR510 . . . . . . . . . . . . . . . . . . . . . . . . . 424 GX0-23.0 2400 | CR511 . . . . . . . . . . . . . . . . . . . . . . . . . 425 GX0-24.0 2400 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 450 GX0-25.0 2420C | NM103 . . . . . . . . . . . . . . . . . . . . . . . 515

MAY 2000

F.15

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL GX0-26.0 2400 | CR512 . . . . . . . . . . . . . . . . . . . . . . . . . 425 GX0-27.0 2400 | CR513 . . . . . . . . . . . . . . . . . . . . . . . . . 425 GX0-27.0 2400 | CR514 . . . . . . . . . . . . . . . . . . . . . . . . . 425 GX0-27.0 2400 | CR515 . . . . . . . . . . . . . . . . . . . . . . . . . 426 GX0-29.0 2420E | NM109. . . . . . . . . . . . . . . . . . . . . . . . 531 GX0-30.0 2420E | PER04 . . . . . . . . . . . . . . . . . . . . . . . . 539 GX0-31.0 2300 | HI01 | C022-02 . . . . . . . . . . . . . . . . . . 266 GX0-32.0 2300 | HI02 | C022-02 . . . . . . . . . . . . . . . . . . 266 GX0-33.0 2300 | HI03 | C022-02 . . . . . . . . . . . . . . . . . . 267 GX0-34.0 2300 | HI04 | C022-02 . . . . . . . . . . . . . . . . . . 268 GX0-35.0 2400 | CRC03 | 1321/38 . . . . . . . . . . . . . . . . . 433 GX2-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 GX2-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171 GX2-04.0 2420C | N301 . . . . . . . . . . . . . . . . . . . . . . . . . 518 GX2-05.0 2420C | N302 . . . . . . . . . . . . . . . . . . . . . . . . . 518 GX2-06.0 2420C | N401 . . . . . . . . . . . . . . . . . . . . . . . . . 519 GX2-07.0 2420C | N402 . . . . . . . . . . . . . . . . . . . . . . . . . 520 GX2-08.0 2420C | N403 . . . . . . . . . . . . . . . . . . . . . . . . . 520 HA0-02.0 2400 | LX01 . . . . . . . . . . . . . . . . . . . . . . . . . . 399 HA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . . 171

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE HA0-04.0 2400 | REF02 . . . . . . . . . . . . . . . . . . . . . . . . . 473 HA0-05.0 2300 | NTE02 . . . . . . . . . . . . . . . . . . . . . . . . . 247 HA0-05.0 2400 | K301 . . . . . . . . . . . . . . . . . . . . . . . . . . 487 HA0-05.0 2400 | NTE02 . . . . . . . . . . . . . . . . . . . . . . . . . 488 HA0-05.0 2300 | K301 . . . . . . . . . . . . . . . . . . . . . . . . . . 245 HA0-05.0 - Provider Relinquished Care Date 2300 | DTP03 . . . . . . . . . . . . . . . . . . . . . . . . . 213 XA0-03.0 2300 | CLM01 . . . . . . . . . . . . . . . . . . . . . . . . 171 XA0-12.0 2300 | CLM02 . . . . . . . . . . . . . . . . . . . . . . . . 172 XA0-19.0 2300 | AMT02. . . . . . . . . . . . . . . . . . . . . . . . . 220 YA0-02.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 YA0-02.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 YA0-02.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 YA0-02.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 YA0-06.0 2010AA | NM109 . . . . . . . . . . . . . . . . . . . . . . . 86 YA0-06.0 2010AA | REF02 . . . . . . . . . . . . . . . . . . . . . . . 92 YA0-06.0 2010AB | NM109 . . . . . . . . . . . . . . . . . . . . . . 101 YA0-06.0 2010AB | REF02 . . . . . . . . . . . . . . . . . . . . . . 107 ZA0-02.0 1000A | NM109 . . . . . . . . . . . . . . . . . . . . . . . . 69 ZA0-04.0 1000B | NM109 . . . . . . . . . . . . . . . . . . . . . . . . 75

F.16

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

F.2

Complete NSF to ASC X12 837 Map

This NSF matrix shows all data elements in NSF 3.01 and their corresponding ASC X12 element by table-position-data element and associated code value where pertinent. Translator means this value is created via the translator not the transaction set. Moving from a flat file format to a nested loop structure has many ramifications. Qualifiers are often used in the nested loop structure to determine the meaning of a subsequent element. When this happens, it is possible that more than one NSF value may be mapped to a single X12 element. An example of this is shown on page 560 in CAS03. The NSF values mapped to CAS03 will map dependent upon the values in CAS01 and CAS02. For example, FB0-07.0 (Deductible) maps if CAS01=PR and CAS02=1 (Deductible). FB0-08.0 (Co-insurance) maps if CAS01=PR and CAS02=2.
AA0-01.0 RECORD ID AA0 AA0-02.0 SUB ID AA0-03.0 RESERVED (AA0-03.0) AA0-04.0 SUBMISSION TYPE AA0-05.0 SUBMISSION NO AA0-06.0 SUB NAME AA0-07.0 SUB ADDR1 AA0-08.0 SUB ADDR2 AA0-09.0 SUB CITY AA0-10.0 SUB STATE AA0-11.0 SUB ZIP AA0-12.0 SUB REGION AA0-13.0 SUB CONTACT AA0-14.0 SUB PHONE AA0-15.0 CREATION DATE AA0-16.0 SUBMISSION TIME AA0-17.0 RECEIVER ID AA0-18.0 RECEIVER TYPE CODE AA0-19.0 VERSION CODE-NATIONAL AA0-20.0 VERSION CODE-LOCAL AA0-21.0 TEST/PROD IND AA0-22.0 PASSWORD AA0-23.0 RETRANSMISSION STATUS AA0-24.0 ORIGINAL SUB ID AA0-25.0 VENDOR APP CAT AA0-26.0 VENDOR SOFTWARE VER AA0-27.0 VENDOR SOFTWARE UPDTE AA0-28.0 COB FILE INDICATOR (COB) AA0-29.0 PROCESS FROM DATE (COB) AA0-30.0 PROCESS THRU DATE (COB) AA0-31.0 ACKNOWLEDGEMENT REQUESTED AA0-32.0 DATE OF RECEIPT AA0-33.0 FILLER-NATIONAL BA0-01.0 RECORD ID BA0 BA0-02.0 EMC PROV ID BA0-03.0 BATCH TYPE

AA0" 1-020-NM101 (41) 1-020-NM109 Not Mapped CPU 1-010-BHT03 1-020-NM103 Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped 1-045-PER02 1-045-PER04 1-010-BHT04 1-010-BHT05 1-020-NM109 1-020-NM101 (40) 2-005-SBR09 003.01"

Not Mapped 0-010-ISA15 0-010-ISA04 0-010-BHT02 Not Mapped Not Mapped Not Mapped

Not Mapped

Not Mapped

Not Mapped

Not Mapped

Not Mapped Translator Not Mapped BA0" 2-015-NM109 (85,87) 2-035-REF02 100"

MAY 2000

F.17

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

BA0-04.0 BATCH NO BA0-05.0 BATCH ID BA0-06.0 PROV TAX ID BA0-07.0 RESERVED (BA0-07.0) BA0-08.0 PROV TAX ID TYPE BA0-09.0 NATIONAL PROVIDER IDENTIFIER BA0-10.0 PROV UPIN NUMBER BA0-11.0 RESERVED (BA0-11.0) BA0-12.0 PROV MEDICAID NO BA0-13.0 PROV CHAMPUS NO BA0-14.0 PROV BLUE SHIELD NO BA0-15.0 PROV COMMERCIAL NO BA0-16.0 PROV NO 1 BA0-17.0 PROV NO 2 BA0-18.0 ORGANIZATION NAME BA0-19.0 PROV LAST NAME BA0-20.0 PROV FIRST NAME BA0-21.0 PROV MI BA0-22.0 PROV SPECIALTY BA0-23.0 SPECIALTY LICENSE NO BA0-24.0 STATE LICENSE NO BA0-25.0 DENTIST LICENSE NO BA0-26.0 ANESTHESIA LICENSE NO

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE Translator Not Mapped 2-015-NM109 (85,87) 2-035-REF02 (SY,EI) Not Mapped 2-015-NM109 (85,87) 2-035-REF02
BA0-27.0 PROV PARTICIPATION IND (COB) BA0-28.0 FILLER-NATIONAL BA1-01.0 RECORD ID BA1 BA1-02.0 EMC PROV ID BA1-03.0 BATCH TYPE BA1-04.0 BATCH NO

Not Mapped Not Mapped BA1" 2-015-NM109 (85,87) 2-035-REF02 100" Translator Not Mapped Not Mapped 2-025-N301 2-025-N302 2-030-N401 2-030-N402 2-030-N403 2-040-PER04 2-025-N301 2-025-N302 2-030-N401 2-030-N402 2-030-N403 2-040-PER04 Not Mapped CA0" Not Mapped 2-130-CLM01 2-015-NM103 (QC) 2-015-NM104 2-015-NM105 2-015-NM107

2-035-REF02 2-015-NM109(85,87) 2-015-NM109 (85,87) 2-035-REF02 (1G) Not Mapped 2-015-NM109 (85,87) 2-035-REF02 (1D) 2-015-NM109 (85,87) 2-035-REF02 (1H) 2-015-NM109 (85,87) 2-035-REF02 (1B) 2-015-NM109 (85,87) 2-035-REF02 (G2) 2-015-NM109 (85,87) 2-035-REF02 2-015-NM109 (85,87) 2-035-REF02 2-015-NM103 (85,87) 2-015-NM103 (85,87) 2-015-NM104 2-035-REF02 (0B) 2-015-NM105 2-003-PRV03 Not Mapped 2-015-NM109 (85,87) 2-035-REF02(0B) Not Mapped Not Mapped

BA1-05.0 BATCH ID BA1-06.0 PROV TYPE ORG BA1-07.0 PROV SVC ADDR1 BA1-08.0 PROV SVC ADDR2 BA1-09.0 PROV SVC CITY BA1-10.0 PROV SVC STATE BA1-11.0 PROV SVC ZIP BA1-12.0 PROV SVC PHONE BA1-13.0 PROV PAY TO ADDR1 BA1-14.0 PROV PAY TO ADDR2 BA1-15.0 PROV PAY TO CITY BA1-16.0 PROV PAY TO STATE BA1-17.0 PROV PAY TO ZIP BA1-18.0 PROV PAY TO PHONE BA1-19.0 FILLER-NATIONAL CA0-01.0 RECORD ID CA0 CA0-02.0 RESERVED (CA0-02.0) CA0-03.0 PAT CONTROL NO CA0-04.0 PAT LAST NAME CA0-05.0 PAT FIRST NAME CA0-06.0 PAT MI CA0-07.0 PAT GENERATION

F.18

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

CA0-08.0 PAT DATE OF BIRTH CA0-09.0 PAT SEX CA0-10.0 PAT TYPE OF RESIDENCE CA0-11.0 PAT ADDR1 CA0-12.0 PAT ADDR2 CA0-13.0 PAT CITY CA0-14.0 PAT STATE CA0-15.0 PAT ZIP CA0-16.0 PAT PHONE CA0-17.0 PAT MARITAL STATUS CA0-18.0 PAT STUDENT STATUS CA0-19.0 PAT EMPLOYMENT STATUS CA0-20.0 PAT DEATH IND CA0-21.0 PAT DATE OF DEATH CA0-22.0 OTHER INSURANCE IND CA0-23.0 CLAIM EDITING IND CA0-24.0 TYPE OF CLAIM IND CA0-25.0 LEGAL REP IND CA0-26.0 ORIGIN CODE CA0-27.0 PAYOR CLM CONTROL NO CA0-28.0 PROVIDER NUMBER CA0-29.0 CLAIM ID NO CA0-30.0 FILLER-NATIONAL CA1-01.0 RECORD ID CA1 CA1-02.0 RESERVED (CA1-02.0) CA1-03.0 PAT CONTROL NO CA1-04.0 PURCHASE ORDER NUMBER

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL 2-032-DMG02 2-032-DMG03 Not Mapped 2-025-N301 2-025-N302 2-030-N401 2-030-N402 2-030-N403 Not Mapped Not Mapped Not Mapped Not Mapped Translator 2-007-PAT06 Not Mapped 2-005-SBR09 Not Mapped 2-015-NM101 (QD) Not Mapped Not Mapped 2-015-NM109 (85,87) 2-035-REF02 Not Mapped Not Mapped CA1" Not Mapped 2-130-CLM01
DA0-01.0 RECORD ID DA0 DA0-02.0 SEQUENCE NO CA1-07.0 PATIENT HEALTH RECORD NUMBER CA1-08.0 AUTH FACILITY NUMBER CA1-09.0 MULTIPLE CLAIM INDICATOR CA1-10.0 FILLER-NATIONAL CB0-01.0 RECORD ID CB0 CB0-02.0 RESERVED (CB0-02.0) CB0-03.0 PAT CONTROL NO CB0-04.0 RESP PERSON LAST NAME CB0-05.0 RESP PERSON FIRST NAME CB0-06.0 RESP PERSON MI CB0-07.0 RESP PERSON ADDR1 CB0-08.0 RESP PERSON ADDR2 CB0-09.0 RESP PERSON CITY CB0-10.0 RESP PERSON STATE CB0-11.0 RESP PERSON ZIP CB0-12.0 RESP PERSON PHONE CB0-13.0 FILLER-NATIONAL CA1-05.0 TRIBE CA1-06.0 RESIDENCY CODE

2-015-NM109 2-015-NM108 (PB) 2-015-NM109 2-015-NM108 (PB)

Not Mapped Not Mapped

Not Mapped Not Mapped CB0" Not Mapped 2-130-CLM01 2-015-NM103 (QD)

2-015-NM104 2-015-NM105 2-025-N301 2-025-N302 2-030-N401 2-030-N402 2-030-N403 Not Mapped Not Mapped

NOTE: If the patient has other primary insurance and Medicare is secondary, the NSF requires a separate DA0 record for each payer. The first DA0 carries information about the primary payer, the second DA0 holds information about the secondary payer. (See Section H for sequencing and payer specific mapping of the NSF)

DA0" 2-005-SBR01 2-290-SBR01 2-130-CLM01

Not Mapped
DA0-03.0 PAT CONTROL NO

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

DA0-04.0 CLAIM FILING IND DA0-05.0 SOURCE OF PAY DA0-06.0 INSURANCE TYPE CODE DA0-07.0 PAYOR ORGANIZATION ID

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE Translator 2-005-SBR09 2-290-SBR09 2-005-SBR05 2-290-SBR05 2-325-NM109 2-015-NM109 2-540-SVD01 2-035-REF02 2-325-NM103 (PR) 2-290-SBR03 2-005-SBR03 2-290-SBR04 2-005-SBR04 Not Mapped Not Mapped 2-180-REF02 (G1) 2-310-OI03 2-130-CLM08 2-310-OI04 2-130-CLM10 2-005-SBR02 2-290-SBR02 2-007-PAT01 (18) 2-015-NM109 (C1) 2-325-NM109 (C1) 2-015-NM103 2-325-NM103 2-015-NM104 2-325-NM104 2-015-NM105 2-325-NM105 2-015-NM107 2-325-NM107 2-032-DMG03 2-305-DMG03 2-032-DMG02 2-305-DMG02
DA1-03.0 PAT CONTROL NO DA1-04.0 PAYOR ADDR1 DA1-05.0 PAYOR ADDR2 DA1-06.0 PAYOR CITY DA1-07.0 PAYOR STATE DA1-08.0 PAYOR ZIP DA1-09.0 DISALLOWED COST CONT DA1-10.0 DISALLOWED OTHER DA1-11.0 ALLOWED AMOUNT DA1-12.0 DEDUCTIBLE AMOUNT DA1-13.0 COINSURANCE AMOUNT DA1-14.0 PAYOR AMOUNT PAID DA1-15.0 ZERO PAY IND DA1-16.0 ADJUDICATION IND 1 DA1-17.0 ADJUDICATION IND 2 DA1-18.0 ADJUDICATION IND 3 DA1-19.0 CHAMPUS SPNSR BRANCH DA0-25.0 INSURED EMPL STATUS DA0-26.0 SUPPLEMENTAL INS IND DA0-27.0 INSURANCE LOCATION ID DA0-28.0 MEDICAID ID NUMBER DA0-29.0 SUPPLMTL PATIENT ID (COB) DA0-30.0 ASSIGN FOR 4081 CLM (COB) DA0-31.0 COB ROUTING INDICATOR (COB) DA0-32.0 FILLER-NATIONAL DA1-01.0 RECORD ID DA1 DA1-02.0 SEQUENCE NO

Not Mapped Not Mapped Not Mapped Not Mapped

Not Mapped

DA0-08.0 PAYOR CLAIM OFFICE NO DA0-09.0 PAYOR NAME DA0-10.0 GROUP NO DA0-11.0 GROUP NAME DA0-12.0 PPO/HMO IND DA0-13.0 PPO ID DA0-14.0 PRIOR AUTH NO DA0-15.0 ASSIGN OF BENEFITS DA0-16.0 PAT SIGNATURE SOURCE DA0-17.0 PAT REL TO INSURED

2-470-REF02 (F5)

Not Mapped Not Mapped DA1" 2-005-SBR01 2-290-SBR01 2-130-CLM01 2-025-N301 2-025-N302 2-030-N401 2-030-N402 2-030-N403 2-295-CAS03 2-295-CAS03 2-295-CAS03 2-295-CAS03 2-295-CAS03 2-295-CAS03 Not Mapped 2-295-CAS02 2-295-CAS05 2-295-CAS08 Not Mapped

DA0-18.0 INSURED ID NO DA0-19.0 INSURED LAST NAME DA0-20.0 INSURED FIRST NAME DA0-21.0 INSURED MI DA0-22.0 INSURED GENERATION DA0-23.0 INSURED SEX DA0-24.0 INSURED DATE OF BIRTH

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DA1-20.0 CHAMPUS SPNSR GRADE DA1-21.0 CHAMPUS SPNSR STATUS DA1-22.0 INS CARD EFFECT DATE DA1-23.0 INS CARD TERM DATE DA1-24.0 BALANCE DUE DA1-25.0 EOMB DATE 1 (COB) DA1-26.0 EOMB DATE 2 (COB) DA1-27.0 EOMB DATE 3 (COB) DA1-28.0 EOMB DATE 4 (COB) DA1-29.0 CLAIM RECEIPT DATE (COB) DA1-30.0 BENE PAID AMT (COB)

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped
DA2-08.0 INSURED ZIP DA2-09.0 INSURED PHONE DA2-10.0 INSURED RETIRE DATE DA2-11.0 INSURED SPOUSE RETIRE DA2-12.0 INSURED EMPLR NAME DA2-13.0 INSURED EMPLR ADDR1 DA2-14.0 INSURED EMPLR ADDR2 DA2-15.0 INSURED EMPLR CITY DA2-16.0 INSURED EMPLR STATE DA2-17.0 INSURED EMPLR ZIP DA2-18.0 EMPLOYEE ID NO DA2-19.0 FILLER-NATIONAL DA3-01.0 RECORD ID DA3 DA2-06.0 INSURED CITY DA2-07.0 INSURED STATE DA2-03.0 PAT CONTROL NO DA2-04.0 INSURED ADDR1 DA2-05.0 INSURED ADDR2

2-130-CLM01 2-025-N301 (IL) 2-332-N301 (IL) 2-025-N302 2-332-N302 2-030-N401 2-340-N401 2-030-N402 2-340-N402 2-030-N403 2-340-N403 Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped
DA3

Not Mapped 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18

DA1-31.0 BENE CHECK/EFT TRACE NO (COB) DA1-32.0 BENE CHECK/EFT DATE (COB) DA1-33.0 PROV PAID AMT (COB)

Not Mapped

Not Mapped 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18

DA1-34.0 PROV CHECK/EFT TRACE NO (COB) DA1-35.0 PROV CHECK DATE (COB) DA1-36.0 INTEREST PAID (COB)

Not Mapped Not Mapped Not Mapped

DA3-02.0 SEQUENCE NO

2-005-SBR01 2-290-SBR01

DA3-03.0 PAT CONTROL NO DA3-04.0 CLAIM REASON 1

2-130-CLM01

DA1-37.0 APPROVED AMOUNT (COB) 2-300-AMT02 (AAE) DA1-38.0 CONTRACTUAL AGREEMENT IND DA1-39.0 FILLER-NATIONAL DA2-01.0 RECORD ID DA2 DA2-02.0 SEQUENCE NO

Not Mapped Not Mapped DA2" 2-005-SBR01 2-290-SBR01

2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17

MAY 2000

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DA3-05.0 DOLLAR AMOUNT 1

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18
DA3-14.0 CLAIM REASON CODE 6

2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-295-CAS02 2-295-CAS05 2-295-CAS08 2-295-CAS11 2-295-CAS14 2-295-CAS17 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-320-MOA03 2-320-MOA04 2-320-MOA05 2-320-MOA06 2-320-MOA07 2-320-MOA03 2-320-MOA04 2-320-MOA05 2-320-MOA06 2-320-MOA07 2-320-MOA03 2-320-MOA04 2-320-MOA05 2-320-MOA06 2-320-MOA07 2-320-MOA03 2-320-MOA04 2-320-MOA05 2-320-MOA06 2-320-MOA07 2-320-MOA03 2-320-MOA04 2-320-MOA05 2-320-MOA06 2-320-MOA07 Translator 2-355-REF02 (T4)

DA3-06.0 CLAIM REASON CODE 2

DA3-15.0 DOLLAR AMOUNT 6

DA3-07.0 DOLLAR AMOUNT 2

DA3-16.0 CLAIM REASON CODE 7

DA3-08.0 CLAIM REASON CODE 3

DA3-17.0 DOLLAR AMOUNT 7

DA3-09.0 DOLLAR AMOUNT 3

DA3-18.0 CLAIM MESSAGE CODE 1

DA3-10.0 CLAIM REASON CODE 4

DA3-19.0 CLAIM MESSAGE CODE 2

DA3-20.0 CLAIM MESSAGE CODE 3

DA3-11.0 DOLLAR AMOUNT 4

DA3-21.0 CLAIM MESSAGE CODE 4

DA3-12.0 CLAIM REASON CODE 5

DA3-22.0 CLAIM MESSAGE CODE 5

DA3-13.0 DOLLAR AMOUNT 5

DA3-23.0 CLAIM DETAIL LINE COUNT DA3-24.0 CLAIM ADJUST IND

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DA3-25.0 PROV ADJUST AMT

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 2-295-CAS03 2-295-CAS06 2-295-CAS09 2-295-CAS12 2-295-CAS15 2-295-CAS18 Not Mapped Not Mapped
EA0-16.0 SAME/SIMILAR SYMP DATE EA0-17.0 DISABILITY TYPE EA0-18.0 DISABILITY-FROM DATE EA0-19.0 DISABILITY-TO DATE EA0-20.0 REFER PROV NPI EA0-21.0 REFER PROV UPIN (COB) EA0-22.0 REFER PROV TAX TYPE (COB) EA0-23.0 REFER PROV TAX ID (COB) EA0-24.0 REFER PROV LAST NAME EA0-25.0 REFER PROV FIRST NAME EA0-26.0 REFER PROV MI EA0-27.0 REFER PROV STATE EA0-28.0 ADMISSION DATE-1 EA0-29.0 DISCHARGE DATE-1 EA0-30.0 LAB IND EA0-31.0 LAB CHARGES EA0-32.0 DIAGNOSIS CODE-1 EA0-33.0 DIAGNOSIS CODE-2 EA0-34.0 DIAGNOSIS CODE-3 EA0-35.0 DIAGNOSIS CODE-4 EA0-36.0 PROV ASSIGN IND EA0-37.0 PROV SIGNATURE IND EA0-38.0 PROV SIGNATURE DATE EA0-39.0 FACILITY/LAB NAME EA0-40.0 DOCUMENTATION IND EA0-41.0 TYPE OF DOCUMENTATION EA0-42.0 FUNCTNL STATUS CODE

2-135-DTP03 (438) Not Mapped 2-135-DTP03 (360) 2-135-DTP03 (361) 2-250-NM109 (UP) 2-271-REF02 Not Mapped

DA3-26.0 BENE ADJUST AMT

DA3-27.0 ORIG APPROVE AMT DA3-28.0 ORIG PAID AMT DA3-29.0 ORIG PAYOR CLM CONTROL NO DA3-30.0 FILLER-NATIONAL EA0-01.0 RECORD ID EA0 EA0-02.0 RESERVED (EA0-02.0) EA0-03.0 PAT CONTROL NO EA0-04.0 EMPL RELATED IND EA0-05.0 ACCIDENT IND EA0-06.0 SYMPTOM IND

Not Mapped Not Mapped 2-250-NM103 (DN) 2-250-NM104 2-250-NM105 Not Mapped 2-135-DTP03 (435) 2-135-DTP03 (096) Translator 2-175-AMT02 (NE) 2-231-HI01-2 (BK) 2-231-HI02-2 (BF) 2-231-HI03-2 (BF) 2-231-HI04-2 (BF) 2-130-CLM07 2-130-CLM06 Not Mapped 2-250-NM103 (FA,TL,77,LI) 2-155-PWK02 2-420-PWK02 2-155-PWK01 Not Mapped

2-355-REF02(F8) Not Mapped EA0" Not Mapped 2-130-CLM01 2-130-CLM11-1 2-130-CLM11-1 2-135-DTP01 (431) OR 2-135-DTP01 (439) OR 2-135-DTP01 (484)

EA0-07.0 ACCIDENT/SYMPTOM DATE EA0-08.0 EXT CAUSE OF ACCIDENT EA0-09.0 RESPONSIBILITY IND EA0-10.0 ACCIDENT STATE EA0-11.0 ACCIDENT HOUR EA0-12.0 ABUSE IND EA0-13.0 RELEASE OF INFO IND EA0-14.0 RELEASE OF INFO DATE EA0-15.0 SAME/SIMILAR SYMP IND

2-135-DTP03 (439) Not Mapped 2-130-CLM11-1 (AP) 2-130-CLM11-4 2-135-DTP03 (439) 2-135-DTP02 (TR) Not Mapped 2-130-CLM09 Not Mapped Translator

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

EA0-43.0 SPECIAL PROGRAM IND EA0-44.0 CHAMPUS NONAVAIL IND EA0-45.0 SUPV PROV IND EA0-46.0 RESUBMISSION CODE EA0-47.0 RESUB REFERENCE NO EA0-48.0 DATE LAST SEEN EA0-49.0 DATE DOCUMENT SENT EA0-50.0 HOMEBOUND INDICATOR EA0-51.0 BLOOD UNITS PAID (COB) EA0-52.0 BLOOD UNITS REMAINING (COB) EA0-53.O CARE PLAN OVERSIGHT (CPO) ID

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 2-130-CLM12 2-180-REF02 Not Mapped Not Mapped Not Mapped 2-180-REF02 (F8) 2-135-DTP03 (304) 2-455-DTP03 (304) Not Mapped 2-220-CRC01 (75) 2-220-CRC03 (IH) Not Mapped
EA1-17.0 RESERVED (EA1-17.0) EA1-18.0 SUPV PROV LAST EA1-19.0 SUPV PROV FIRST EA1-20.0 SUPV PROV MI EA1-21.0 SUPV PROV STATE EA1-22.0 EMT/PARAMEDIC LAST NAME EA1-23.0 EMT/PARAMEDIC FIRST NAME EA1-24.0 EMT/PARAMEDIC MI EA1-25.0 DATE CARE ASSUMED EA1-12.0 RETURN TO WORK DATE EA1-13.0 CONSULT/SURGERY DATE EA1-14.0 ADMISSION DATE-2 EA1-15.0 DISCHARGE DATE-2 EA1-16.0 SUPV PROV NPI

2-135-DTP03 (296) Not Mapped Not Mapped Not Mapped 2-250-NM109 (MP) 2-271-REF02 Not Mapped 2-250-NM103 (DQ) 2-250-NM104 2-250-NM105 Not Mapped

Not Mapped

Not Mapped

2-250-NM109 2-250-NM101 (FA) 2-250-NM108 (MP) 2-271-REF02

Not Mapped Not Mapped 2-135-DTP03 (090) Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped EA2" Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped FA0" 2-365-LX01

EA0-54.0 INVESTIGAT DEVICE EXEMPTION ID EA0-55.0 FILLER-NATIONAL EA1-01.0 RECORD ID EA1 EA1-02.0 RESERVED (EA1-02.0) EA1-03.0 PAT CONTROL NO EA1-04.0 FACILITY/LAB NPI EA1-05.0 RESERVED (EA1-05.0) EA1-06.0 FACILITY/LAB ADDR1 EA1-07.0 FACILITY/LAB ADDR2 EA1-08.0 FACILITY/LAB CITY EA1-09.0 FACILITY/LAB STATE EA1-10.0 FACILITY/LAB ZIP CODE EA1-11.0 MEDICAL RECORD NO

2-180-REF01 (LX) 2-180-REF02 Not Mapped EA1" Not Mapped 2-130-CLM01 2-250-NM103 (FA,TL,77,LI) 2-271-REF02 Not Mapped 2-265-N301 2-265-N302 2-270-N401 2-270-N402 2-270-N403 Not Mapped

EA1-26.0 DIAGNOSIS CODE -5 EA1-27.0 DIAGNOSIS CODE -6 EA1-28.0 DIAGNOSIS CODE -7 EA1-29.0 DIAGNOSIS CODE -8 EA1-30.0 FILLER-NATIONAL EA2-01.0 RECORD ID EA2 EA2-02.0 RESERVED (EA2-02.0) EA2-03.0 PAT CONTROL NO EA2-04.0 FILLER-EPSDT EA2-94.0 FILLER-NATIONAL EA2-95.0 FILLER-LOCAL FA0-01.0 RECORD ID FA0 FA0-02.0 SEQUENCE NO

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FA0-03.0 PAT CONTROL NO FA0-04.0 LINE ITEM CONTROL NO FA0-05.0 SVC FROM DATE FA0-06.0 SVC TO DATE FA0-07.0 PLACE OF SVC FA0-08.0 TYPE OF SVC CODE FA0-09.0 HCPCS PROCEDURE CODE FA0-10.0 HCPCS MODIFIER 1 FA0-11.0 HCPCS MODIFIER 2 FA0-12.0 HCPCS MODIFIER 3 FA0-13.0 LINE CHARGES FA0-14.0 DIAG CODE POINTER1 FA0-15.0 DIAG CODE POINTER2 FA0-16.0 DIAG CODE POINTER3 FA0-17.0 DIAG CODE POINTER4 FA0-18.0 UNITS OF SVC FA0-19.0 ANESTHESIA/OXYGEN MINUTES FA0-20.0 EMERGENCY IND FA0-21.0 COB IND FA0-22.0 HPSA IND FA0-23.0 RENDERING PROV NPI

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL 2-130-CLM01 2-470-REF02 (6R) 2-455-DTP03 (472) 2-455-DTP03 (472) 2-130-CLM05-1 2-370-SV105 2-370-SV106
FA0-35.0 PRIMARY PAID AMOUNT FA0-29.0 REVIEW BY CODE IND FA0-30.0 MULTI PROCEDURE IND FA0-31.0 MAMMOGRAPHY CERT NO FA0-32.0 CLASS FINDINGS FA0-33.0 PODIATRY SVC COND FA0-34.0 CLIA ID NO

Not Mapped Not Mapped 2-470-REF02 (EW) Not Mapped Not Mapped 2-470-REF02 (X4) 2-180-REF02(X4) 2-545-CAS03 2-370-SV101-6 2-255-PRV03 Not Mapped Not Mapped

2-370-SV101-2 (HC) 2-370-SV101-3 2-370-SV101-4 2-370-SV101-5 2-370-SV102 2-370-SV107-1 2-370-SV107-2 2-370-SV107-3 2-370-SV107-4 2-370-SV104 (UN)

FA0-36.0 HCPCS MODIFIER 4 FA0-37.0 PROVIDER SPECIALTY FA0-38.0 PODIATRY THERAPY IND FA0-39.0 PODIATRY THERAPY TYPE FA0-40.0 HOSPICE EMPLOYED PROV IND FA0-41.0 HGB/HCT DATE FA0-42.0 HGB RESULT FA0-43.0 HCT RESULT FA0-44.0 PATIENT WEIGHT FA0-45.0 EPO DOSAGE

2-450-CRC02 (70) 2-455-DTP03 (738) 2-462-MEA03 (TR,R1) 2-462-MEA03 (TR,R2) 2-090-PAT08 (01) 2-462-MEA03 (OG,R3) 2-455-DTP03 (739) 2-462-MEA03 (TR,R4) 2-545-CAS03 Not Mapped

2370-SV104 (MJ) 2-370-SV109 Not Mapped Not Mapped 2-250-NM109 (MP) OR 2-500-NM109 (MP) 2-250-NM109 (UP) 2-500-NM109 (UP) Not Mapped Translator 2-545-CAS03 2-545-CAS03

FA0-46.0 SERUM CREATINE DATE FA0-47.0 CREATINE RESULT FA0-48.0 OBLIGATED ACCEPT AMT FA0-49.0 DRUG DISCOUNT AMOUNT FA0-50.0 TYPE OF UNITS INDICATOR (COB)

FA0-24.0 REFERRING PROV NPI FA0-25.0 REFERRING PROV STATE FA0-26.0 PUR SVC IND FA0-27.0 DISALLOW COST CONTAIN FA0-28.0 DISALLOWED OTHER

2-370-SV103 2-195-CR106 2-425-CR106

FA0-51.0 APPROVED AMOUNT (COB) FA0-52.0 PAID AMOUNT (COB)

2-475-AMT02 (AAE) 2-540-SVD02

MAY 2000

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

FA0-53.0 BENE LIABILITY AMOUNT (COB)

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

FB0-07.0 DEDUCTIBLE AMOUNT

2-545-CAS03 2-545-CAS03 2-500-NM109 (UP) Not Mapped 2-490-PS101 (QB) 2-500-NM109 (QB) 2-271-REF02 2-250-NM109 Not Mapped Not Mapped Not Mapped 2-370-SV101-2 2-370-SV104 Not Mapped Not Mapped Not Mapped Not Mapped 2-370-SV115 2-370-SV111 2-370-SV112 Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18

FB0-08.0 COINSURANCE AMOUNT FB0-09.0 ORDERING PROV ID FB0-10.0 ORDERING PROV STATE FB0-11.0 PUR SVC PROV ID

FA0-54.0 BALANCE BILL LIMITING CHG (COB)

2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18

FB0-12.0 PUR SVC STATE FB0-13.0 PEN GRAMS OF PROTEIN FB0-14.0 PEN CALORIES FB0-15.0 NATIONAL DRUG CODE

FA0-55.0 LIMITING CHARGE PERCENT (COB) FA0-56.0 PERF PROV PHONE (COB) FA0-57.0 PERF PROV TAX TYPE (COB) FA0-58.0 PERF PROV TAX ID (COB) FA0-59.0 PERF PROV ASSIGN IND (COB) FA0-60.0 PRE-TRANSPLANT IND FA0-61.0 ICD-10-PCS FA0-62.0 UNIVERSAL PRODUCT CODE NUMBER FA0-63.0 DIAG CODE POINTER 5 FA0-64.0 DIAG CODE POINTER 6 FA0-65.0 DIAG CODE POINTER 7 FA0-66.0 DIAG CODE POINTER 8 FB0-01.0 RECORD ID FB0 FB0-02.0 SEQUENCE NO FB0-03.0 PAT CONTROL NO FB0-04.0 LINE ITEM CONTROL NO FB0-05.0 PUR SVC CHARGE FB0-06.0 ALLOWED AMOUNT

Not Mapped Not Mapped

2-500-NM108 (24,34) 2-525-REF01 (SY,EI)

FB0-16.0 NATIONAL DRUG UNITS FB0-17.0 PRESCRIPTION NO FB0-18.0 PRESCRIPTION DATE FB0-19.0 PRESCRIPT NO OF MOS FB0-20.0 SPEC PRICING IND FB0-21.0 COPAY STATUS IND FB0-22.0 EPSDT IND

2-500-NM108 (24,34) 2-525-REF02 (SY,EI)

2-130-CLM07 Not Mapped Not Mapped

2-470-REF02 (OZ) 2-470-REF02 (VP) Not Mapped Not Mapped Not Mapped Not Mapped FB0" 2-365-LX01 2-130-CLM01 2-470-REF02 (6R) 2-490-PS102 2-545-CAS03

FB0-23.0 FAMILY PLANNING IND FB0-24.0 DME CHARGE IND FB0-25.0 HPSA FACILITY ID FB0-26.0 HPSA FACILITY ZIP FB0-27.0 PUR SVC NAME FB0-28.0 PUR SVC ADDR1 FB0-29.0 PUR SVC ADDR2 FB0-30.0 PUR SVC CITY FB0-31.0 PUR SVC ZIP FB0-32.0 PUR SVC PHONE FB0-33.0 DRUG DAYS SUPPLY

F.26

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

FB0-34.0 PAYMENT TYPE IND (COB) FB0-35.0 FILLER-NATIONAL FB1-01.0 RECORD ID FB1 FB1-02.0 SEQUENCE NO FB1-03.0 PAT CONTROL NO FB1-04.0 LINE ITEM CONTROL NO FB1-05.0 PLACE OF SVC NAME FB1-06.0 ORDERING PROV LAST FB1-07.0 ORDERING PROV FIRST FB1-08.0 ORDERING PROV MI FB1-09.0 ORDERING PROV UPIN FB1-10.0 REFERRING PROV LAST FB1-11.0 REFERRING PROV FIRST FB1-12.0 REFERRING PROV MI FB1-13.0 REFERRING PROV UPIN FB1-14.0 RENDERING PROV LAST FB1-15.0 RENDERING PROV FIRST FB1-16.0 RENDERING PROV MI FB1-17.0 RENDERING PROV UPIN FB1-18.0 SUPV PROV LAST FB1-19.0 SUPV PROV FIRST FB1-20.0 SUPV PROV MI FB1-21.0 SUPV PROV ID FB1-22.0 SUPV PROV UPIN FB1-23.0 FILLER-NATIONAL FB2-01.0 RECORD ID FB2 FB2-02.0 SEQUENCE NO

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL Not Mapped Not Mapped FB1" 2-365-LX01 2-130-CLM01 2-470-REF02 (6R) Not Mapped 2-500-NM103 (DK) 2-500-NM104 2-500-NM105 2-500-NM109 (UP) 2-500-NM103 (DN) 2-500-NM104 2-500-NM105 2-500-NM109 (UP) 2-250-NM103 (82) 2-500-NM103 (82) 2-250-NM104 2-500-NM104 2-250-NM105 2-500-NM105 Not Mapped 2-500-NM103 (DQ) 2-500-NM104 2-500-NM105 2-500-NM109 (MP) Not Mapped Not Mapped FB2" 2-365-LX01
FB2-03.0 PAT CONTROL NO FB2-04.0 LINE ITEM CONTROL NO FB2-05.0 PROV TYPE IND A FB2-06.0 PROV A TYPE ADDR 1 FB2-07.0 PROV A TYPE ADDR 2 FB2-08.0 PROV A TYPE CITY FB2-09.0 PROV A TYPE STATE FB2-10.0 PROV A ZIP FB2-11.0 PROV TYPE IND B FB2-12.0 PROV B TYPE ADDR 1 FB2-13.0 PROV B TYPE ADDR 2 FB2-14.0 PROV B TYPE CITY FB2-15.0 PROV B TYPE STATE FB2-16.0 PROV B ZIP FB2-17.0 PROV TYPE IND C FB2-18.0 PROV C TYPE ADDR 1 FB2-19.0 PROV C TYPE ADDR 2 FB2-20.0 PROV C TYPE CITY FB2-21.0 PROV C TYPE STATE FB2-22.0 PROV C ZIP FB2-23.0 FILLER-NATIONAL FB3-01.0 RECORD ID FB3 FB3-02.0 SEQUENCE NO FB3-03.0 PAT CONTROL NO FB3-04.0 LINE ITEM CONTROL NO FB3-05.0 REASON CODE 1

2-130-CLM01 2-470-REF02 (6R) Not Mapped 2-514-N301 (DK,DQ) 2-514-N302 2-520-N401 2-520-N402 2-520-N403 Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped FB3" 2-365-LX01 2-130-CLM01 2-470-REF02(6R) 2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17

MAY 2000

F.27

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

FB3-06.0 DOLLAR AMOUNT 1

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18 2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18 2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18 2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18 2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18
FB3-15.0 REASON CODE 6

2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18 2-545-CAS02 2-545-CAS05 2-545-CAS08 2-545-CAS11 2-545-CAS14 2-545-CAS17 2-545-CAS03 2-545-CAS06 2-545-CAS09 2-545-CAS12 2-545-CAS15 2-545-CAS18 Not Mapped FD0" Not Mapped Not Mapped Not Mapped Not Mapped FE0" Not Mapped Not Mapped Not Mapped

FB3-07.0 REASON CODE 2

FB3-16.0 DOLLAR AMOUNT 6

FB3-08.0 DOLLAR AMOUNT 2

FB3-17.0 REASON CODE 7

FB3-09.0 REASON CODE 3

FB3-18.0 DOLLAR AMOUNT 7

FB3-10.0 DOLLAR AMOUNT 3

FB3-19.0 FILLER-NATIONAL FD0-01.0 RECORD ID FD0 FD0-02.0 SEQUENCE NO FD0-03.0 PAT CONTROL NO FD0-04.0 FILLER-DENTAL FD0-64.0 FILLER-NATIONAL FE0-01.0 RECORD ID FE0 FE0-02.0 SEQUENCE NO FE0-03.0 PAT CONTROL NO FE0-04.0 FILLER-TPO FE0-06.0 TPO REFERENCE NUMBER FE0-16.0 FILLER-NATIONAL GA0-01.0 RECORD ID GA0 GA0-02.0 SEQUENCE NO GA0-03.0 PAT CONTROL NO GA0-04.0 RESERVED (GA0-04.0)

FB3-11.0 REASON CODE 4

FB3-12.0 DOLLAR AMOUNT 4

FB3-13.0 REASON CODE 5

2-180-REF02 (9A) Not Mapped GA0" 2-365-LX01 2-130-CLM01 Not Mapped MAY 2000

FB3-14.0 DOLLAR AMOUNT 5

F.28

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GA0-05.0 PATIENTS WEIGHT GA0-06.0 HOSPITAL ADMIT GA0-07.0 TYPE OF TRANSPORT GA0-08.0 BED CONFINED-BEFORE GA0-09.0 BED CONFINED-AFTER GA0-10.0 MOVED BY STRETCHER GA0-11.0 UNCONSCIOUS/SHOCK GA0-12.0 EMERGENCY SITUATION GA0-13.0 PHYSICAL RESTRAINTS GA0-14.0 VISIBLE HEMORRHAGING GA0-15.0 TRANSPORTED TO/FOR GA0-16.0 MEDICALLY NECESSARY GA0-17.0 MILES GA0-18.0 ORIGIN INFO GA0-19.0 DESTINATION INFO GA0-20.0 PURPOSE OF ROUND TRIP GA0-21.0 PURPOSE OF STRETCHER GA0-22.0 PATIENT DISCHARGED GA0-23.0 PATIENT ADMITTED GA0-24.0 SERVICES AVAILABLE GA0-25.0 FILLER-NATIONAL GC0-01.0 RECORD ID GC0

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL 2-195-CR102 (LB) 2-425-CR102 (LB) 2-220-CRC03 (01) 2-450-CRC03 (01) 2-195-CR103 2-425-CR103 2-220-CRC03 (02) 2-450-CRC03 (02) 2-220-CRC03 (03) 2-450-CRC03 (03) 2-220-CRC03 (04) 2-450-CRC03 (04) 2-220-CRC03 (05) 2-450-CRC03 (05) 2-220-CRC03 (06) 2-450-CRC03 (06) 2-220-CRC03 (07) 2-450-CRC03 (07) 2-220-CRC03 (08) 2-450-CRC03 (08) 2-195-CR104 2-425-CR104 2-220-CRC03 (09) 2-450-CRC03 (09) 2-195-CR106 (DH) 2-425-CR106 (DH) Not Mapped Not Mapped 2-195-CR109 2-425-CR109 2-195-CR110 2-425-CR110 2-135-DTP03 (096) 2-135-DTP03 (435) 2-220-CRC03 (60) 2-450-CRC03 (60) Not Mapped GC0"
GC0-02.0 SEQUENCE NO GC0-03.0 PAT CONTROL NO GC0-04.0 RESERVED (GC0-04.0) GC0-05.0 INITIAL TREATMENT DATE GC0-06.0 DATE OF LAST X-RAY GC0-07.0 NO IN SERIES

2-365-LX01 2-130-CLM01 Not Mapped 2-135-DTP03 (454) 2-455-DTP03 (454) 2-135-DTP03 (455) 2-455-DTP03 (455) 2-200-CR201 2-430-CR201 2-200-CR202 2-430-CR202 2-200-CR203 2-430-CR203 2-200-CR204 2-430-CR204

GC0-08.0 LEVEL OF SUBLUXATION GC0-08.0 LEVEL OF SUBLUXATION GC0-09.0 TREATMENT MONTHS/YEARS GC0-10.0 NO TREATMENTS - MONTH GC0-11.0 NATURE OF CONDITION GC0-12.0 DATE OF MANIFESTATION GC0-13.0 COMPLICATION IND GC0-14.0 SYMPTOMS DESCRIPTION GC0-14.0 SYMPTOMS DESCRIPTION GC0-15.0 X-RAY IND GC0-16.0 FILLER-NATIONAL GD0-01.0 RECORD ID GD0 GD0-02.0 SEQUENCE NO GD0-03.0 PAT CONTROL NO GD0-04.0 CERTIFICATION TYPE GD0-05.0 MEDICAL NECESSITY

2-200-CR206 (MO) 2-430-CR206 (MO) 2-200-CR207 2-430-CR207 2-200-CR208 2-430-CR208 2-135-DTP03 (453) 2-455-DTP03 (453) 2-200-CR209 2-430-CR209 2-200-CR210 2-430-CR210 2-200-CR211 2-430-CR211 2-200-CR212 2-430-CR212 Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

MAY 2000

F.29

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

GD0-06.0 PROGNOSIS GD0-07.0 HCPCS PROCEDURE CODE GD0-08.0 AMBULATORY GD0-09.0 AMBULATION/THERAPY GD0-10.0 CONFINED BED/CHAIR GD0-11.0 ROOM CONFINED GD0-12.0 AMBULATION/MOBILITY GD0-13.0 BODY POSITIONING GD0-14.0 RESPIRATORY/OTHER GD0-15.0 BREATHING IMPAIRED GD0-16.0 FREQ/IMMED CHANGES GD0-17.0 OPERATE CONTROLS GD0-18.0 SIDERAILS PART/BED GD0-19.0 OWNS EQUIPMENT GD0-20.0 MATTRESS/SIDERAILS GD0-21.0 EQUIPMENT/ASSISTANCE GD0-22.0 ORTHOPEDIC IMPAIR GD0-23.0 PLANNED REGIMEN GD0-24.0 DECUBITUS ULCERS GD0-25.0 EQUIPMENT USE GD0-26.0 INSULIN DEPENDENT GD0-27.0 DIABETIC CONTROL GD0-28.0 APNEA EPISODES GD0-29.0 SURGERY ALTERNATIVE GD0-30.0 TOTAL KNEE REPLACE GD0-31.0 DATE SURGERY GD0-32.0 DATE CPM GD0-33.0 LYMPHEDEMA

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE Not Mapped

GD0-34.0 ORDERING PROV LAST GD0-35.0 ORDERING PROV FIRST

Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

GD0-36.0 ORDERING PROV MI GD0-37.0 ORDERING PROV ID GD0-38.0 ORDERING PROV PHONE GD0-39.0 DATE CERTIFICATION GD0-40.0 CERTIFICATION ON FILE GD0-41.0 DIAGNOSIS CODE-1 GD0-42.0 DIAGNOSIS CODE-2 GD0-43.0 DIAGNOSIS CODE-3 GD0-44.0 DIAGNOSIS CODE-4 GD0-45.0 NURSING HOME IND GD0-46.0 NH FROM DATE GD0-47.0 NH TO DATE GD0-48.0 RESPIRATORY TRACT GD0-49.0 SUPV OF EQUIPMENT USE GD0-50.0 PROPEL/LIFT CHAIR GD0-51.0 LEG ELEVATION GD0-52.0 PATIENT WEIGHT GD0-53.0 RECLINING WHEELCHAIR GD0-54.0 MANUAL OPERATION GD0-55.0 SIDE TRANSFER CHAIR GD0-56.0 FILLER-NATIONAL GD1-01.0 RECORD ID GD1 GD1-02.0 SEQUENCE NO GD1-03.0 PAT CONTROL NO GD1-04.0 NARRATIVE GD1-05.0 FILLER-NATIONAL

F.30

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GE0-01.0 RECORD ID GE0 GE0-02.0 SEQUENCE NO GE0-03.0 PAT CONTROL NO GE0-04.0 CERTIFICATION TYPE GE0-05.0 ONSET DT OF THERAPY GE0-06.0 THERAPY DURATION GE0-07.0 LAST CERT DATE GE0-08.0 NO OF MONTHS CERT GE0-09.0 DT LAST SEEN BY PHY GE0-10.0 NON VISIT IND GE0-11.0 PAT AGE GE0-12.0 PAT HEIGHT GE0-13.0 PAT WEIGHT GE0-14.0 LEVEL OF CONS IND GE0-15.0 AMBULATORY IND GE0-16.0 OTHER FORMS OF NUTR IND GE0-17.0 METHOD ADMIN IND GE0-18.0 ADMIN TECH IND GE0-19.0 TOTAL CAL PER DAY GE0-20.0 PRODUCT NAME 1 GE0-21.0 CAL PER PRODUCT 1 GE0-22.0 HCPCS PROCEDURE CODE GE0-23.0 HCPCS MODIFIER 1 GE0-24.0 HCPCS MODIFIER 2 GE0-25.0 ENTERAL FREQ FED 1 GE0-26.0 NARRATIVE FIELD GE0-27.0 PRODUCT NAME 2 GE0-28.0 CAL PER PRODUCT 2

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped
GE0-29.0 ENTERAL FREQ FED 2 GE0-30.0 FILLER-NATIONAL GP0-01.0 RECORD ID GP0 GP0-02.0 SEQUENCE NO GP0-03.0 PAT CONTROL NO GP0-04.0 CERTIFICATION TYPE GP0-05.0 ONSET DT OF THERAPY GP0-06.0 THERAPY DURATION GP0-07.0 LAST CERT DATE GP0-08.0 NO OF MONTHS CERT GP0-09.0 DT LAST SEEN BY PHY GP0-10.0 NON VISIT IND GP0-11.0 PAT AGE GP0-12.0 PAT HEIGHT GP0-13.0 PAT WEIGHT GP0-14.0 LEVEL OF CONS IND

Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

GP0-15.0 AMBULATORY IND GP0-16.0 OTHER FORMS OF NUTR IND GP0-17.0 TYPE OF MIX IND GP0-18.0 PARENTERAL FREQ FED GP0-19.0 HCPCS PROCEDURE CODE GP0-20.0 HCPCS MODIFIER 1 GP0-21.0 HCPCS MODIFIER 2 GP0-22.0 AMINO ACID NAME GP0-23.0 AMINO ACID VOLUME GP0-24.0 AMINO ACID CONC GP0-25.0 AMINO ACID WEIGHT GP0-26.0 DEXTROSE VOLUME

Not Mapped Not Mapped Not Mapped

Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

MAY 2000

F.31

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

GP0-27.0 DEXTROSE CONC GP0-28.0 LIPIDS VOLUME GP0-29.0 LIPIDS CONC GP0-30.0 LIPIDS FREQ GP0-31.0 NARRATIVE FIELD GP0-32.0 ADMIN TECH IND GP0-33.0 FILLER-NATIONAL GU0-01.0 RECORD ID GU0 GU0-02.0 SEQUENCE NO GU0-03.0 PAT CONTROL NO GU0-04.0 CERTIFICATION TYPE GU0-05.0PLACE OF SERVICE GU0-06.0 REPLACEMENT ITEM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped GU0" 2-365-LX01 2-130-CLM01 2-435-CR301 2-370-SV105 2-445-CRC01 (09), 2-445-CRC02 (Y or N) 2-445-CRC03 (ZV)
GU0-25.0 CERT FORM NUMBER GU0-26.0 REPLY ALN L01 N01 GU0-27.0 REPLY ALN L01 N02 GU0-28.0 REPLY ALN L01 N03 GU0-29.0 REPLY ALN L01 N04 GU0-30.0 REPLY ALN L01 N05 GU0-31.0 REPLY ALN L01 N06 GU0-32.0 REPLY ALN L01 N07 GU0-33.0 REPLY ALN L01 N08 GU0-34.0 REPLY ALN L01 N09 GU0-35.0 REPLY ALN L01 N10 GU0-36.0 REPLY ALN L01 N11 GU0-37.0 REPLY ALN L01 N12 GU0-38.0 REPLY ALN L01 N13 GU0-39.0 REPLY ALN L01 N14 GU0-40.0 REPLY ALN L01 N15 GU0-41.0 REPLY ALN L01 N16 GU0-23.0 ORDERING PROV PHONE GU0-21.0 LENGTH OF NEED GU0-22.0 DATE CERT SIGNED GU0-18.0 DT LAST MEDICAL EXAM GU0-19.0 INITIAL DATE GU0-20.0 REV RECERT DATE

Not Mapped 2-455-DTP03 2-455-DTP01 (463) 2-455- DTP03 2-455-DTP01 (607) 2-435-CR303 2-435-CR302 (MO) 2-455-DTP03 2-455-DTP01 (461) 2-530-PER04 2-530-PER01 (IC) 2-530-NM101 (DK) 2-455- CRC01 (09) 2-455-CRC02 (Y) 2-455-CRC03 (38) 2-551-LQ02 2-552-FRM02 2-552-FRM02 2-552-FRM02 OR 2-552-FRM03 2-552-FRM02 2-552-FRM02 2-552-FRM02 OR 2-552-FRM03 2-552-FRM02 2-552-FRM02 OR 2-552-FRM03 2-552-FRM02 2-552-FRM02 2-552-FRM02 2-552-FRM02 2-552-FRM02 2-552-FRM02 2-552-FRM02 Not Mapped

GU0-24.0 CERT ON FILE

GU0-07.0 HCPCS PROCEDURE CODE GU0-08.0 HCPCS MODIFIER GU0-09.0 WARRANTY REPLY GU0-10.0 WARRANTY LENGTH GU0-11.0 WARRANTY TYPE GU0-12.0 DIAGNOSIS CODE-1 GU0-13.0 DIAGNOSIS CODE-2 GU0-14.0 DIAGNOSIS CODE-3 GU0-15.0 DIAGNOSIS CODE-4 GU0-16.0 PATIENT HEIGHT

2-370-SV101-2 2-370-SV101-3 Not Mapped Not Mapped Not Mapped 2-231-HI01-2 2-231-HI01-1 (BK) 2-231-HI02-2 2-231-HI02-1 (BF) 2-231-HI03-2 2-231-HI03-1 (BF) 2-231-HI04-2 2-231-HI04-1 (BF) 2-462-MEA03 2-462-MEA01 (OG) 2-462-MEA02 (HT) 2-007- PAT08

GU0-17.0 PATIENT WEIGHT

F.32

MAY 2000

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

GU0-42.0 REPLY ALN L01 N17 GU0-43.0 REPLY ALN L01 N18 GU0-44.0 REPLY ALN L01 N19 GU0-45.0 REPLY ALN L01 N20 GU0-46.0 REPLY ALN L01 N21 GU0-47.0 REPLY ALN L01 N22 GU0-48.0 REPLY ALN L01 N23 GU0-49.0 REPLY ALN L01 N24 GU0-50.0 REPLY ALN L05 N01 GU0-51.0 REPLY ALN L05 N02 GU0-52.0 REPLY ALN L05 N03 GU0-53.0 REPLY ALN L08 N01 GU0-54.0 REPLY ALN L08 N02 GU0-55.0 REPLY ALN L08 N03 GU0-56.0 REPLY ALN L08 N04 GU0-57.0 REPLY ALN L20 N01 GU0-58.0 REPLY ALN L60 N01 GU0-59.0 REPLY NUM L01 N01 GU0-60.0 REPLY NUM L01 N02 GU0-61.0 REPLY NUM L01 N03 GU0-62.0 REPLY NUM L04 N01 GU0-63.0 REPLY NUM L04 N02 GU0-64.0 REPLY NUM L04 N03 GU0-65.0 REPLY NUM L04 N04 GU0-66.0 REPLY NUM L04 N05 GU0-67.0 REPLY NUM L04 N06 GU0-68.0 REPLY NUM L04 N07 GU0-69.0 REPLY PCT L04 N01

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL Not Mapped 2-552-FRM02 2-552-FRM02 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 Not Mapped 2-552-FRM04 2-552-FRM04 2-552-FRM04 2-552-FRM04 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM03 2-552-FRM05
GX0-06.0 LENGTH OF NEED GX0-07.0 TYPE OF EQUIPMENT 1 GX0-08.0 TYPE OF EQUIPMENT 2 GX0-09.0 REASON FOR EQUIPMENT GX0-10.0 OXYGEN PRESCRIBED FROM DATE GX0-11.0 OXYGEN PRESCRIBED TO DATE GX0-12.0 DATE OXYGEN PRESCRIBED GX0-13.0 DATE PATIENT EVALUATED GX0-05.0 TYPE OF OXYGEN SYSTEM Value D GX0-05.0 TYPE OF OXYGEN SYSTEM Value N GU0-70.0 REPLY PCT L04 N02 GU0-71.0 REPLY PCT L04 N03 GU0-72.0 FILLER - NATIONAL GX0-01.0 RECORD ID GX0 GX0-02.0 SEQUENCE NO GX0-03.0 PAT CONTROL NO GX0-04.0 TYPE OF CERTIFICATION GX0-05.0 TYPE OF OXYGEN SYSTEM Value Y

2-552-FRM05 2-552-FRM05 Not Mapped Not Mapped 2-365-LX01 2-130-CLM01 2-215-CR501 2-445-CR501

2-215-CRC02 (N) 2-215-CRC03 (37) 2-215-CRC03 (AL) 2-445-CRC02 (N) 2-445-CRC03 (37) 2-445-CRC03 (AL)

2-215-CRC02 (N) 2-215-CRC03 (37) 2-215-CRC02 (Y) 2-215-CRC03 (AL) 2-445-CRC02 (N) 2-445-CRC03 (37) 2-445-CRC02 (Y) 2-445-CRC03 (AL)

2-215-CRC02 (Y) 2-215-CRC03 (37) 2-445-CRC02 (Y) 2-445-CRC03 (37) 2-215-CR502 2-445-CR502 Not Mapped Not Mapped Not Mapped

2-455-DTP03 (463)

2-455-DTP03 (607)

2-455-DTP03 (461) Not Mapped

MAY 2000

F.33

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

GX0-14.0 OXYGEN FLOW RATE GX0-15.0 FREQUENCY OF USE GX0-16.0 DURATION GX0-17.0 ARTERIAL BLOOD GAS ON 4 LPM

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 2-470-REF02 2-470-REF01 (TP) Not Mapped Not Mapped
GX0-36.0 DELIVERY SYSTEM TYPE GX0-33.0 DIAGNOSIS CODE-3 GX0-34.0 DIAGNOSIS CODE-4 GX0-35.0 CERTIFICATION ON FILE

2-231-HI03-2 (BF) 2-231-HI04-02 (BF) 2-450-CRC02 (Y) 2-450-CRC03 (38) Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped 2-365-LX01 2-130-CLM11 2-514-N301 NM101=TL 2-514-N302 2-520-N401 2-520-N402 2-520-N403 Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped Not Mapped

2-462-MEA03 2-462-MEA01 (TR) 2-462-MEA02 (C0N)

GX0-37.0 FILLER-NATIONAL GX1-01.0 RECORD ID GX1

GX0-18.0 OXYGEN SATURATION ON 4 LPM

2-264-MEA03 2-462-MEA01 (TR) 2-462-MEA02 (ZO)

GX1-02.0 SEQUENCE NO GX1-03.0 PAT CONTROL NO GX1-04.0 TEST RESULTS GX1-05.0 MEDICAL FINDINGS

GX0-19.0 DATE TEST PRESCRIBED ON 4LPM GX0-20.0 INPATIENT/OUTPATIENT INDICATOR GX0-21.0 NATIONAL FILLER GX0-22.0 ARTERIAL BLOOD GAS GX0-23.0 OXYGEN SATURATION GX0-24.0 DATE TEST PERFORMED GX0-25.0 ENTITY PERFORMING O2/ABG TEST GX0-26.0 TEST CONDITIONS GX0-27.0 CLINICAL FINDINGS Value Y,byte260" GX0-27.0 CLINICAL FINDINGS Value Y,byte261" GX0-27.0 CLINICAL FINDINGS Value Y,byte262" GX0-28.0 PORTABLE OXYGEN FLOW RATE GX0-29.0 ORDERING PHYSICIAN ID GX0-30.0 ORDERING PROVIDER PHONE GX0-31.0 DIAGNOSIS CODE-1 GX0-32.0 DIAGNOSIS CODE-2

2-135-DTP03 (119) 2-455-DTP03 (119)

2-215-CRC03 (P1) 2-455-CRC03 (P1) NOT MAPPED 2-445-CR510 2-445-CR511 2-455-DTP03 (481) 2-455-DTP03 (480)

GX1-06.0 EXERCISE ROUTIN GX1-07.0 FILLER-NATIONAL GX1-08.0 FILLER-LOCAL GX2-01.0 RECORD ID GX2 GX2-02.0 SEQUENCE NO GX2-03.0 PAT CONTROL NO GX2-04.0 TEST FACILITY ADDR 1 GX2-05.0 TEST FACILITY ADDR 2 GX2-06.0 TEST FACILITY CITY

2-500-NM103 2-500-NM101 (TL) 2-445-CR512

2-445-CR513 (1)

GX2-07.0 TEST FACILITY STATE GX2-08.0 TEST FACILITY ZIP GX2-09.0 PAT FACILITY NAME

2-445-CR514 (1)

2-445-CR515 (1)

GX2-10.0 PAT FACILITY ADDR 1 GX2-11.0 PAT FACILITY ADDR 2 GX2-12.0 PAT FACILITY CITY GX2-13.0 PAT FACILITY STATE GX2-14.0 PAT FACILITY ZIP GX2-15.0 FILLER-NATIONAL

Not Mapped 2-500-NM109 (DK)

2-530-PER04) 2-231-HI01-2 (BK) 2-231-HI02-2 (BF)

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HA0-01.0 RECORD ID HA0 HA0-02.0 SEQUENCE NO HA0-03.0 PAT CONTROL NO HA0-04.0 LINE ITEM CONTROL NO HA0-05.0 EXTRA NARRATIVE DAA

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL HA0" 2-365-LX01 2-130-CLM01 2-470-REF02 (6R) 2-190-NTE02 2-485-NTE02 2-185-K301 2-480-K301 2-135-DTP03 (091) XA0" Not Mapped 2-130-CLM01 Translator Translator Translator Translator Translator Translator Translator Not Mapped 2-130-CLM02
YA0-07.0 RESERVED (YA0-07.0) YA0-08.0 BATCH SVC LINE COUNT YA0-09.0 BATCH RECORD COUNT YA0-10.0 BATCH CLAIM COUNT YA0-11.0 BATCH TOTAL CHARGES YA0-12.0 FILLER-NATIONAL ZA0-01.0 RECORD ID ZA0 ZA0-02.0 SUB ID XA0-20.0 TOTAL PURCHASE SVC CHARGES XA0-21.0 PROV DISCOUNT INFORMATION XA0-22.0 REMARKS XA0-23.0 FILLER-NATIONAL YA0-01.0 RECORD ID YA0 YA0-02.0 EMC PROV ID YA0-03.0 BATCH TYPE YA0-04.0 BATCH NO YA0-05.0 BATCH ID YA0-06.0 PROV TAX ID

Translator

Not Mapped Not Mapped Not Mapped YA0" 2-015-NM109 (85,87) 2-035-REF02 100" Translator Not Mapped 2-015-NM109 (85,87) 2-035-REF02 (SY,EI) Not Mapped Translator Translator Translator Translator Not Mapped ZA0" 1-020-NM101 (41) 1-020-NM109 Not Mapped 1-020-NM101 (40) 1-020-NM109 Translator Translator Translator Translator Translator

XA0-01.0 RECORD ID XA0 XA0-02.0 RESERVED (XA0-02.0) XA0-03.0 PAT CONTROL NO XA0-04.0 RECORD CXX COUNT XA0-05.0 RECORD DXX COUNT XA0-06.0 RECORD EXX COUNT XA0-07.0 RECORD FXX COUNT XA0-08.0 RECORD GXX COUNT XA0-09.0 RECORD HXX COUNT XA0-10.0 CLAIM RECORD COUNT XA0-11.0 RESERVED (XA0-11.0) XA0-12.0 TOTAL CLAIM CHARGES XA0-13.0 TOTAL DISAL COST CONT CHGS XA0-14.0 TOTAL DISAL OTHER CHARGES XA0-15.0 TOTAL ALLOWED AMOUNT XA0-16.0 TOTAL DEDUCTIBLE AMOUNT XA0-17.0 TOTAL COINSURANCE AMOUNT XA0-18.0 TOTAL PAYOR AMOUNT PAID XA0-19.0 PAT AMOUNT PAID

Translator
ZA0-03.0 RESERVED (ZA0-03.0)

Translator Translator

ZA0-04.0 RECEIVER ID ZA0-05.0 FILE SVC LINE COUNT

Translator

ZA0-06.0 FILE RECORD COUNT ZA0-07.0 FILE CLAIM COUNT ZA0-08.0 BATCH COUNT ZA0-09.0 FILE TOTAL CHARGES

Translator

Translator 2-175-AMT02 (F5)

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ZA0-10.0 FILE TOTAL PAID AMT (COB)

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE

ZA0-11.0 FILE TOTAL APPROV AMT (COB) ZA0-12.0 FILLER-NATIONAL

Not Mapped

Not Mapped Not Mapped

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

G Credit/Debit Card Use

G.1 Credit/Debit Card Scenario 837 Transaction Set
A business scenario using credit/debit cards as an alternate payment vehicle for the patient portion of post-adjudicated claims is defined in this appendix. This scenario does not apply to all health care business environments using the 837. Implementers of this option must ensure that no current federal or state privacy regulations are violated. The use of this payment option is currently prohibited in conjunction with federal health plans such as Medicaid, Champus, VA, etc. This capability, which can be used to improve the providers accounts receivable situation, is applicable only when trading partners agree to the opportunities and constraints defined in the following business scenario. The scenario has been included as an appendix to this 837 implementation guide after several years of work, as well as presentations and review with the appropriate ANSI X12N committees, including the 837 work group, the 835 work group, and work group 11 (business modeling). The Business Need: Patient to Provider Payment Options Providers today can offer patients a variety of service payment options when the patients portion of the cost is known either before or at the time of service. Examples of payment options include cash, check, and billing (i.e., being billed). Another option, which is the topic of this appendix, is to use a patients credit or debit card when the amount of the co-payment or service charge is known. Providers typically have a credit card terminal that is connected through a dial-up phone line to their credit card processing network. The business need of increasing cash flow and providing payment options to a patient reflects a new use of a patients credit/debit card as an option for payment of the patient/subscriber portion of a claim when that amount is not known at the time of service. This new payment option is being requested to: improve patient payment flexibility potentially reduce provider billing costs provide faster access to monies due from patients, and improve accounts receivable management Before using this flexible payment option, the provider, value-added network, and/or an intermediary have to form a partnership where credit/debit card transactions are accepted as part of the reimbursement process. These agreements must comply with all current federal and state privacy regulations. The patient/subscriber also must choose to use his or her credit/debit card for a future yet-to-be-determined amount. The patient/subscriber would provide his or her consent up to a maximum amount allowing the provider/ value-added network to bill the credit card after the claim has been adjudicated. This patient consent form also authorizes the transmission of credit/debit card information over a health care EDI network. The consent form must identify how the transaction will be used, and who will receive the information . It authorizes the service providers to use the account number in this transaction as described. The concept of preMAY 2000

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authorized payment is currently in use in other industries, and customer acceptance of this type of payment vehicle has increased. To implement this payment alternative, the patients/subscribers credit or debit card information would be carried in the 837, along with selected provider information. This information involves approximately 200 characters of data for each instance of credit or debit card use. The providers claims submission system would be enhanced to incorporate the required credit/debit card information into the 837 transaction. The 837 would then be transmitted to the Automated Clearing House/ processor/payer for claim adjudication. After the claim is adjudicated and coordination of benefits issues are resolved, the payer pays his or her portion of the claim and returns its explanation in an 835. At this point, the value-added network could determine the amount to be applied to the patients credit or debit card, and initiate a credit or debit card transaction to complete the claim payment. The amount charged to the patients credit or debit card would then be reported to the provider in a separate transaction. Figure G1, Scenario: Patient Uses a Credit/Debit Card, depicts an example of how credit/debit card information could be transmitted using the standard 837 methodology. Business Process Flow for Credit/Debit Card Payment Alternative for Post-adjudicated Claims A. B. The provider/Automated Clearing House agrees to accept credit or debit cards. The subscriber signs a consent form to pre-authorize charges up to a maximum amount and authorizes the use of their account number in this network. The patient incurs the charges. The provider submits an 837, including some claims containing credit or debit card information. The Automated Clearing House notes the credit or debit card option and information, and passes the claim to the payer. The payer adjudicates the claim and determines the coordination of benefits (COB). If no COB is involved, the payer returns the adjudicated claim to the Automated Clearing House or provider with the 835. The Automated Clearing House creates the credit or debit card transaction(s), as appropriate, to close out the claim payment.

C. D. E. F.

G.

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A Provider Value-Added Network or Clearinghouse 837 or Payer

B C

Create 837, Including Credit Card Information D

Use Credit Card Information to Create Matching File; Forward 837 to Payor E 835

Adjudicate Claim F 835 Credit Card Processor or Acquiring Bank

Payment Co-Payment & Adjudication Information Received

Check Credit Card File Create Credit Card Transactions

Authorization Message

835 Credit Card Payment Advice, or Rejection Code Providers Bank Funds Moved Update sent to Issuing Bank

Issuers Bank

Figure G1. Scenario: Patient Uses a Credit/Debit Card (Patient payment amount unknown)

Credit/Debit Card Information This is a map of only the additional information necessary to carry credit/debit card information. Loop ID-2010BD carries only information about the person whose credit/debit card is being used in the transaction. This person may or may not be the subscriber.
Data Element

Table

Loop

Position

Segt ID

Qualifier

Description

2010AA

035

REF01/02

128

8U LU ST TT 06 IJ RB EM

Bank Assigned Security ID Location Number Store Number Terminal Code Systems Number SIC Rate Code Electronic Payment Reference Number

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL 2 2 2 2010BD 2010BD 2010BD 055 055 085 NM101 NM108/09 REF01/02 98 66 128

ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE AO MI BB Account of Credit Card Holder Charge Card Number Authorization Number; card read or data manually entered Maximum Amount

2300

175

AMT01/02

522

MA

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H Medicare Primary, Secondary and Supplemental Payers

How To Map Other Insurance Coverage To The NSF
The 837 transaction set is used to submit a claim to a Payer for payment. If the Payer on the 837 is Medicare, Medicare can be either the primary or secondary payer. When Medicare is the secondary payer, primary payer information MUST be supplied in loop 2320. In some situations, after Medicare adjudicates a claim, Medicare will forward the claim to one or two supplementary payer(s) for additional payment. The 837 transaction set is used to identify the supplemental payer(s).

H.1

How to Indicate Whether Medicare is Primary or Secondary

When Medicare is the primary payer, send a P in segment SBR (Position 005). Loop 2320 is not required if the patient does not have other supplemental insurance. When Medicare is the secondary payer, send S in segment SBR (Position 005). Report the primary payer in the first occurrence of loop 2320 and repeat for other insurance.

H.2

How to Indicate Other Payers Supplementary to Medicare

The 837 transaction set will accommodate a total of three payers including Medicare. These can be (1) Medicare as primary payer and a maximum of two supplemental payers (supply supplemental information in the first and second occurrence of the 2320 loop), or (2) another primary payer, Medicare as secondary payer, and a maximum of one supplemental payer (supply the primary payer in the first occurrence of the 2320 loop and the supplemental payer information in the second occurrence of the 2320 loop). Medicare as Primary Payer If Medicare is primary and the patient has NO other insurance coverage:
ANSI 837 Tbl/Pos 2-005 2-005 2-005 Seg/El SBR01 SBR05 SBR09 Value P NSF 3.01 Field # DA0-02.0 NO MAP DA0-04.0 DA0-05.0 DA0-06.0 Value 01 P C MP Not Used IF Medicare Primary TRANSLATOR GENERATED TRANSLATOR GENERATED Comments

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If Medicare is primary and the patient has other insurance coverage, such supplementary coverage will be mapped to loop 2320 as described later in this Section. The Medicare primary coverage is mapped as described above. Medicare as Secondary Payer If the patient has other primary insurance and Medicare is secondary, the NSF requires a separate DA0 record for each payer. The first DA0 carries information about the primary payer, the second DA0 holds information about the secondary payer (Medicare B). Produce the second DA0 using the following map:
ANSI 837 Tbl/Pos 2-005 2-005 Seg/El SBR01 SBR05 Value S 12,13, 14, 15, 16, 41, 42, 43 MB NSF 3.01 Field # DA0-02.0 DA0-06.0 Value 02 12,13, 14, 15, 16, 41, 42, 43 C Comments

2-005

SBR09

DA0-05.0

Produce the first DA0/DA1 using the following map to loop 2320:
ANSI 837 Tbl/Pos 2-290 2-290 2-290 2-290 2-290 2-290 2-295 2-295 2-295 2-295 2-295 2-295 2-295 2-295 2-295 2-295 2-295 2-300 2-290 2-310 2-310 2-325 2-325 2-325 2-325 2-325 2-332 2-332 2-340 Seg/El SBR01 SBR02 SBR03 SBR04 SBR05 SBR08 CAS02 CAS03 CAS02 CAS03 CAS02 CAS03 CAS02 CAS03 CAS02 CAS03 CAS02 CAS03 SBR09 OI03 OI04 NM101 NM102 NM103 NM108 NM109 N301 N302 N401 Value P NSF 3.01 Field # DA0-02.0 DA0-17.0 DA0-10.0 DA0-11.0 DA0-06.0 DA0-25.0 NO MAP DA1-11.0 NO MAP DA1-14.0 NO MAP DA1-09.0 NO MAP DA1-10.0 NO MAP, DA1-12.0 NO MAP DA1-13.0 DA0-05.0 DA0-15.0 DA0-16.0 NO MAP NO MAP DA0-09.0 NO MAP DA0-07.0 DA1-04.0 DA1-05.0 DA1-06.0 Value 01 See Implementation Detail Prim Payor Grp Nmbr Prim Payor Grp Name ANSI=NSF See Implementation Detail Prim Payr Allwd Amt Prim Payr Paid Amt Prim Payr Disallwd Cost Cont Prim Payr Disallowed Prim Payr Deductible Prim Payr Coinsurance See Implementation Detail ANSI=NSF ANSI=NSF Comments

GP, OT B6 D C9 A6 D2 B9

GP, OT

PR 2 PI

Primary Payer Name Prim Ident. Number Prim Payr Address 1 Prim Payr Address 2 Prim Payr City MAY 2000

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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 2-340 2-340 N402 N403 DA1-07.0 DA1-08.0

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL Prim Payr State Prim Payr Zip

Only report the primary policy holder (Insured) name, ID number, address and demographics if patient is not the insured on primary payers policy:
ANSI 837 Tbl/Pos 2-305 2-305 2-305 2-325 2-325 2-325 2-325 2-325 2-325 2-325 2-332 2-332 2-340 2-340 2-340 Seg/El DMG01 DMG02 DMG03 NM101 NM102 NM103 NM104 NM105 NM108 NM109 N301 N302 N401 N402 N403 Value D8 NSF 3.01 Field # NO MAP DA0-24.0 DA0-23.0 NO MAP NO MAP DA0-19.0 DA0-20.0 DA0-21.0 NO MAP DA0-18.0 DA2-04.0 DA2-05.0 DA2-06.0 DA2-07.0 DA2-08.0 Value Comments Insured date of birth Insured sex , Insured Last Name Insured first Name Insured Middle Initial Insured Ident. Number Insured Address 1 Insured Address 2 Insured City Insured State Insured Zip

IL 1

CI

Report the Employers name if the insureds policy is an employer group plan.
ANSI 837 Tbl/Pos 2-325 2-325 2-325 Seg/El NM101 NM102 NM103 Value 36 2 NSF 3.01 Field # NO MAP NO MAP DA2-12.0 Value Comments

Employer Name

Supplementary Coverage If the patient has other insurance coverage supplementary to Medicare, if Medicare is Primary, the supplementary coverage will be secondary, and if Medicare is Secondary (another primary payor exists), the supplementary coverage will be tertiary. Map both cases as follows: Produce the second or third DA0 using the following map:
ANSI 837 Tbl/Pos 2-005 2-005 2-005 Seg/El SBR01 SBR05 SBR09 Value S, T NSF 3.01 Field # DA0-02.0 NO MAP DA0-04.0 DA0-05.0 DA0-06.0 Value 02, 03 P C MP Comments Secondary/Tertiary Not Used Translator Generated Translator Generated

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Produce the second or third DA0/DA1 using the following map to LOOP 2320:
ANSI 837 Tbl/Pos 2-290 2-290 2-290 2-290 2-290 Seg/El SBR01 SBR02 SBR03 SBR04 SBR05 Value S, T NSF 3.01 Field # DA0-02.0 DA0-17.0 DA0-10.0 DA0-11.0 DA0-06.0 DA0-04.0 Value 02, 03 Comments Secondary/Tertiary See Implementation Detail Supp. Payer Group Number Supp. Payer Group Name See Implementation Detail Translator Generated

Report the supplementary payer name, ID, and address as required by Carrier:
ANSI 837 Tbl/Pos 2-290 2-325 2-325 2-325 2-325 2-325 2-332 2-332 2-340 2-340 2-340 Seg/El SBR09 NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 Value PR 2 PI NSF 3.01 Field # DA0-05.0 NO MAP NO MAP DA0-09.0 NO MAP DA0-07.0 DA1-04.0 DA1-05.0 DA1-06.0 DA1-07.0 DA1-08.0 Value Comments See Implementation Detail

Supp. Payer Name Supp. Payer ID Number Supp. Payer Address 1 Supp. Payer Address 2 Supp. Payer City Supp. Payer State Supp. Payer Zip

Only report the supplementary policy holder (Insured) name, ID number, address and demographics if patient is not the insured on primary supplementary policy:
ANSI 837 Tbl/Pos 2-305 2-305 2-305 2-325 2-325 2-325 2-325 2-325 2-325 2-325 2-332 2-332 2-340 2-340 2-340 Seg/El DMG01 DMG02 DMG03 NM101 NM102 NM103 NM104 NM105 NM108 NM109 N301 N302 N401 N402 N403 Value D8 NSF 3.01 Field # NO MAP DA0-24.0 DA0-23.0 NO MAP NO MAP DA0-19.0 DA0-20.0 DA0-21.0 NO MAP DA0-18.0 DA2-04.0 DA2-05.0 DA2-06.0 DA2-07.0 DA2-08.0 Value Comments Insured date of birth Insured sex

IL 1

Insured Last Name Insured first Name Insured Middle Initial Insured ID Number Insured Address 1 Insured Address 2 Insured City Insured State Insured ZIP

CI

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I National Uniform Claim Committee Recommendations

I.1 National Uniform Claim Committee (NUCC)
The National Uniform Claim Committee was created to develop a data set for use by the non-institutional health care community to transmit claim and encounter information to and from all third-party payers. It is chaired by the American Medical Association (AMA), with the Health Care Financing Administration (HCFA) as a critical partner. The Committee includes representation from key provider and payer organizations, as well as standards setting organizations, state and federal regulators, and the National Uniform Billing Committee (NUBC). The NUCC was formally named in the administrative simplification section of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) as one of the organizations to be consulted by ANSI-accredited standards development organizations as they develop, adopt, or modify national standards for health care transactions. As such, the NUCC is intended to have an authoritative voice regarding national standard content and data definitions for non-institutional health care claims in the United States. The NUCCs recommendations in this area are explicitly designed to complement and expedite the work of X12 in complying with the provisions of P.L. 104-191. The NUCC is comprised of key parties who are affected by health care EDI those at either end of a health care transaction such as payors and providers. In addition, the NUCC includes representatives of standards development organizations, regulatory agencies, and the National Uniform Billing Committee. Criteria for membership are: a national scope and representation of a unique constituency affected by health care EDI from one of the above categories, with an emphasis on maintaining or enhancing the provider/payor balance in the original NUCC composition. Each Committee member is intended to represent the perspective of the sponsoring organization and the applicable constituency. Representatives are responsible for communicating information between the Committee and the group(s) they represent. The following organizations serve on the NUCC as voting members:
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American Medical Association Health Care Financing Administration Alliance for Managed Care American Association of Health Plans ANSI ASC X12N Blue Cross Blue Shield Association Health Insurance Association of America Medical Group Management Association National Association for Medical Equipment Services National Association of Insurance Commissioners National Association of State Medicaid Directors National Uniform Billing Committee

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The National Uniform Claim Committee (NUCC) completed the development and voted to approve its standardized data set March 5, 1997. This data set is intended to apply to the claims and equivalent encounters and coordination of benefits transactions specified in the HIPAA. The NUCC data set was constructed based upon the combined universe of fields included in the HCFA 1500 paper claim form, the Medicare NSF and the ASC X12 837. Recommendations regarding data requirements were then made. The definitions for the recommendations of the data requirements include the following: R - Required: provider must supply data element on every claim, payer must accept data element. RIA - Required If Applicable: conditional on a specific situation such as an accident. NRUC - Not Required: unless specified Under Contract (Includes federal or state government requirements that may not be formalized in a payer-provider contract but are not generally applicable to all payers). NR - Not Required: for submission/receipt of a claim or encounter.

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J X12N 837 Professional Implementation Guide Alias Index

This is an alphabetical list of all segment and element names in the 837 professional implementation guide. It has been included in this Implementation Guide to assist users in locating specific data elements.

NAME

PAGE

NAME

PAGE

Accident/Employment/Related Causes 2300 | CLM11 | C024...................................... 170 Additional Billing Provider Name Information 2010AA | N2 ..................................................... 87 Additional Credit/Debit Card Holder Name Information 2010BD | N2 ................................................... 149 Additional Ordering Provider Name Information 2420E | N2...................................................... 532 Additional Other Payer Name Information 2330B | N2...................................................... 362 Additional Other Subscriber Name Information 2330A | N2...................................................... 353 Additional Patient Name Information 2010CA | N2 ................................................... 160 Additional Pay-to Provider Name Information 2010AB | N2 ................................................... 102 Additional Payer Name Information 2010BB | N2 ................................................... 133 Additional Referring Provider Name Information 2310A | N2...................................................... 287 Additional Referring Provider Name Information 2420F | N2...................................................... 546 Additional Rendering Provider Name Information 2310B | N2...................................................... 295 Additional Rendering Provider Name Information 2420A | N2...................................................... 506 Additional Responsible Party Name Information 2010BC | N2 ................................................... 142

Additional Service Facility Location Name Information 2310D | N2 .....................................................306 Additional Service Facility Location Name Information 2420C | N2 .....................................................517 Additional Submitter Name 1000A | N201 ....................................................70 Additional Submitter Name Information 1000A | N2 ........................................................70 Additional Subscriber Name Information 2010BA | N2 ...................................................120 Additional Supervising Provider Name Information 2310E | N2......................................................315 Additional Supervising Provider Name Information 2420D | N2 .....................................................526 Adjusted Amount - Claim Level 2320 | CAS03 .................................................323 Adjusted Amount - Claim Level 2320 | CAS06 .................................................323 Adjusted Amount - Claim Level 2320 | CAS09 .................................................323 Adjusted Amount - Claim Level 2320 | CAS12 .................................................323 Adjusted Amount - Claim Level 2320 | CAS15 .................................................323 Adjusted Amount - Claim Level 2320 | CAS18 .................................................323 Adjusted Amount - Line Level 2430 | CAS03 .................................................558 Adjusted Amount - Line Level 2430 | CAS06 .................................................558 Adjusted Amount - Line Level 2430 | CAS09 .................................................558

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NAME PAGE

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NAME PAGE

Adjusted Amount - Line Level 2430 | CAS12 ................................................. 558 Adjusted Amount - Line Level 2430 | CAS15 ................................................. 558 Adjusted Amount - Line Level 2430 | CAS18 ................................................. 558 Adjusted Repriced Claim Number 2300 | REF ..................................................... 235 Adjusted Repriced Line Item Reference Number 2400 | REF ..................................................... 469 Adjusted Units - Claim Level 2320 | CAS04 ................................................. 323 Adjusted Units - Claim Level 2320 | CAS07 ................................................. 323 Adjusted Units - Claim Level 2320 | CAS10 ................................................. 323 Adjusted Units - Claim Level 2320 | CAS13 ................................................. 323 Adjusted Units - Claim Level 2320 | CAS16 ................................................. 323 Adjusted Units - Claim Level 2320 | CAS19 ................................................. 323 Adjusted Units - Line Level 2430 | CAS04 ................................................. 558 Adjusted Units - Line Level 2430 | CAS07 ................................................. 558 Adjusted Units - Line Level 2430 | CAS10 ................................................. 558 Adjusted Units - Line Level 2430 | CAS13 ................................................. 558 Adjusted Units - Line Level 2430 | CAS16 ................................................. 558 Adjusted Units - Line Level 2430 | CAS19 ................................................. 558 Adjustment Group Code 2430 | CAS01 ................................................. 558 Adjustment Reason Code - Claim Level 2320 | CAS02 ................................................. 323 Adjustment Reason Code - Claim Level 2320 | CAS05 ................................................. 323 Adjustment Reason Code - Claim Level 2320 | CAS08 ................................................. 323 Adjustment Reason Code - Claim Level 2320 | CAS11 ................................................. 323 Adjustment Reason Code - Claim Level 2320 | CAS14 ................................................. 323

Adjustment Reason Code - Claim Level 2320 | CAS17 .................................................323 Adjustment Reason Code - Line Level 2430 | CAS02 .................................................558 Adjustment Reason Code - Line Level 2430 | CAS05 .................................................558 Adjustment Reason Code - Line Level 2430 | CAS08 .................................................558 Adjustment Reason Code - Line Level 2430 | CAS11..................................................558 Adjustment Reason Code - Line Level 2430 | CAS14 .................................................558 Adjustment Reason Code - Line Level 2430 | CAS17 .................................................558 Allowed amount, Pricing 2300 | HCP02 .................................................271 Ambulance Certification 2300 | CRC.....................................................257 Ambulance Certification 2400 | CRC.....................................................427 Ambulance transport code 2400 | CR103 .................................................412 Ambulance Transport Code 2300 | CR103 .................................................248 Ambulance Transport Information 2300 | CR1 .....................................................248 Ambulance Transport Information 2400 | CR1 .....................................................412 Ambulance Transport Reason Code 2300 | CR104 .................................................248 Ambulance Transport Reason Code 2400 | CR104 .................................................412 Ambulatory Patient Group (APG) 2300 | REF .....................................................240 Ambulatory Patient Group (APG) 2400 | REF .....................................................479 Anesthesia Modifying Units 2400 | QTY .....................................................462 Anesthesia Modifying Units 2400 | QTY02 .................................................462 Approved Amount 2400 | AMT .....................................................485 Approved APG amount, Pricing 2300 | HCP07 .................................................271 Approved APG amount, Pricing 2400 | HCP07 .................................................495

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NAME PAGE NAME

004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

PAGE

Approved APG code, Pricing 2300 | HCP06 ................................................. 271 Approved APG code, Pricing 2400 | HCP06 ................................................. 495 Arterial Blood Gas 2400 | CR510 ................................................. 423 Assignment of Benefits Indicator 2300 | CLM08 ................................................. 170 Assignment of Benefits Indicator 2320 | OI03..................................................... 344 Attachment Control Number 2300 | PWK06 ................................................ 214 Attachment Report Type Code 2300 | PWK01 ................................................ 214 Attachment Transmission Code 2300 | PWK02 ................................................ 214 Attachment Transmission Code 2400 | PWK02 ................................................ 410 Beginning of Hierarchical Transaction BHT .................................................................. 63 Billing Provider Additional Name 2010AA | N201 ................................................. 87 Billing Provider Address 2010AA | N3 ..................................................... 88 Billing Provider Address 1 2010AA | N301 ................................................. 88 Billing Provider Address 2 2010AA | N302 ................................................. 88 Billing Provider City/State/ZIP Code 2010AA | N4 ..................................................... 89 Billing Provider Contact Information 2010AA | PER................................................... 96 Billing Provider Country Code 2010AA | N404 ................................................. 89 Billing Provider Name 2010AA | NM103 .............................................. 84 Billing Provider Name 2010AA | NM104 .............................................. 84 Billing Provider Name 2010AA | NM105 .............................................. 84 Billing Provider Name 2010AA | NM107 .............................................. 84 Billing Provider Name 2010AA | NM1 .................................................. 84 Billing Provider Primary Identification Number 2010AA | NM109 .............................................. 84

Billing Provider Secondary Identification 2010AA | REF ...................................................91 Billing Provider Secondary Identification Number 2010AA | REF02 ...............................................91 Billing Providers City 2010AA | N401 .................................................89 Billing Providers State 2010AA | N402 .................................................89 Billing Providers Zip Code 2010AA | N403 .................................................89 Billing/Pay-to Provider Hierarchical Level 2000A | HL ........................................................77 Billing/Pay-to Provider Specialty Information 2000A | PRV .....................................................79 Bundled/Unbundled Line Number 2430 | SVD06 .................................................554 Certification Condition Code Applies Indicator 2300 | CRC02 .................................................257 Certification Condition Code Applies Indicator 2300 | CRC02 .................................................260 Certification Condition Code Applies Indicator 2400 | CRC02 .................................................432 Certification Condition Code, Ambulance Certification 2400 | CRC02 .................................................427 Certification Period, Home Oxygen Therapy 2400 | CR502 .................................................423 Certification Type Code. Oxygen Therapy 2400 | CR501 .................................................423 Claim Adjudication Date 2330B | DTP ...................................................366 Claim Adjustment Group Code 2320 | CAS01 .................................................323 Claim filing indicator code 2320 | SBR09 .................................................318 Claim Filing Indicator Code 2000B | SBR09 ............................................... 110 Claim Identification Number for Clearing Houses and Other Transmission Intermediaries 2300 | REF .....................................................238

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Claim Information 2300 | CLM ..................................................... 170 Claim Level Adjustments 2320 | CAS ..................................................... 323 Claim Note 2300 | NTE ..................................................... 246 Claim or Encounter Indicator BHT06 .............................................................. 63 Claim Original Reference Number (ICN/DCN) 2300 | REF02 ................................................. 229 Claim Pricing/Repricing Information 2300 | HCP ..................................................... 271 Claim Submission Reason Code 2300 | CLM05 | C023-03 ................................ 170 Claim Supplemental Information 2300 | PWK .................................................... 214 Clinical Laboratory Improvement Amendment (CLIA) Identification 2400 | REF ..................................................... 475 Clinical Laboratory Improvement Amendment (CLIA) Number 2300 | REF ..................................................... 231 Co-Pay Waiver 2400 | SV115 .................................................. 400 Complication Indicator. Spinal Manipulation 2300 | CR209 ................................................. 251 Complication Indicator. Spinal Manipulation 2400 | CR209 ................................................. 415 Condition Indicator 2300 | CRC04................................................. 257 Condition Indicator 2300 | CRC05................................................. 257 Condition Indicator 2300 | CRC06................................................. 257 Condition Indicator 2300 | CRC07................................................. 257 Condition Indicator 2400 | CRC03................................................. 427 Condition Indicator 2400 | CRC04................................................. 427 Condition Indicator 2400 | CRC05................................................. 427 Condition Indicator 2400 | CRC06................................................. 427

Condition Indicator 2400 | CRC07 .................................................427 Condition Indicator 2400 | CRC03 .................................................432 Condition Indicator 2400 | CRC04 .................................................432 Condition Indicator 2400 | CRC05 .................................................432 Condition Indicator 2400 | CRC06 .................................................432 Condition Indicator 2400 | CRC07 .................................................432 Condition Indicator 2300 | CRC03 .................................................257 Condition Indicator 2300 | CRC03 .................................................260 Contract Allowance or Charge Percent 2400 | CN103 .................................................466 Contract Amount 2300 | CN102 .................................................217 Contract Amount 2400 | CN102 .................................................466 Contract Code 2300 | CN104 .................................................217 Contract Code 2400 | CN104 .................................................466 Contract Information 2300 | CN1 .....................................................217 Contract Information 2400 | CN1 .....................................................466 Contract Percent 2300 | CN103 .................................................217 Contract Type Code 2300 | CN101 .................................................217 Contract type code 2400 | CN101 .................................................466 Contract Version 2400 | CN106 .................................................466 Contract Version Identifier 2300 | CN106 .................................................217 Coordination of Benefits (COB) Allowed Amount 2320 | AMT .....................................................334 Coordination of Benefits (COB) Approved Amount 2320 | AMT .....................................................333

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Coordination of Benefits (COB) Covered Amount 2320 | AMT ..................................................... 336 Coordination of Benefits (COB) Discount Amount 2320 | AMT ..................................................... 337 Coordination of Benefits (COB) Patient Paid Amount 2320 | AMT ..................................................... 339 Coordination of Benefits (COB) Patient Responsibility Amount 2320 | AMT ..................................................... 335 Coordination of Benefits (COB) Payer Paid Amount 2320 | AMT ..................................................... 332 Coordination of Benefits (COB) Per Day Limit Amount 2320 | AMT ..................................................... 338 Coordination of Benefits (COB) Tax Amount 2320 | AMT ..................................................... 340 Coordination of Benefits (COB) Total Claim Before Taxes Amount 2320 | AMT ..................................................... 341 Credit or Debit Card Authorization Number 2010BD | REF02 ............................................ 150 Credit-Debit Card Holder Additional Name Information 2010BD | N201 ............................................... 149 Credit/Debit Card Billing Information 2010AA | REF................................................... 94 Credit/Debit Card Holder Name 2010BD | NM103 ............................................ 146 Credit/Debit Card Holder Name 2010BD | NM104 ............................................ 146 Credit/Debit Card Holder Name 2010BD | NM105 ............................................ 146 Credit/Debit Card Holder Name 2010BD | NM107 ............................................ 146 Credit/Debit Card Holder Name 2010BD | NM1 ................................................ 146 Credit/Debit Card Information 2010BD | REF ................................................ 150 Credit/Debit Card Maximum Amount 2300 | AMT ..................................................... 219 Credit/Debit Card Number 2010BD | NM109 ............................................ 146 Date - Accident 2300 | DTP ..................................................... 194

Date - Acute Manifestation 2300 | DTP .....................................................190 Date - Acute Manifestation 2400 | DTP .....................................................456 Date - Admission 2300 | DTP .....................................................208 Date - Assumed and Relinquished Care Dates 2300 | DTP .....................................................212 Date - Authorized Return to Work 2300 | DTP .....................................................206 Date - Begin Therapy Date 2400 | DTP .....................................................440 Date - Certification Revision Date 2400 | DTP .....................................................437 Date - Date Last Seen 2300 | DTP .....................................................186 Date - Date Last Seen 2400 | DTP .....................................................445 Date - Disability Begin 2300 | DTP .....................................................201 Date - Disability End 2300 | DTP .....................................................203 Date - Discharge 2300 | DTP .....................................................210 Date - Estimated Date of Birth 2300 | DTP .....................................................199 Date - Hearing and Vision Prescription Date 2300 | DTP .....................................................200 Date - Initial Treatment 2300 | DTP .....................................................182 Date - Initial Treatment 2400 | DTP .....................................................458 Date - Last Certification Date 2400 | DTP .....................................................442 Date - Last Menstrual Period 2300 | DTP .....................................................196 Date - Last Worked 2300 | DTP .....................................................205 Date - Last X-ray 2300 | DTP .....................................................197 Date - Last X-ray 2400 | DTP .....................................................454 Date - Onset of Current Illness/Symptom 2300 | DTP .....................................................188

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Date - Onset of Current Symptom/Illness 2400 | DTP ..................................................... 452 Date - Order Date 2300 | DTP ..................................................... 180 Date - Order Date 2400 | DTP ..................................................... 444 Date - Oxygen Saturation/Arterial Blood Gas Test 2400 | DTP ..................................................... 449 Date - Referral Date 2300 | DTP ..................................................... 184 Date - Referral Date 2400 | DTP ..................................................... 439 Date - Service Date 2400 | DTP ..................................................... 435 Date - Shipped 2400 | DTP ..................................................... 451 Date - Similar Illness/Symptom Onset 2300 | DTP ..................................................... 192 Date - Similar Illness/Symptom Onset 2400 | DTP ..................................................... 460 Date - Test 2400 | DTP ..................................................... 447 Date of Birth 2010CA | DMG02 ........................................... 164 Date of Birth - Patient 2010BA | DMG02............................................ 124 Date of Birth - Subscriber 2320 | DMG02 ................................................ 342 Date of Death 2000B | PAT06................................................ 114 Date of Death 2000C | PAT06................................................ 154 Delay Reason Code 2300 | CLM20 ................................................. 170 Demonstration Project Identifier 2300 | REF ..................................................... 242 Diagnosis 2300 | HI02 | C022 ......................................... 265 Diagnosis 2300 | HI03 | C022 ......................................... 265 Diagnosis 2300 | HI04 | C022 ......................................... 265 Diagnosis 2300 | HI05 | C022 ......................................... 265

Diagnosis 2300 | HI06 | C022.......................................... 265 Diagnosis 2300 | HI07 | C022.......................................... 265 Diagnosis 2300 | HI08 | C022.......................................... 265 Diagnosis Code Pointer 2400 | SV107 | C004 ......................................400 Discipline type code 2305 | CR701 .................................................276 DME Duration 2400 | CR303 .................................................421 DMERC CMN Indicator 2400 | PWK ....................................................410 DMERC Condition Indicator 2400 | CRC.....................................................432 DMERC Report Type Code 2400 | PWK01 ................................................410 Durable Medical Equipment Certification 2400 | CR3 .....................................................421 Emergency Indicator 2400 | SV109 ..................................................400 EPSDT Indicator 2400 | SV111 ..................................................400 ESRD Paid Amount 2320 | MOA08 ................................................347 Estimated Date of Birth 2300 | DTP03 .................................................199 Exception code 2300 | HCP15 .................................................271 Exception code 2400 | HCP15 .................................................495 Facility Type Code 2300 | CLM05 | C023-01 ................................170 Family Planning Indicator 2400 | SV112 ..................................................400 File Information 2300 | K3 ........................................................244 File Information 2400 | K3 ........................................................487 Foreign Currency Information 2000A | CUR.....................................................81 Form Identification Code 2440 | LQ........................................................567 Form Identification Code 2440 | LQ01....................................................567

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Form Identifier 2440 | LQ02.................................................... 567 Gender - Patient 2010CA | DMG03 ........................................... 164 Gender - Patient 2010BA | DMG03............................................ 124 Gender - Subscriber 2320 | DMG03 ................................................ 342 Group or Plan Name 2000B | SBR04............................................... 110 Group or Plan Name 2320 | SBR04 ................................................. 318 Group or Policy Number 2000B | SBR03............................................... 110 Group or Policy Number 2320 | SBR03 ................................................. 318 HCPCS Payable Amount 2320 | MOA02 ................................................ 347 Health Care Diagnosis Code 2300 | HI ......................................................... 265 Health Care Services Delivery 2305 | HSD ..................................................... 278 Health Care Services Delivery 2400 | HSD ..................................................... 491 Home Health Care Plan Information 2305 | CR7 ..................................................... 276 Home Oxygen Therapy Information 2400 | CR5 ..................................................... 423 Homebound Indicator 2300 | CRC..................................................... 263 Hospice Employee Indicator 2400 | CRC02................................................. 430 Hospice Employee Indicator 2400 | CRC..................................................... 430 Immunization Batch Number 2400 | REF ..................................................... 478 Individual relationship code 2320 | SBR02 ................................................. 318 Insurance type code 2000B | SBR05............................................... 110 Insurance type code 2320 | SBR05 ................................................. 318 Investigational Device Exemption Number 2300 | REF ..................................................... 236

Laboratory/Facility Additional Name Information 2310D | N201 .................................................306 Laboratory/Facility Address 1 2310D | N301 .................................................307 Laboratory/Facility Address 2 2310D | N302 .................................................307 Laboratory/Facility City 2310D | N401 .................................................308 Laboratory/Facility Country Code 2310D | N404 .................................................308 Laboratory/Facility Name 2310D | NM103 ..............................................303 Laboratory/Facility Primary Identifier 2310D | NM109 ..............................................303 Laboratory/Facility Secondary Identification Number 2310D | REF02 ...............................................310 Laboratory/Facility State 2310D | N402 .................................................308 Laboratory/Facility Zip Code 2310D | N403 .................................................308 Line Adjudication Date 2430 | DTP .....................................................566 Line Adjudication Information 2430 | SVD .....................................................554 Line Adjustment 2430 | CAS .....................................................558 Line Counter 2400 | LX01 ....................................................398 Line Item Control Number 2400 | REF .....................................................472 Line Note 2400 | NTE .....................................................488 Line Pricing/Repricing Information 2400 | HCP .....................................................495 Mammography Certification Number 2300 | REF .....................................................226 Mammography Certification Number 2400 | REF .....................................................474 Mandatory Medicare (Section 4081) Crossover Indicator 2300 | REF .....................................................224 Measurement identifier 2400 | MEA01 .................................................464 Medical Record Number 2300 | REF .....................................................241

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Medicare Assignment Code 2300 | CLM07 ................................................. 170 Medicare Outpatient Adjudication Information 2320 | MOA .................................................... 347 Modulus, Amount 2305 | HSD04 ................................................. 278 Modulus, Unit 2305 | HSD03 ................................................. 278 Nature of Condition Code. Spinal Manipulation 2300 | CR208 ................................................. 251 Nature of Condition Code. Spinal Manipulation 2400 | CR208 ................................................. 415 Ordering Provider Additional Name Information 2420E | N201.................................................. 532 Ordering Provider Address 2420E | N3...................................................... 533 Ordering Provider Address 1 2420E | N301.................................................. 533 Ordering Provider Address 2 2420E | N302.................................................. 533 Ordering Provider City 2420E | N401.................................................. 534 Ordering Provider City/State/ZIP Code 2420E | N4...................................................... 534 Ordering Provider Contact Information 2420E | PER................................................... 538 Ordering Provider Country Code 2420E | N404.................................................. 534 Ordering Provider First Name 2420E | NM104............................................... 529 Ordering Provider Generation 2420E | NM107............................................... 529 Ordering Provider Last Name 2420E | NM103............................................... 529 Ordering Provider Middle Name 2420E | NM105............................................... 529 Ordering Provider Name 2420E | NM1................................................... 529 Ordering Provider Primary Identifier 2420E | NM109............................................... 529 Ordering Provider Secondary Identification 2420E | REF ................................................... 536

Ordering Provider Secondary Identifier 2420E | REF02 ...............................................536 Ordering Provider State 2420E | N402..................................................534 Ordering Provider Zip Code 2420E | N403..................................................534 Original Reference Number (ICN/DCN) 2300 | REF .....................................................229 Other Insurance Coverage Information 2320 | OI.........................................................344 Other Payer Claim Adjustment Indicator 2330B | REF ...................................................372 Other Payer Contact Information 2330B | PER ...................................................363 Other Payer Identification 2420G | NM109 ..............................................549 Other Payer identification code 2430 | SVD01 .................................................554 Other Payer Name 2330B | NM1...................................................359 Other Payer Patient Identification 2330C | REF ...................................................376 Other Payer Patient Information 2330C | NM1 ..................................................374 Other Payer Primary Identification Number 2330B | NM109...............................................359 Other Payer Prior Authorization or Referral Number 2330B | REF ...................................................370 Other Payer Prior Authorization or Referral Number 2420G | NM1 ..................................................549 Other Payer Prior Authorization or Referral Number 2420G | REF...................................................552 Other Payer Prior Authorization or Referral Number 2420G | REF02...............................................552 Other Payer Purchased Service Provider 2330F | NM1 ...................................................386 Other Payer Purchased Service Provider Identification 2330F | REF ...................................................388 Other Payer Referring Provider 2330D | NM1 ..................................................378

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Other Payer Referring Provider Identification 2330D | REF................................................... 380 Other Payer Referring Provider Identification 2330D | REF02............................................... 380 Other Payer Rendering Provider 2330E | NM1................................................... 382 Other Payer Rendering Provider Secondary Identification 2330E | REF ................................................... 384 Other Payer Secondary Identifier 2330B | REF ................................................... 368 Other Payer Service Facility Location 2330G | NM1 .................................................. 390 Other Payer Service Facility Location Identification 2330G | REF................................................... 392 Other Payer Service Facility Location Identification 2330G | REF02............................................... 392 Other Payer Supervising Provider 2330H | NM1 .................................................. 394 Other Payer Supervising Provider Identification 2330H | REF................................................... 396 Other Payer Supervising Provider Identification 2330H | REF02............................................... 396 Other Subscriber Address 2330A | N3...................................................... 354 Other Subscriber City/State/ZIP Code 2330A | N4...................................................... 355 Other Subscriber Information 2320 | SBR ..................................................... 318 Other Subscriber Name 2330A | NM1................................................... 350 Other Subscriber Primary Identifier 2330A | NM109............................................... 350 Other Subscriber Secondary Identification 2330A | REF ................................................... 357 Other Subscriber Secondary Identification 2330A | REF02 ............................................... 357 Outpatient Reimbursement Rate 2320 | MOA01 ................................................ 347 Oxygen Flow Rate 2400 | REF ..................................................... 480

Oxygen Saturation 2400 | CR511..................................................423 Oxygen test condition code 2400 | CR512 .................................................423 Oxygen test finding code 2400 | CR513 .................................................423 Oxygen test finding code 2400 | CR514 .................................................423 Oxygen test finding code 2400 | CR515 .................................................423 Paid Amount 2430 | SVD02 .................................................554 Paid units of service 2430 | SVD05 .................................................554 Participation Agreement 2300 | CLM16 .................................................170 Patient Account Number 2300 | CLM01 .................................................170 Patient Additional Name Information 2010CA | N201 ...............................................160 Patient Address 2010CA | N3 ...................................................161 Patient Address 1 2010CA | N301 ...............................................161 Patient Address 2 2010CA | N302 ...............................................161 Patient Amount Paid 2300 | AMT .....................................................220 Patient Birth Date 2010BA | DMG02............................................124 Patient City Name 2010CA | N401 ...............................................162 Patient City/State/ZIP Code 2010CA | N4 ...................................................162 Patient Condition Description, Chiropractic 2400 | CR210 .................................................415 Patient Condition Description, Chiropractic 2400 | CR211..................................................415 Patient Condition Description. Spinal Manipulation 2300 | CR210 .................................................251 Patient Condition Description. Spinal Manipulation 2300 | CR211..................................................251 Patient Condition Information: Vision 2300 | CRC.....................................................260

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Patient Country Code 2010CA | N404 ............................................... 162 Patient Demographic Information 2010CA | DMG ............................................... 164 Patient First Name 2010CA | NM104 ............................................ 157 Patient Gender Code 2010BA | DMG03............................................ 124 Patient Generation 2010CA | NM107 ............................................ 157 Patient Hierarchical Level 2000C | HL ..................................................... 152 Patient Information 2000B | PAT.................................................... 114 Patient Information 2000C | PAT.................................................... 154 Patient Last Name 2010CA | NM103 ............................................ 157 Patient Last Name 2330C | NM103 .............................................. 374 Patient Middle Initial 2010CA | NM105 ............................................ 157 Patient Name 2010CA | NM1 ................................................ 157 Patient Secondary Identification 2010CA | REF................................................. 166 Patient Signature Source Code 2300 | CLM10 ................................................. 170 Patient Signature Source Code 2320 | OI04..................................................... 344 Patient State Code 2010CA | N402 ............................................... 162 Patient Weight 2300 | CR102 ................................................. 248 Patient Weight 2000C | PAT08................................................ 154 Patient Weight 2400 | CR102 ................................................. 412 Patient Weight 2000B | PAT08................................................ 114 Patient Zip Code 2010CA | N403 ............................................... 162 Patients Other Payer Primary Identification Number 2330C | NM109 .............................................. 374

Patients Other Payer Secondary Identifier 2330C | REF02 ...............................................376 Patients Primary Identification Number 2010CA | NM109 ............................................157 Patients Relationship to Insured 2000C | PAT01................................................154 Pattern Code 2305 | HSD07 .................................................278 Pay-to Provider Additional Identifier 2010AB | REF02.............................................106 Pay-to Provider Additional Name 2010AB | N201 ...............................................102 Pay-to Provider Address 2010AB | N3 ...................................................103 Pay-to Provider Address 1 2010AB | N301 ...............................................103 Pay-to Provider Address 2 2010AB | N302 ...............................................103 Pay-to Provider City Name 2010AB | N401 ...............................................104 Pay-to Provider City/State/ZIP Code 2010AB | N4 ...................................................104 Pay-to Provider Country Code 2010AB | N404 ...............................................104 Pay-to Provider First Name 2010AB | NM104 ..............................................99 Pay-to Provider Last or Organizational Name 2010AB | NM103 ..............................................99 Pay-to Provider Middle Name 2010AB | NM105 ..............................................99 Pay-to Provider Name 2010AB | NM1 ..................................................99 Pay-to Provider Name Suffix 2010AB | NM107 ..............................................99 Pay-to Provider Primary Identification Number 2010AB | NM109 ..............................................99 Pay-to Provider State Code 2010AB | N402 ...............................................104 Pay-to Provider Zip Code 2010AB | N403 ...............................................104 Pay-to-Provider Secondary Identification 2010AB | REF.................................................106 Payer Additional Name Information 2010BB | N201 ...............................................133

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Payer Additional Name Information 2330B | N201.................................................. 362 Payer Address 2010BB | N3 ................................................... 134 Payer Address 1 2010BB | N301 ............................................... 134 Payer Address 2 2010BB | N302 ............................................... 134 Payer City Name 2010BB | N401 ............................................... 135 Payer City/State/ZIP Code 2010BB | N4 ................................................... 135 Payer Country Code 2010BB | N404 ............................................... 135 Payer Name 2010BB | NM103 ............................................ 130 Payer Name 2330B | NM103............................................... 359 Payer Name 2420G | NM103 .............................................. 549 Payer Name 2010BB | NM1 ................................................ 130 Payer Primary Identifier 2010BB | NM109 ............................................ 130 Payer responsibility sequence number code 2320 | SBR01 ................................................. 318 Payer Responsibility Sequence Number Code 2000B | SBR01............................................... 110 Payer Secondary Identification 2010BB | REF................................................. 137 Payer State Code 2010BB | N402 ............................................... 135 Payer Zip Code 2010BB | N403 ............................................... 135 Place of Service Code 2300 | CLM05 | C023 ..................................... 170 Place of Service Code 2400 | SV105.................................................. 400 Policy compliance code 2300 | HCP14 ................................................. 271 Policy compliance code 2400 | HCP14 ................................................. 495 Postage Claimed Amount 2400 | AMT ..................................................... 486

Pregnancy Indicator 2000B | PAT09 ................................................ 114 Prescription Number 2400 | SV4 ......................................................408 Pricing rate 2300 | HCP05 .................................................271 Pricing/Repricing Allowed Amount 2400 | HCP02 .................................................495 Pricing/Repricing Approved Procedure Code 2400 | HCP10 .................................................495 Pricing/Repricing Approved Units or Inpatient Days 2400 | HCP12 .................................................495 Pricing/Repricing Identification Number 2400 | HCP04 .................................................495 Pricing/repricing methodology 2300 | HCP01 .................................................271 Pricing/repricing methodology 2400 | HCP01 .................................................495 Pricing/Repricing Rate 2400 | HCP05 .................................................495 Pricing/Repricing Savings Amount 2400 | HCP03 .................................................495 Principal Diagnosis 2300 | HI01 | C022.......................................... 265 Prior Authorization or Referral Number 2300 | REF .....................................................227 Prior Authorization or Referral Number 2400 | REF .....................................................470 Procedure identifier 2400 | SV101 | C003 ......................................400 Procedure identifier 2430 | SVD03 | C003......................................554 Procedure Modifier 1 2400 | SV101 | C003-03 .................................400 Procedure Modifier 1 2430 | SVD03 | C003-03.................................554 Procedure Modifier 2 2400 | SV101 | C003-04 .................................400 Procedure Modifier 2 2430 | SVD03 | C003-04.................................554 Procedure Modifier 3 2400 | SV101 | C003-05 .................................400 Procedure Modifier 3 2430 | SVD03 | C003-05.................................554

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Procedure Modifier 4 2400 | SV101 | C003-06 ................................. 400 Procedure Modifier 4 2430 | SVD03 | C003-06 ................................ 554 Professional Component 2320 | MOA09 ................................................ 347 Professional Service 2400 | SV1...................................................... 400 Property and Casualty Claim Number 2010BA | REF................................................. 128 Property and Casualty Claim Number 2010CA | REF................................................. 168 Provider Signature on File 2300 | CLM06 ................................................. 170 Provider Specialty Code 2000A | PRV03 ................................................. 79 Provider Specialty Code 2310A | PRV03 ............................................... 285 Provider Specialty Code 2000A | PRV03 ................................................. 79 Provider Specialty Code 2310A | PRV03 ............................................... 285 Provider Specialty Code 2310B | PRV03 ............................................... 293 Provider Specialty Code 2420A | PRV03 ............................................... 504 Provider Specialty Code 2420F | PRV03 ............................................... 544 Purchased Service Charge Amount 2400 | PS102.................................................. 489 Purchased Service Information 2400 | PS1...................................................... 489 Purchased Service Provider Identifier 2400 | PS101.................................................. 489 Purchased Service Provider Name 2310C | NM1 .................................................. 298 Purchased Service Provider Name 2330F | NM103............................................... 386 Purchased Service Provider Name 2420B | NM1................................................... 509 Purchased Service Provider Primary Identifier 2310C | NM109 .............................................. 298 Purchased Service Provider Secondary Identification 2310C | REF................................................... 301

Purchased Service Provider Secondary Identification 2420B | REF ...................................................512 Purchased Service Provider Secondary Identifier 2310C | REF02 ...............................................301 Purchased Service Provider Secondary Identifier 2420B | REF02 ...............................................512 Purchased Service Providers Primary Identification Number 2420B | NM109...............................................509 Question Number/Letter 2440 | FRM01 .................................................569 Question Response 2440 | FRM02 .................................................569 Question Response 2440 | FRM03 .................................................569 Question Response 2440 | FRM04 .................................................569 Question Response 2440 | FRM05 .................................................569 Receiver Additional Name Information 1000B | N2........................................................76 Receiver Additional Name Information 1000B | N201....................................................76 Receiver Name 1000B | NM103.................................................74 Receiver Name 1000B | NM1.....................................................74 Receiver Primary Identification Number 1000B | NM109.................................................74 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification 2400 | REF .....................................................477 Referring Provider Additional Name Information 2310A | N201 ..................................................287 Referring Provider Additional Name Information 2420F | N201..................................................546 Referring Provider First Name 2310A | NM104 ...............................................282 Referring Provider Generation 2310A | NM107 ...............................................282 Referring Provider Generation 2420F | NM107 ...............................................541

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Referring Provider Last Name 2310A | NM103............................................... 282 Referring Provider Last Name 2330D | NM103 .............................................. 378 Referring Provider Middle Name 2310A | NM105............................................... 282 Referring Provider Name 2310A | NM1................................................... 282 Referring Provider Name 2420F | NM1................................................... 541 Referring Provider Primary Identifier 2310A | NM109............................................... 282 Referring Provider Secondary Identification 2310A | REF ................................................... 288 Referring Provider Secondary Identification 2420F | REF ................................................... 547 Referring Provider Secondary IdentifiER 2310A | REF02 ............................................... 288 Referring Provider Specialty Information 2310A | PRV ................................................... 285 Referring Provider Specialty Information 2420F | PRV ................................................... 544 Referring Providers Identification Number 2420F | NM109............................................... 541 Reject reason code 2300 | HCP13 ................................................. 271 Reject reason code 2400 | HCP13 ................................................. 495 Relationship Code 2000B | SBR02............................................... 110 Release of Information Code 2300 | CLM09 ................................................. 170 Release of Information Code 2320 | OI06..................................................... 344 Remarks Code 2320 | MOA03 ................................................ 347 Remarks Code 2320 | MOA04 ................................................ 347 Remarks Code 2320 | MOA05 ................................................ 347 Remarks Code 2320 | MOA06 ................................................ 347

Remarks Code 2320 | MOA07 ................................................347 Rendering Provider Additional Name Information 2310B | N201..................................................295 Rendering Provider Additional Name Information 2420A | N201 ..................................................506 Rendering Provider First Name 2310B | NM104...............................................290 Rendering Provider First Name 2420A | NM104 ...............................................501 Rendering Provider Generation 2310B | NM107...............................................290 Rendering Provider Generation 2420A | NM107 ...............................................501 Rendering Provider Last Name 2310B | NM103...............................................290 Rendering Provider Last Name 2420A | NM103 ...............................................501 Rendering Provider Middle Name 2310B | NM105...............................................290 Rendering Provider Middle Name 2420A | NM105 ...............................................501 Rendering Provider Name 2310B | NM1...................................................290 Rendering Provider Name 2420A | NM1 ...................................................501 Rendering Provider Primary Identifier 2310B | NM109...............................................290 Rendering Provider Primary Identifier 2420A | NM109 ...............................................501 Rendering Provider Secondary Identification 2310B | REF ...................................................296 Rendering Provider Secondary Identification 2420A | REF ...................................................507 Rendering Provider Secondary Identifier 2310B | REF02 ...............................................296 Rendering Provider Secondary Identifier 2420A | REF02 ...............................................507 Rendering Provider Specialty Information 2310B | PRV ...................................................293

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Rendering Provider Specialty Information 2420A | PRV ................................................... 504 Repriced Claim Number 2300 | REF ..................................................... 233 Repriced Line Item Reference Number 2400 | REF ..................................................... 468 Repricing Organization Identifier 2300 | HCP04 ................................................. 271 Responsible Party Additional Name Information 2010BC | N201 ............................................... 142 Responsible Party Address 2010BC | N3 ................................................... 143 Responsible Party Address 1 2010BC | N301 ............................................... 143 Responsible Party Address 2 2010BC | N302 ............................................... 143 Responsible Party City Name 2010BC | N401 ............................................... 144 Responsible Party City/State/ZIP Code 2010BC | N4 ................................................... 144 Responsible Party Country Code 2010BC | N404 ............................................... 144 Responsible Party First Name 2010BC | NM104 ............................................ 139 Responsible Party Generation 2010BC | NM107 ............................................ 139 Responsible Party Last or Organization Name 2010BC | NM103 ............................................ 139 Responsible Party Middle Name 2010BC | NM105 ............................................ 139 Responsible Party Name 2010BC | NM1 ................................................ 139 Responsible Party State Code 2010BC | N402 ............................................... 144 Responsible Party Zip Code 2010BC | N403 ............................................... 144 Round Trip Purpose Description 2300 | CR109 ................................................. 248 Sales Tax Amount 2400 | AMT ..................................................... 484 Savings amount, Pricing 2300 | HCP03 ................................................. 271 Segment Count SE01............................................................... 572

Service Authorization Exception Code 2300 | REF .....................................................222 Service Facility Location 2310D | NM1 ..................................................303 Service Facility Location 2420C | NM1 ..................................................514 Service Facility Location Additional Name 2420C | N201 .................................................517 Service Facility Location Address 2310D | N3 .....................................................307 Service Facility Location Address 2420C | N3 .....................................................518 Service Facility Location Address 1 2420C | N301 .................................................518 Service Facility Location Address 2 2420C | N302 .................................................518 Service Facility Location City 2420C | N401 .................................................519 Service Facility Location City/State/ZIP 2310D | N4 .....................................................308 Service Facility Location City/State/ZIP 2420C | N4 .....................................................519 Service Facility Location Country Code 2420C | N404 .................................................519 Service Facility Location Identification Number 2420C | NM109 ..............................................514 Service Facility Location Name 2420C | NM103 ..............................................514 Service Facility Location Secondary Identification 2310D | REF ...................................................310 Service Facility Location Secondary Identification 2420C | REF ...................................................521 Service Facility Location Secondary Identification Number 2420C | REF02 ...............................................521 Service Facility Location State 2420C | N402 .................................................519 Service Facility Location ZIP Code 2420C | N403 .................................................519 Service Facility Name 2330G | NM103 ..............................................390 Service Line 2400 | LX ........................................................398

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Special Program Code 2300 | CLM12 ................................................. 170 Spinal Manipulation Service Information 2300 | CR2 ..................................................... 251 Spinal Manipulation Service Information 2400 | CR2 ..................................................... 415 Stretcher Purpose Description 2300 | CR110.................................................. 248 Stretcher Purpose Description 2400 | CR110.................................................. 412 Subluxation Level Code 2300 | CR203 ................................................. 251 Subluxation Level Code 2300 | CR204 ................................................. 251 Subluxation Level Code 2400 | CR203 ................................................. 415 Subluxation Level Code 2400 | CR204 ................................................. 415 Submitted charge amount 2400 | SV102.................................................. 400 Submitter EDI Contact Information 1000A | PER ..................................................... 71 Submitter Name 1000A | NM103................................................. 67 Submitter Name 1000A | NM104................................................. 67 Submitter Name 1000A | NM105................................................. 67 Submitter Name 1000A | NM1..................................................... 67 Submitter Primary Identification Number 1000A | NM109................................................. 67 Subscriber Additional Name Information 2330A | N201.................................................. 353 Subscriber Address 2010BA | N3 ................................................... 121 Subscriber Address 1 2010BA | N301 ............................................... 121 Subscriber Address 1 2330A | N301.................................................. 354 Subscriber Address 2 2010BA | N302 ............................................... 121 Subscriber Address 2 2330A | N302.................................................. 354

Subscriber City Name 2010BA | N401 ...............................................122 Subscriber City Name 2330A | N401 ..................................................355 Subscriber City/State/ZIP Code 2010BA | N4 ...................................................122 Subscriber Country Code 2010BA | N404 ...............................................122 Subscriber Country Code 2330A | N404 ..................................................355 Subscriber Demographic Information 2010BA | DMG................................................124 Subscriber Demographic Information 2320 | DMG ....................................................342 Subscriber First Name 2010BA | NM104 ............................................ 117 Subscriber First Name 2330A | NM104 ...............................................350 Subscriber Generation 2010BA | NM107 ............................................ 117 Subscriber Generation 2330A | NM107 ...............................................350 Subscriber Hierarchical Level 2000B | HL......................................................108 Subscriber Information 2000B | SBR ................................................... 110 Subscriber Last Name 2010BA | NM103 ............................................ 117 Subscriber Last Name 2330A | NM103 ...............................................350 Subscriber Middle Name 2010BA | NM105 ............................................ 117 Subscriber Middle Name 2330A | NM105 ...............................................350 Subscriber Name 2010BA | NM1 ................................................ 117 Subscriber Primary Identifier 2010BA | NM109 ............................................ 117 Subscriber Secondary Identification 2010BA | REF .................................................126 Subscriber State Code 2010BA | N402 ...............................................122 Subscriber State Code 2330A | N402 ..................................................355 Subscriber Zip Code 2010BA | N403 ...............................................122

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Subscriber Zip Code 2330A | N403.................................................. 355 Subscribers Additional Name Information 2010BA | N201 ............................................... 120 Supervising Provider Additional Name Information 2310E | N201.................................................. 315 Supervising Provider Additional Name Information 2420D | N201 ................................................. 526 Supervising Provider First Name 2310E | NM104............................................... 312 Supervising Provider First Name 2420D | NM104 .............................................. 523 Supervising Provider Generation 2310E | NM107............................................... 312 Supervising Provider Generation 2420D | NM107 .............................................. 523 Supervising Provider Last Name 2310E | NM103............................................... 312 Supervising Provider Last Name 2330H | NM103 .............................................. 394 Supervising Provider Last Name 2420D | NM103 .............................................. 523 Supervising Provider Middle Name 2310E | NM105............................................... 312 Supervising Provider Middle Name 2420D | NM105 .............................................. 523 Supervising Provider Name 2310E | NM1................................................... 312 Supervising Provider Name 2420D | NM1 .................................................. 523 Supervising Provider Primary Identifier 2310E | NM109............................................... 312 Supervising Provider Secondary Identification 2310E | REF ................................................... 316 Supervising Provider Secondary Identification 2420D | REF................................................... 527 Supervising Provider Secondary Identifier 2310E | REF02 ............................................... 316 Supervising Provider Secondary Identifier 2420D | REF02............................................... 527

Supervising Providers Identification Number 2420D | NM109 ..............................................523 Supporting Documentation 2440 | FRM.....................................................569 Terms Discount Percent 2300 | CN105 .................................................217 Terms discount percent 2400 | CN105 .................................................466 Test Result 2400 | MEA.....................................................464 Test Results 2400 | MEA03 .................................................464 Time Code 2305 | HSD08 .................................................278 Total Purchased Service Amount 2300 | AMT .....................................................221 Total Submitted Charges 2300 | CLM02 .................................................170 Total visits projected, home health 2305 | CR703 .................................................276 Total visits rendered, home health 2305 | CR702 .................................................276 Transaction Set Control Number ST02 .................................................................62 Transaction Set Control Number SE02...............................................................572 Transaction Set Header ST .....................................................................62 Transaction Set Purpose Code BHT02 ..............................................................63 Transaction Set Trailer SE...................................................................572 Transmission Type Identification REF ..................................................................66 Transport Distance 2300 | CR106 .................................................248 Transport Distance 2400 | CR106 .................................................412 Transport purpose description 2400 | CR109 .................................................412 Treatment Number in Month. Spinal Manipulation 2300 | CR207 .................................................251 Treatment Number in Month. Spinal Manipulation 2400 | CR207 .................................................415

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Treatment Number. Spinal Manipulation 2300 | CR201 ................................................. 251 Treatment Number. Spinal Manipulation 2400 | CR201 ................................................. 415 Treatment Series Period. Spinal Manipulation 2300 | CR206 ................................................. 251 Treatment Series Period. Spinal Manipulation 2400 | CR206 ................................................. 415 Treatment Series Total. Spinal Manipulation 2300 | CR202 ................................................. 251

Treatment Series Total. Spinal Manipulation 2400 | CR202 .................................................415 Units or Minutes 2400 | SV104 ..................................................400 Universal Product Number (UPN) 2400 | REF .....................................................482 X-ray Availability Indicator, Chiropractic 2400 | CR212 .................................................415 X-ray Availability Indicator. Spinal Manipulation 2300 | CR212 .................................................251

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004010X098 837 HEALTH CARE CLAIM: PROFESSIONAL

K Loop 2440 Example

This Appendix is included to clarify how Loop 2440 - Form Identification - is used. On the next page is an example of a Medicare DMERC form, DMERC 08.02. If a DMERC provider were submitting a claim to Medicare and needed to include the information from this form on the claim submission, that information is carried in the 2440 loop in the following manner. The LQ segment is used to identify the form that is being attached to the claim. LQ01 is the Form Identification Code. This is the qualifier to identify a specific industry code list. There are two possible values for LQ01: Code AS Form Type Code is used to indicate that a Home Health form is being included with the claim. Code UT Health Care Financing Administration (HCFA) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms is used to indicate that a DMERC form is being included with the claim. LQ02 is the Form Identifier. This element carries the DMERC or Home Health form number. In the example given on the next page the LQ segment would be completed as follows:

LQ*UT*0802~
The next segment, the FRM, is used to answer the questions on the form identified in the LQ segment. The FRM elements are used to identify the question being answered (FRM01) One FRM is used for each question answered. The answer is placed in the appropriate FRM element: for Yes/No answers use FRM02, for answers that are in text (and those that dont fit another FRM element) use FRM03, for dates use FMR04, and for percents use FMR05. For the example given on the next page the following FMR segments would look like this:

FRM*1A**J0234~ FRM*1B**500~ FRM*1C**4~ FRM*4*Y~ FRM*5A**5~ FRM*5B**3~ FMR*8**METHODIST HOSPITAL~ FRM*9*INDIANAPOLIS~ FRM*10**INDIANA~ FRM*11***19971101~ FRM*12*Y~ FRM*1*N~

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Note that the answers to question 5A and 5B are carried in FRM03. It is not necessary to order the FRM segments in any particular order. The entire 2440 loop would look like this: (carriage returns are not allowed in actual transmissions)

LQ*UT*0802~ FRM*1A**J0234~ FRM*1B**500~ FRM*1C**4~ FRM*4*Y~ FRM*5A**5~ FRM*5B**3~ FMR*8**METHODIST HOSPITAL~ FRM*9*INDIANAPOLIS~ FRM*10**INDIANA~ FRM*11***19971101~ FRM*12*Y~ FRM*1*N~
The loop can be used 1 time so only 1 form can be attached to a line, but there can be more than one line per claim (up to 50 lines, maximum).

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MAY 2000

Effective 10/01/95

DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER

DMERC Information Form: IMMUNOSUPPRESSIVE DRUGS ALL INFORMATION ON THIS FORM MAY BE COMPLETED BY THE SUPPLIER

DMERC 08.02

Certification Type/Date: INITIAL

Mary Q. Public 1002 Main Street Indianapolis, IN 46250 (317) 555 9999 HICN ___444-22-4444A__

REVISED
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

XYZ Supplies 9999 Clark Street Indianapolis, IN 46224 (317) 555-7777

PT DOB ;

NSC # __9911223344_____

PLACE OF SERVICE 12 NAME and ADDRESS of FACILITY if applicable (see reverse):

10-15-23 Sex (M/F

TRANSPLANT DIAGNOSIS CODES (ICD-9) (CIRCLE APPROPRIATE CODES): V42 .0 (KIDNEY) V42.6 (LUNG)

V42.1 (HEART);

V42.7 (LIVER);

V42.8 (BONE MARROW);

V42.8 (OTHER-SPECIFY)

ANSWERS

ANSWER QUESTIONS 1 - 5 AND 8 - 12 FOR IMMUNOSUPPRESSIVE DRUGS (Circle Y for Yes, N for No, or D for Does Not Apply, Unless Otherwise Noted) Questions 6 and 7, reserved for other or future use. What are the drug(s) prescribed and the dosage and frequency of administration of each? HCPCS MG TIMES PER DAY 1. J0234 500
__________ __________

4
________ ________

2. __________ 3. __________

4. Has the patient had an organ transplant that was covered by Medicare?

Enter Correct Number(s) 3 5

5. Which organ(s) have been transplanted? (List most recent transplant) (May enter up to three different organs). 1 2 3 4 5 Heart Liver Kidney Bone Marrow Lung

Methodist Hospital Indianapolis Indiana 19971101 Y N

8. Name of facility where transplant was performed. 9. City where facility is located. 10. State where facility is located. 11. On what date was the patient discharged from the hospital following this transplant surgery? 12. Was there a prior transplant failure of this same organ?

PHYSICIAN NAME, ADDRESS (Printed or Typed)

Dr. John R. Smith 1212 Hospital Lane Indianapolis, In 46224

UPIN: D12345

____________________________________ SUPPLIERS SIGNATURE (A Stamped Signature Is Not Acceptable)

1-1-99 DATE

__Jane Jones, Owner /XYZ Supplies________________ PRINT NAME

TELEPHONE #:

(317) 272 -9999

Rev. 7/25/95

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