837 Post Adjudicated Claims Data Reporting: Dental (005010X300, 005010X300A1)

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

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)

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

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

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

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

Required

I06

Interchange Sender ID

M 1

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

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

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

Required

I07

Interchange Receiver ID

M 1

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

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
Must be a positive unsigned number and must be identical to the value in IEA02.

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

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

GS*HC - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

To indicate the beginning of a functional group and to provide control information

X12 Comments:

A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱XX✱SENDER CODE✱RECEIVER CODE✱20071231✱0802✱1✱X✱005010X300A1~

✱

✱

Application
Send's Code

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

This is the 2-character Functional Identifier Code assigned to each transaction set by X12. The specific code for a transaction set defined by this implementation guide is presented in section 1.2, Version Information.

CODE

DEFINITION

Health Care Claim (837)

Required

142

Application Sender's Code

M 1

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

Code identifying party receiving transmission; codes agreed to by trading partners

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

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.

Use this time for the creation time. The recommended format is HHMM.

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.

For implementations compliant with this guide, GS06 must be unique within a single transmission (that is, within a single ISA to IEA enveloping structure). The authors recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender.

Required

455

Responsible Agency Code

M 1

1/2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

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

INDUSTRY NAME: Version, Release, or Industry Identifier Code

This is the unique Version/Release/Industry Identifier Code assigned to an implementation by X12N. The specific code for a transaction set defined by this implementation guide is presented in section 1.2, Version Information.

CODE SOURCE 881:Version / Release / Industry Identifier Code

CODE

DEFINITION

005010X300A1

Post Adjudicated Claims Data Reporting: Dental

ST*837 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱837✱987654✱005010X300A1~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely identifying a Transaction Set

SEMANTIC: The transaction set identifier (ST01) is 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

837

Health Care Claim

Required

329

Transaction Set Control Number

M 1

4/9

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

The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

SEMANTIC: The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.

INDUSTRY NAME: Implementation Guide Version Name

This element must be populated with the guide identifier named in Section 1.2.
This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.

CODE

DEFINITION

005010X300A1

Post Adjudicated Claims Data Reporting: Dental

BHT*0019 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0019✱00✱44445✱20120213✱0345✱RP~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 1000A - SUBMITTER NAME

Required

1005

Hierarchical Structure Code

M 1

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

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

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.

CODE

DEFINITION

Original

Original transmissions are transmissions which have never been sent to the receiver.

Reissue

If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent.

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.

INDUSTRY NAME: Originator Application Transaction Identifier

The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.

Required

373

Date

O 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

INDUSTRY NAME: Claim or Encounter Identifier

CODE

DEFINITION

Reporting

NM1*41 - SUBMITTER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: 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.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The submitter is the entity responsible for the creation and formatting of this transaction.

TR3 Example:

NM1✱41✱2✱ABC SUBMITTER✱✱✱✱✱46✱999999999~

NM1

✱

✱

Loop 1000A - SUBMITTER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Submitter Last or Organization Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Submitter Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*IC - SUBMITTER EDI CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
The contact information in this segment identifies 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.
There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

Loop 1000B - RECEIVER NAME

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the contact name is different than the name contained in the Submitter Name (NM1) segment of this loopANDit is the first iteration of the Submitter EDI Contact Information (PER) segment.If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter Contact Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*40 - RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱40✱2✱XYZ RECEIVER✱✱✱✱✱46✱111222333~

NM1

✱

✱

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Receiver

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Receiver Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Receiver Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - BILLING PROVIDER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

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.

The first HL01 within each ST-SE envelope 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.

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

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 item-level information.

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 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

Additional Subordinate HL Data Segment in This Hierarchical Structure.

PRV*BI - BILLING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱BI✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Billing

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

CUR*85 - FOREIGN CURRENCY INFORMATION

X12 Name:

Currency

X12 Purpose:

To specify the currency (dollars, pounds, francs, etc.) used in a transaction

X12 Syntax:

C0807
If CUR08 is present, then CUR07 is required.
C0907
If CUR09 is present, then CUR07 is required.
L101112
If CUR10 is present, then at least one of CUR11 or CUR12 are required.
C1110
If CUR11 is present, then CUR10 is required.
C1210
If CUR12 is present, then CUR10 is required.
L131415
If CUR13 is present, then at least one of CUR14 or CUR15 are required.
C1413
If CUR14 is present, then CUR13 is required.
C1513
If CUR15 is present, then CUR13 is required.
L161718
If CUR16 is present, then at least one of CUR17 or CUR18 are required.
C1716
If CUR17 is present, then CUR16 is required.
C1816
If CUR18 is present, then CUR16 is required.
L192021
If CUR19 is present, then at least one of CUR20 or CUR21 are required.
C2019
If CUR20 is present, then CUR19 is required.
C2119
If CUR21 is present, then CUR19 is required.

X12 Comments:

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

Loop:

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.

TR3 Notes:

It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.

TR3 Example:

CUR✱85✱CAD~

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

100

Currency Code

M 1

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

The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

280

Exchange Rate

O 1

4/10

Not Used

Entity Identifier Code

O 1

2/3

Not Used

100

Currency Code

O 1

Not Used

669

Currency Market/Exchange Code

O 1

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

NM1*85 - BILLING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: 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.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI.
When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment.
The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

NM1✱85✱1✱SMITH✱JOHN✱B✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Billing Provider Last or Organizational Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

If, for whatever reason, the data is not stored within the payer's system, do not use.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - BILLING PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Billing Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Address Line

N4 - BILLING PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Billing Provider City Name

Situational

156

State or Province Code

X 1

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

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

SITUATIONAL RULE: Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send.

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

REF - BILLING PROVIDER TAX IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the tax identification number (TIN) of the entity paid for the submitted services.

TR3 Example:

REF✱EI✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Tax Identification Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*0B - BILLING PROVIDER LICENSE INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱0B✱654321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider License Information

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - BILLING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

HL - SUBSCRIBER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.

TR3 Example:

HL✱2✱1✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope 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.

Required

734

Hierarchical Parent ID Number

O 1

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

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 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.

The claim (Loop ID-2300) can be used 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 for one or more dependents of the subscriber are being sent under the same billing provider HL (for example, a spouse and son are both treated by the same provider). In that case, the subscriber HL04 = 1 because there is at least one dependent to this subscriber. The dependent HL (spouse) would then be sent followed by the Loop ID-2300 for the spouse. The next HL would be the dependent HL for the son followed by the Loop ID-2300 for the son.
In order to send claims for the subscriber and one or more dependents, the Subscriber HL, with Relationship Code SBR02=18 (Self), would be followed by the Subscriber's Loop ID-2300 for the Subscriber's claims. Then the Subscriber HL would be repeated, followed by one or more Patient HL loops for the dependents, with the proper Relationship Code in PAT01, each followed by their respective Loop ID-2300 for each dependent's claims.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SBR*N - SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

To record information specific to the primary insured and the insurance carrier for that insured

Loop:

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SBR✱N✱18~

SBR

✱

1138

Payer Resp
Seq No Code

✱

1069

Individual
Relat Code

✱

✱

✱

✱

✱

✱

584

Employment
Status Code

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

CODE

DEFINITION

Unconfirmed

Situational

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

SITUATIONAL RULE: Requried when the patient is the subscriber. If not required by this implementation guide, do not send.

CODE

DEFINITION

Self

Not Used

127

Reference Identification

O 1

1/50

Not Used

Name

O 1

1/60

Not Used

1336

Insurance Type Code

O 1

1/3

Not Used

1143

Coordination of Benefits Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
When submitting to an All Payer Claims Database or Health Benefit Exchange, this is the Subscriber as defined within the payers enrollment files. When submitting Medicare or Medicaid encounters, the patient is always the subscriber.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when an identifier has been assigned by the receiver. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when an identifier has been assigned by the receiver. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Address Line

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Subscriber City Name

Situational

156

State or Province Code

X 1

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

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Subscriber Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

REF*SY - SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when:

The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange.
AND
The social security number is allowed to be used for this purpose under applicable law or regulation.
AND
The social security number is available in the payer's system.

If not required by this implementation guide, do not send.

TR3 Notes:

Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2010BB - DATA RECEIVER

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*ZD - DATA RECEIVER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱ZD✱2✱Medicaid Agency~

NM1

✱

✱

Loop 2000C - PATIENT HIERARCHICAL LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Party to Receive Reports

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Data Receiver Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - PATIENT HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the data receiver is a reporting entity, such as an APCD or Health Insurance Exchange, AND the patient is not the subscriber.

TR3 Notes:

The information reported in this loop describes the patient as known by the payer's system.
When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.
There are no HLs subordinate to the Patient HL.

TR3 Example:

HL✱3✱2✱23✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Required

734

Hierarchical Parent ID Number

O 1

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

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

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

Required

736

Hierarchical Child Code

O 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.

PAT - PATIENT INFORMATION

X12 Name:

Patient Information

X12 Purpose:

To supply patient information

X12 Syntax:

P0506
If either PAT05 or PAT06 is present, then the other is required.
P0708
If either PAT07 or PAT08 is present, then the other is required.

Loop:

Loop 2000C - PATIENT HIERARCHICAL LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

PAT✱01~

PAT

✱

1069

Individual
Relat Code

✱

✱

Employment
Status Code

✱

✱

✱

✱

✱

✱

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

Specifies the patient's relationship to the person insured.

CODE

DEFINITION

Spouse

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Not Used

1384

Patient Location Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

Weight

X 1

1/10

Not Used

1073

Yes/No Condition or Response Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient has been assigned an identifier that is different than the subscriber identifier reported in Loop ID 2010BA NM109.If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Address Line

N4 - PATIENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Patient City Name

Situational

156

State or Province Code

X 1

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

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Patient Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

DMG*D8 - PATIENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Patient Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Patient Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

REF*SY - PATIENT SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Social Security Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

CLM - CLAIM INFORMATION

X12 Name:

Health Claim

X12 Purpose:

To specify basic data about the claim

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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 patient 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 patient. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent.

TR3 Example:

CLM✱013193000001✱500✱✱✱11:B:1✱Y✱A✱Y✱Y~

CLM

✱

1028

Claim Submt
Identifier

✱

✱

✱

✱

Health Care
Serv Loc.

✱

1073

✱

✱

✱

✱

Patient Sig
Source Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

1383

Claim Submt
Reason Code

✱

Required

1028

Claim Submitter's Identifier

M 1

1/38

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

INDUSTRY NAME: Patient Control Number

The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

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

INDUSTRY NAME: Total Claim Charge Amount

The Total Claim Charge Amount must be greater than or equal to zero.
The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
This amount represents the sum of the line charge amounts included in this portion of the claim.

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

Not Used

1343

Non-Institutional Claim Type Code

O 1

1/2

Required

C023

Health Care Service Location Information

O 1

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

X12 COMPOSITE SEMANTIC NOTES: C023-02 qualifies C023-01 and C023-03.

CLM05 applies to all service lines unless it is over written at the line level.

Required

5-1

1331

Facility Code Value

M 1

1/2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

INDUSTRY NAME: Place of Service Code

Required

5-2

1332

Facility Code Qualifier

O 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Place of Service Codes for Professional or Dental Services

CODE SOURCE: 237: Place of Service Codes for Professional Claims

Required

5-3

1325

Claim Frequency Type Code

O 1

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

INDUSTRY NAME: Claim Frequency Code

CODE SOURCE 235: Claim Frequency Type Code

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

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

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider or Supplier Signature Indicator

CODE

DEFINITION

Yes

Situational

1359

Provider Accept Assignment Code

O 1

Code indicating whether the provider accepts assignment

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assignment or Plan Participation Code

Within this element the context of the word assignment is related to the relationship between the provider and the payer.

CODE

DEFINITION

Assigned

Not Assigned

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

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.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefits Assignment Certification Indicator

This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.

CODE

DEFINITION

Not Applicable

Use code `W' when the patient refuses to assign benefits.

Yes

Situational

1363

Release of Information Code

O 1

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

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Not Used

1351

Patient Signature Source Code

O 1

Situational

C024

Related Causes Information

O 1

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

X12 COMPOSITE COMMENTS: C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required.

Required

11-1

1362

Related-Causes Code

M 1

2/3

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

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Situational

11-2

1362

Related-Causes Code

O 1

2/3

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

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Not Used

11-3

1362

Related-Causes Code

O 1

2/3

Situational

11-4

156

State or Province Code

O 1

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

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Auto Accident State or Province Code

CODE SOURCE 22: States and Provinces

Situational

11-5

Country Code

O 1

2/3

Code identifying the country

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE SOURCE 5: Countries, Currencies and Funds

Situational

1366

Special Program Code

O 1

2/3

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

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Special Program Indicator

CODE

DEFINITION

Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)

Physically Handicapped Children's Program

Special Federal Funding

Disability

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1029

Claim Status Code

O 1

1/2

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1383

Claim Submission Reason Code

O 1

Situational

1514

Delay Reason Code

O 1

1/2

Code indicating the reason why a request was delayed

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

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

Natural Disaster

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱439✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Accident Date

DTP*452 - APPLIANCE PLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱452✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

452

Appliance Placement

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Orthodontic Banding Date

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱472✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

DN1 - ORTHODONTIC TOTAL MONTHS OF TREATMENT

X12 Name:

Orthodontic Information

X12 Purpose:

To supply orthodontic information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DN1✱36✱27~
DN1✱✱✱Y~

DN1

✱

✱

✱

✱

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DN101 is the estimated number of treatment months.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Months Count

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DN102 is the number of treatment months remaining.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Months Remaining Count

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: DN104 is the appliance description.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Indicator

The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

P0405
If either DN204 or DN205 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DN2✱8✱E✱✱✱✱JP~

DN2

✱

✱

✱

✱

✱

✱

Required

127

Reference Identification

M 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: DN201 is the tooth number.

INDUSTRY NAME: Tooth Number

The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.

Required

1368

Tooth Status Code

O 1

1/2

Code specifying the status of the tooth

CODE

DEFINITION

To Be Extracted

Missing

Not Used

380

Quantity

O 1

1/15

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Required

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

SEMANTIC: DN206 designates the code set used to identify the tooth in DN201.

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

TR3 Example:

CN1✱02✱550~

CN1

✱

✱

✱

✱

✱

✱

Required

1166

Contract Type Code

M 1

Code identifying a contract type

CODE

DEFINITION

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Amount

Situational

332

Percent, Decimal Format

O 1

1/6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

SEMANTIC: CN103 is the allowance or charge percent.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Percentage

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: CN104 is the contract code.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Code

Situational

338

Terms Discount Percent

O 1

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

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Terms Discount Percentage

Situational

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Version Identifier

AMT*F5 - PATIENT AMOUNT PAID

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

AMT✱F5✱152.45~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Patient Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Patient Amount Paid

Not Used

478

Credit/Debit Flag Code

O 1

REF*9F - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referral Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*G1 - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G1✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior Authorization Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Authorization Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.

TR3 Notes:

The data conveyed in this segment is not related to the provider submission to the payer.

This segment is used only when the payer is submitting this transaction to the Data Receiver through an intermediary that assigns their own unique claim number.

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Number assigned by clearinghouse, van, etc.

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Claim Identifier for Transmission Intermediaries

The value carried in this element is limited to a maximum of 20 positions.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used:

- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.

- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.

Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

K3✱STATE DATA REQUIREMENT~

✱

449

Fixed Form
Information

✱

✱

Composite
Unit of Mea

Required

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

HI - HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

Do not transmit the decimal point for ICD codes. The decimal point is implied.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

HI✱BK:52403✱BF:52404~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2310A - REFERRING PROVIDER NAME

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.

The diagnosis listed in this element is assumed to be the principal diagnosis.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Systemized Nomenclature of Dentistry (SNODENT)

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:

If a new rule names the SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

CODE SOURCE: 135: American Dental Association

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Principal Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1-4

1251

Date Time Period

X 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1073

Yes/No Condition or Response Code

X 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE: 135: American Dental Association

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

2-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

2-4

1251

Date Time Period

X 1

1/35

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

X 1

1/30

Not Used

2-9

1073

Yes/No Condition or Response Code

X 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

See element HI02-1 for a list of valid values.

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE: 135: American Dental Association

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

3-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

3-4

1251

Date Time Period

X 1

1/35

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

X 1

1/30

Not Used

3-9

1073

Yes/No Condition or Response Code

X 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

See element HI02-1 for a list of valid values.

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE: 135: American Dental Association

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

4-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

4-4

1251

Date Time Period

X 1

1/35

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

X 1

1/30

Not Used

4-9

1073

Yes/No Condition or Response Code

X 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

NM1 - REFERRING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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 patient's episode of care being billed/reported in this transaction.
When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DN✱1✱WELBY✱MARCUS✱W✱✱JR✱XX✱1234567891~

NM1

✱

✱

Loop 2310A - REFERRING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Referring Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PRV*RF - REFERRING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱RF✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

REF - REFERRING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310A - REFERRING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referring Provider Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*82 - RENDERING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop 2310B - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider.

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

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.
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 substitute provider (locum tenens) was used, enter that provider's information here.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~

NM1

✱

✱

Loop 2310B - RENDERING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PRV*PE - RENDERING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

REF - RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310B - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*77 - SERVICE FACILITY LOCATION NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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.
This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

TR3 Example:

NM1✱77✱2✱A-OK MOBILE CLINIC✱✱✱✱✱XX✱1112233301~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Service Location

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Laboratory or Facility Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when received on the provider's original claim submission; the Service Location information originates from the 2310 Service Location loop of the provider submitted claim; and the NPI is different than the NPI reported in NM109 of Loop ID 2010AA (Billing Provider).If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Laboratory or Facility Primary Identifier

When an NPI is reported at this level, it must be different than the NPI reported in NM109 of Loop ID 2010AA (Billing Provider). When an NPI is present in this position, the service was performed in a location that is not a component of the Billing Provider.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - SERVICE FACILITY LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Laboratory or Facility Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Laboratory or Facility Address Line

N4 - SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Laboratory or Facility City Name

Situational

156

State or Province Code

X 1

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

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Laboratory or Facility State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Laboratory or Facility Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

REF - SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310D - ASSISTANT SURGEON NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Laboratory or Facility Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DD - ASSISTANT SURGEON NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DD✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567899~

NM1

✱

✱

Loop 2310D - ASSISTANT SURGEON NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Assistant Surgeon

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Assistant Surgeon Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Name Suffix

Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Primary Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PRV*AS - ASSISTANT SURGEON SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱AS✱PXC✱1223S0112X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

REF - ASSISTANT SURGEON SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310D - ASSISTANT SURGEON NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱0B✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Assistant Surgeon Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DQ - SUPERVISING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop 2310E - SUPERVISING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

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.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DQ✱1✱SMITH✱JOHN✱A✱✱✱XX✱2223334444~

NM1

✱

✱

Loop 2310E - SUPERVISING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Use this code for the supervising dentist or physician.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Supervising Provider Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

SBR - OTHER SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

To record information specific to the primary insured and the insurance carrier for that insured

X12 Set Notes:

NOTE: 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.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.
Loop ID 2320 and its suboordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by both the submitting payer and other payers who have previously adjudicated the claim.

This loop is not to be provided for payers who have not adjudicated the claim. For example, the provider submitted claim includes payer information that is subsequent to the payer submitting this transaction.

SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer.

When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider.

When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.

TR3 Example:

SBR✱P✱18✱G00786✱✱✱6✱✱✱CI~

SBR

✱

1138

Payer Resp
Seq No Code

✱

1069

Individual
Relat Code

✱

✱

✱

✱

✱

✱

584

Employment
Status Code

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

When this field is populated based upon the adjudication of the submitting payer, the selection of this code value is similar to how CLP02 in the 835 transaction is performed.

CODE

DEFINITION

Payer Responsibility Four

Payer Responsibility Five

Payer Responsibility Six

Payer Responsibility Seven

Payer Responsibility Eight

Payer Responsibility Nine

Payer Responsibility Ten

Payer Responsibility Eleven

Primary

Secondary

Tertiary

Unknown

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

CODE

DEFINITION

Spouse

Self

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: SBR03 is policy or group number.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer has assigned a group identifier to this benefit plan.ORRequired when SBR06 = 1; and this information was provided on the original claim from the provider.If not required by this implementation guide, do not send.

INDUSTRY NAME: Insured Group or Policy Number

This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.

Situational

Name

O 1

1/60

Free-form name

SEMANTIC: SBR04 is plan name.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer has assigned a group name to this benefit plan; and SBR03 is not used.ORRequired when SBR06 = 1; and this information was provided on the original claim from the provider.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Group Name

Not Used

1336

Insurance Type Code

O 1

1/3

Required

1143

Coordination of Benefits Code

O 1

Code identifying whether there is a coordination of benefits

CODE

DEFINITION

Coordination of Benefits

Use this code when the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 was submitted on the original claim from the provider.

No Coordination of Benefits

Use this code when the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication of the payer submitting this transaction.

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Required

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

CODE

DEFINITION

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Blue Cross/Blue Shield

Champus

Commercial Insurance Co.

Disability

Federal Employees Program

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Other Federal Program

Use code OF when submitting Medicare Part D claims.

Title V

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Use Code ZZ when Type of Insurance is not known.

CAS - CLAIM LEVEL ADJUSTMENTS

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Syntax:

L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
C0605
If CAS06 is present, then CAS05 is required.
C0705
If CAS07 is present, then CAS05 is required.
L080910
If CAS08 is present, then at least one of CAS09 or CAS10 are required.
C0908
If CAS09 is present, then CAS08 is required.
C1008
If CAS10 is present, then CAS08 is required.
L111213
If CAS11 is present, then at least one of CAS12 or CAS13 are required.
C1211
If CAS12 is present, then CAS11 is required.
C1311
If CAS13 is present, then CAS11 is required.
L141516
If CAS14 is present, then at least one of CAS15 or CAS16 are required.
C1514
If CAS15 is present, then CAS14 is required.
C1614
If CAS16 is present, then CAS14 is required.
L171819
If CAS17 is present, then at least one of CAS18 or CAS19 are required.
C1817
If CAS18 is present, then CAS17 is required.
C1917
If CAS19 is present, then CAS17 is required.

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim has claim level adjustment information. If not required by this implementation guide, do not send.

TR3 Notes:

Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
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.
A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
When the payer identified is not the submitting payer, codes and associated amounts must be reported as submitted by the provider.

When the payer identified is the submitting payer, codes and amounts must be reported the same as if creating the 835 to send to the provider.

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

CODE

DEFINITION

Contractual Obligations

Correction and Reversals

Other adjustments

Payor Initiated Reductions

Patient Responsibility

Required

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the number of service units has been adjusted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

SITUATIONAL RULE: Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

SITUATIONAL RULE: Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

SITUATIONAL RULE: Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

SITUATIONAL RULE: Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

SITUATIONAL RULE: Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

AMT*D - COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

AMT✱D✱411~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Payor Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Payer Paid Amount

It is acceptable to show "0" as the amount paid.
When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.

Not Used

478

Credit/Debit Flag Code

O 1

AMT*EAF - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

AMT✱EAF✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

EAF

Amount Owed

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Remaining Patient Liability

Not Used

478

Credit/Debit Flag Code

O 1

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Medicare Outpatient Adjudication

X12 Purpose:

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

TR3 Example:

MOA✱✱✱A4~

MOA

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SEMANTIC: MOA01 is the reimbursement rate.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.ORRequired when SBR06 = 1; and this information was provided on the original claim from the provider.If not required by this implementation guide, do not send.

INDUSTRY NAME: Reimbursement Rate

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.

INDUSTRY NAME: HCPCS Payable Amount

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA03 is the Claim Payment Remark Code. See Code Source 411.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA04 is the Claim Payment Remark Code. See Code Source 411.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA05 is the Claim Payment Remark Code. See Code Source 411.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA06 is the Claim Payment Remark Code. See Code Source 411.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA07 is the Claim Payment Remark Code. See Code Source 411.

INDUSTRY NAME: Claim Payment Remark Code

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA09 is the professional component amount billed but not payable.

INDUSTRY NAME: Non-Payable Professional Component Billed Amount

NM1*IL - OTHER SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

When SBR06 = 1, the information in this segment represents the Subscriber as submitted by the provider for the payer identified in Loop ID 2330B.

When SBR06 = 6, the information in this segment represents the Subscriber as known by the submitting payer.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Insured Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Name Suffix

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Insured Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - OTHER SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Insured Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Address Line

If, for whatever reason, the data is not stored within the payer's system, do not use.

N4 - OTHER SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Other Insured City Name

Situational

156

State or Province Code

X 1

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

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Other Insured Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

REF*SY - OTHER SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Insured Additional Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*PR - OTHER PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱PR✱2✱ABC INSURANCE CO✱✱✱✱✱PI✱11122333~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Payer Last or Organization Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:
1. Both the sender and receiver agree to use the National Plan ID,
2. The receiver has a National Plan ID, and
3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

CODE

DEFINITION

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Payer Primary Identifier

When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

DTP*573 - CLAIM CHECK OR REMITTANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱573✱D8✱20120503~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

573

Date Claim Paid

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Adjudication or Payment Date

REF - OTHER PAYER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Employer's Identification Number

Claim Office Number

National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE: 245: National Association of Insurance Commissioners (NAIC) Code

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*T4 - OTHER PAYER CLAIM ADJUSTMENT INDICATOR

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SBR06 = 6; and this claim is a void or adjustment of a previously adjudicated claim.

If not required by this implementation guide, do not send.

TR3 Example:

REF✱T4✱Y~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Signal Code

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Claim Adjustment Indicator

The only valid value for this element is `Y'.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F8 - OTHER PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SBR06 = 6.
OR
Required when available in the payer's system.

If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱F8✱R555588~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer's Claim Control Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BP - OTHER PAYER ADJUSTED CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SBR06 = 6 and the submitting payer has adjusted this claim.
OR
Required when available in the payer's system.

If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱BP✱R5555589~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Adjustment Control Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer's Adjusted Claim Control Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*QC - OTHER PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the entity reported in Loop ID 2330A (Other Payer Subscriber) is not the patient.

TR3 Notes:

When SBR06 = 1, the information in this segment represents the Patient as submitted by the provider for the payer identified in Loop ID 2330B.

When SBR06 = 6, the information in this segment represents the Patient as known by the submitting payer.

TR3 Example:

NM1✱QC✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Insured Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient has been assigned an identifier that is different than the subscriber identifier reported in Loop ID 2330A NM109.If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Insured Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - OTHER PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Patient Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Patient Address Line

If, for whatever reason, the data is not stored within the payer's system, do not use.

N4 - OTHER PATIENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Other Patient City Name

Situational

156

State or Province Code

X 1

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

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Patient State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Other Patient Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

REF*SY - OTHER PATIENT SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Insured Additional Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

LX - SERVICE LINE NUMBER

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

NOTE: Loop 2400 contains Service Line information.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The LX functions as a line counter.
The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.2.4 for more information on bundling and section 1.4.2.6 for more information on unbundling.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/6

Number assigned for differentiation within a transaction set

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SV3✱AD:D2150✱80✱✱✱✱1~

SV3

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

Oral Cavity
Designat.

✱

1358

Prosthesis/
Inlay Code

✱

✱

✱

✱

✱

✱

C004

Comp. Diag.
Code Point.

Required

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.

Required

1-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CDT = Current Dental Terminology

CODE SOURCE: 135: American Dental Association

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

1-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

1-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

1-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

1-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

1-7

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Not Used

1-8

234

Product/Service ID

O 1

1/48

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

INDUSTRY NAME: Line Item Charge Amount

This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
Zero "0" is an acceptable value for this element.

Situational

1331

Facility Code Value

O 1

1/2

SEMANTIC: SV303 is the place of service code representing the location where the dental treatment was rendered.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Place of Service Code

See CODE SOURCE 237: Place of Service Codes for Professional Claims

Situational

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Do not use this element for reporting of individual teeth. If it is necessary to report one or more individual teeth, use the Tooth Information (TOO) segment in this loop.
If, for whatever reason, the data is not stored within the payer's system, do not use.

Required

4-1

1361

Oral Cavity Designation Code

M 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

CODE SOURCE 135: American Dental Association

Situational

4-2

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

Situational

4-3

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

Situational

4-4

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

Situational

4-5

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

Situational

1358

Prosthesis, Crown or Inlay Code

O 1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

If, for whatever reason, the data is not stored within the payer's system, do not use.

CODE

DEFINITION

Initial Placement

Replacement

When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Count

Number of procedures
If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

352

Description

O 1

1/80

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

X12 COMPOSITE SEMANTIC NOTES:

C004-01 identifies the primary diagnosis code for this service line.
C004-02 identifies the second diagnosis code for this service line.
C004-03 identifies the third diagnosis code for this service line.
C004-04 identifies the fourth diagnosis code for this service line.

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 4, and correspond to Composite Data Elements 01 through 04 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300.
If, for whatever reason, the data is not stored within the payer's system, do not use.

Required

11-1

1328

Diagnosis Code Pointer

M 1

1/2

A pointer to the diagnosis code in the order of importance to this service

Situational

11-2

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Situational

11-3

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Situational

11-4

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

TOO*JP - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

P0102
If either TOO01 or TOO02 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

See Appendix A for code source 135: American Dental Association Codes.
This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱472✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

DTP - PRIOR PLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱441✱D8✱20120401~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

139

Estimated

Required when the exact Prior Placement Date is not known.

441

Prior Placement

Required when the exact Prior Placement Date is known.

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Prior Placement Date

DTP*452 - APPLIANCE PLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱452✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

452

Appliance Placement

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Orthodontic Banding Date

DTP*446 - REPLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱446✱D8✱20120127~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

446

Replacement

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Replacement Date

DTP*196 - TREATMENT START DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

When the Treatment Start Date is used, the Date of Service must not be used.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱196✱D8✱20120115~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

196

Start

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Treatment Start Date

DTP*198 - TREATMENT COMPLETION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

When the Treatment Completion Date is used, the Date of Service must not be used.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱198✱D8✱20120129~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

198

Completion

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Treatment Completion Date

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

TR3 Example:

CN1✱02✱550~

CN1

✱

✱

✱

✱

✱

✱

Required

1166

Contract Type Code

M 1

Code identifying a contract type

CODE

DEFINITION

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Amount

Situational

332

Percent, Decimal Format

O 1

1/6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

SEMANTIC: CN103 is the allowance or charge percent.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Percentage

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: CN104 is the contract code.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Code

Situational

338

Terms Discount Percent

O 1

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

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Terms Discount Percentage

Situational

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Version Identifier

REF*G1 - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G1✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior Authorization Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Authorization or Referral Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9F - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referral Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used:

- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.

- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.

Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

K3✱STATE DATA REQUIREMENT~

✱

449

Fixed Form
Information

✱

✱

Composite
Unit of Mea

Loop 2420A - RENDERING PROVIDER NAME

Required

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

NM1*82 - RENDERING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: 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.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider.

OR

Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider.

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

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 substitute provider (locum tenens) was used, enter that provider's information here.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~

NM1

✱

✱

Loop 2420A - RENDERING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PRV*PE - RENDERING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

REF - RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2420A - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DD - ASSISTANT SURGEON NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

Loop:

Loop 2420B - ASSISTANT SURGEON NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DD✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567899~

NM1

✱

✱

Loop 2420B - ASSISTANT SURGEON NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Assistant Surgeon

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Assistant Surgeon Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Primary Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PRV*AS - ASSISTANT SURGEON SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱AS✱PXC✱1223S0112X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

REF - ASSISTANT SURGEON SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2420B - ASSISTANT SURGEON NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Assistant Surgeon Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DQ - SUPERVISING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

Loop:

Loop 2420C - SUPERVISING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DQ✱1✱SMITH✱JOHN✱A✱✱✱XX✱2223334444~

NM1

✱

✱

Loop 2420C - SUPERVISING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Use this code for the supervising dentist or physician.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱0B✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Supervising Provider Secondary Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

SVD - LINE ADJUDICATION INFORMATION

X12 Name:

Service Line Adjudication

X12 Purpose:

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

X12 Set Notes:

NOTE: SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when 2320 SBR06 = 6 and an 835 sent to the provider would have included service line detail.
OR
Required when the related Loop ID 2320 SBR06 = 1; and the data was present on the provider submitted claim.

If not required by this implementation guide, do not send.

TR3 Notes:

Loop ID 2430 conveys information demonstrating how this line was adjudicated by both the submitting payer and other payers who have previously adjudicated the line.

Loop 2430 and the related 2320 loop are linked using the value reported in Loop 2320 SBR01 and Loop 2430 SVD01.

Loop 2320 SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer.

When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider.

When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.

TR3 Example:

SVD✱43✱55✱AD:D0330✱✱1~

SVD

✱

✱

✱

Comp. Med.
Proced. ID

✱

✱

✱

Required

Identification Code

M 1

2/80

Code identifying a party or other code

SEMANTIC: SVD01 is the payer identification code.

INDUSTRY NAME: Other Payer Primary Identifier

This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVD02 is the amount paid for this service line.

INDUSTRY NAME: Service Line Paid Amount

Zero "0" is an acceptable value for this element.

Required

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

COMMENT: SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.

This element contains the procedure code that was used to pay this service line.

Required

3-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE: 576: Workers Compensation Specific Procedure and Supply Codes

Required

3-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

3-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. This is the first procedure code modifier. If not required by this implementation guide, do not send.

This is the first procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

3-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a second modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

This is the second procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

3-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a third modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

This is the third procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Situational

3-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

This is the fourth procedure code modifier.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

Not Used

3-7

352

Description

O 1

1/80

Not Used

3-8

234

Product/Service ID

O 1

1/48

Not Used

234

Product/Service ID

O 1

1/48

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVD05 is the paid units of service.

INDUSTRY NAME: Paid Service Unit Count

The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.

Situational

554

Assigned Number

O 1

1/6

Number assigned for differentiation within a transaction set

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.

SITUATIONAL RULE: Required when payer bundled this service line. If not required by this implementation guide, do not send.

INDUSTRY NAME: Bundled or Unbundled Line Number

CAS - LINE ADJUSTMENT

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Syntax:

L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
C0605
If CAS06 is present, then CAS05 is required.
C0705
If CAS07 is present, then CAS05 is required.
L080910
If CAS08 is present, then at least one of CAS09 or CAS10 are required.
C0908
If CAS09 is present, then CAS08 is required.
C1008
If CAS10 is present, then CAS08 is required.
L111213
If CAS11 is present, then at least one of CAS12 or CAS13 are required.
C1211
If CAS12 is present, then CAS11 is required.
C1311
If CAS13 is present, then CAS11 is required.
L141516
If CAS14 is present, then at least one of CAS15 or CAS16 are required.
C1514
If CAS15 is present, then CAS14 is required.
C1614
If CAS16 is present, then CAS14 is required.
L171819
If CAS17 is present, then at least one of CAS18 or CAS19 are required.
C1817
If CAS18 is present, then CAS17 is required.
C1917
If CAS19 is present, then CAS17 is required.

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer identified in this Line Adjudication Information Loop ID-2430 made line level adjustments which caused the dollar amount paid for the service line (SVD02) to differ from the amount originally charged for this service. If not required by this implementation guide, do not send.

TR3 Notes:

A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

CODE

DEFINITION

Contractual Obligations

Correction and Reversals

Other adjustments

Payor Initiated Reductions

Patient Responsibility

Required

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the number of service units has been adjusted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

SITUATIONAL RULE: Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

SITUATIONAL RULE: Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

SITUATIONAL RULE: Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

SITUATIONAL RULE: Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

SITUATIONAL RULE: Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

DTP*573 - LINE CHECK OR REMITTANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱573✱D8✱20120503~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

573

Date Claim Paid

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Adjudication or Payment Date

AMT*EAF - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:

In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

AMT✱EAF✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

EAF

Amount Owed

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Remaining Patient Liability

Not Used

478

Credit/Debit Flag Code

O 1

SE - TRANSACTION SET TRAILER

X12 Name:

Transaction Set Trailer

X12 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)

X12 Comments:

SE is the last segment of each transaction set.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SE✱1230✱987654~

✱

✱

Required

Number of Included Segments

M 1

1/10

Total number of segments included in a transaction set including ST and SE segments

INDUSTRY NAME: Transaction Segment Count

Required

329

Transaction Set Control Number

M 1

4/9

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

The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.

GE - FUNCTIONAL GROUP TRAILER

X12 Name:

Functional Group Trailer

X12 Purpose:

To indicate the end of a functional group and to provide control information

X12 Comments:

The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GE✱1✱1~

✱

Number of
TS Included

✱

Required

Number of Transaction Sets Included

M 1

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

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GE02 in this trailer must be identical to the same data element in the associated functional group header, GS06.

IEA - INTERCHANGE CONTROL TRAILER

X12 Name:

Interchange Control Trailer

X12 Purpose:

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Example:

IEA✱1✱000000905~

IEA

✱

I16

Num of Incl
Funct Group

✱

Required

I16

Number of Included Functional Groups

M 1

1/5

A count of the number of functional groups included in an interchange

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

837 Post Adjudicated Claims Data Reporting: Dental (005010X300, 005010X300A1)

OCTOBER 2016

Copyright © 2008-16, X12 Incorporated, Format © 2008-16 Washington Publishing Company. Exclusively published by the Washington Publishing Company. No part of this publication may be distributed, posted, reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written permission of the copyright owner.

Abstract

The Post Adjudicated Claims Data Reporting: Dental Implementation Guide describes the use of the ASC X12 Health Care Claim (837) transaction set for reporting health care dental service post adjudicated data:

to satisfy state and federal reporting requirements such as; Medicare and Medicaid encounters, All Payer Claims Databases, and Health Care Insurance Exchanges
for use in health data analysis from payer data

Preface

ASC X12 standards are developed to identify the broadest data requirements for a transaction set. Type 3 Technical Reports (TR3) define explicit data requirements for a specific business purpose. Trading partners who implement according to the instructions in this TR3 can exchange data with multiple trading partners in a consistent manner.

Trading partners define their specific transport requirements separately. Neither ASC X12 standards nor TR3s define transport requirements.

1.1 Implementation Purpose and Scope

The purpose of this implementation guide is to define the transaction set used to exchange post adjudicated claims data. The entities involved in this exchange include payers and organizations that receive post adjudicated claim data. This exchange may be performed directly or via transmission intermediaries, such as clearinghouses and value added networks. For further clarification on definitions of the participants, see section 1.5 Business Terminology of this implementation guide.

This is the technical report document for the ASC X12N 837 Health Care Claims (837) transaction for dental post adjudicated data reporting.

This document provides a definitive statement of what trading partners must be able to support in this implementation of the 837.

1.2 Version Information

This implementation guide is based on the October 2003 ASC X12 standards, referred to as Version 5, Release 1, Sub-release 0 (005010).

The unique Version/Release/Industry Identifier Code for transaction sets that are defined by this implementation guide is 005010X300A1.

The two-character Functional Identifier Code for the transaction set included in this implementation guide:

HC Health Care Claim (837)

The Version/Release/Industry Identifier Code and the applicable Functional Identifier Code must be transmitted in the Functional Group Header (GS segment) that begins a functional group of these transaction sets. For more information, see the descriptions of GS01 and GS08 in Appendix C.

1.3.1 Batch and Real-time Usage

There are multiple methods available for sending and receiving business transactions electronically. Two common modes for EDI transactions are batch and real-time.

Batch - In a batch mode the sender does not remain connected while the receiver processes the transactions. Processing is usually completed according to a set schedule. If there is an associated business response transaction (such as a 271 Response to a 270 Request for Eligibility), the receiver creates the response transaction and stores it for future delivery or transmits the response transaction back to the sender of the original transaction. The sender of the original transmission reconnects at a later time and picks up the response transaction if the transaction was not transmitted back to the sender of the original transaction. This implementation guide does not set specific response time parameters for these activities.

Real-Time - In real-time mode the sender remains connected while the receiver processes the transactions and returns a response transaction to the sender. This implementation guide does not set specific response time parameters for implementers.

This implementation guide was based on requirements for batch mode. Willing trading partners may use batch or real-time mode.

1.3.2 Other Usage Limitations

When processing in batch mode, receiving trading partners may have system limitations which control the size of the transmission they can receive. Some submitters may have the capability and the desire to transmit large 837 transactions with thousands of claims contained in them. This implementation guide limits the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. Willing trading partners can agree to higher limits. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA.

When a claim is processed in real-time, only one CLM per ISA/IEA is allowed and must be responded to in a single communication session.

1.4 Business Usage

This transaction set is used by trading partners to exchange post adjudicated claims data. Trading partners include:

payers
All Payer Claims Database administrators
Health Insurance Exchange administrators
other data reporting entities

For purposes of this standard, the payer is an entity that pays claims or administers the insurance product, benefit, or both. For example, a payer may be an insurance company, health maintenance organization (HMO), government agency (Medicare, Medicaid, TRICARE, 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 segment of the health care/insurance industry.

The transaction defined by this implementation guide is intended to originate with the payer to report encounter or post adjudicated claim data to:

another payer.
an All Payer Claims Database maintained by public health entities.
a Health Insurance Exchange.

1.4.1 Health Care Transaction Flow

Each ASC X12 implementation guide explains how to use ASC X12 transaction sets to meet a single defined business purpose. The following diagrams, current as of version 005010, depict the business functions supported by the ASC X12 health care implementation guide. The intent of these diagrams is to represent the possible exchanges between trading partners using these implementation guides. Trading partners include entities that administer part or all of a health plan, fund the plan and enroll members, and provide the health care services

Health Care Claim and Encounter plus Additional Support Information
005010X222 837 Health Care Claim: Professional
005010X223 837 Health Care Claim: Institutional
005010X224 837 Health Care Claim: Dental
005010X214 277 Health Care Claim Acknowledgment
Health Care Claim Payment
005010X221 835 Health Care Claim Payment/Advice
Post Adjudicated Claim Data Reporting (PACDR)
005010X298 837 Post Adjudicated Claim Data Reporting: Professional
005010X299 837 Post Adjudicated Claim Data Reporting: Institutional
005010X300 837 Post Adjudicated Claim Data Reporting: Dental

This section and the associated diagram does not limit or prohibit other means of payer's receiving claims (for example, provider submitted paper claims or claims received directly from subscribers or patients) from being represented in these transactions. The intent is only to show the data flow when EDI transactions are used starting with the original data source to the final destination. The implementation guide was developed with the understanding a payer will not always have the full 837 data set available to be forwarded in a Post Adjudciation transaction.

1.4.2 Data Changed By Adjudication

Payer adjudication practices may result in altered representations of claim data. This section describes a few of those possible scenarios and how to represent that data in a way that allows the receiver to understand what transpired. The examples follow the claim from the originating provider, through adjudication to the 835 transaction, and then show how the adjudicated data is presented in the data reporting transaction. Only the noteworthy segments are shown in the examples.

1.4.2.1 Typical adjudication

Claim and Line adjudicated as submitted.
The original claim from the provider included a single line item and was adjudicated as a single line item by the payer.

Provider claim:	CLM1CL100**11:B:1~ SV3AD:A100***1~
835 to provider	CLP1CL110075*122011092600001~ SVCAD:A100751~ CASCO4525~
Health Plan Claim:	CLM1CL100**11:B:1~ REFF82011092600001~ SV3AD:A100**1~ SVD<Related SBR01 value>75AD:A*1~ CASCO4525~

1.4.2.2 Adjudicated procedure different than submitted

Adjudicated procedure is different than the submitted procedure.
The original claim from the provider included a single line item with procedure code A. During adjudication, the payer changed the procedure code to B.

Provider claim:	CLM2CL100**11:B:1~ SV3AD:A100***1~AD:~
835 to provider:	CLP2CL110050*122011092600002~ SVCAD:B100501AD:A~ CASCO45*50~
Health Plan Claim:	CLM2CL100**11:B:1~ REFF82011092600002~ SV3AD:A100**1~ SVD<Related SBR01 value>50AD:B*1~ CASCO4550~

1.4.2.3 Adjudicated Line Split

Adjudicated procedure is different than the submitted procedure.
The original claim from the provider included a single line item with a range of service dates that spanned across eligibility or benefit years requiring split processing by the payer.

Provider claim:	CLM3CL300**11:B:1~ SV3AD:A300**3~ DTP472RD820101231-20110102~
835 to provider:	CLP3CL1300225*122011092600003~ SVCAD:A100751~ DTM47220101231~ CASCO4525~ SVCAD:A2001502~ DTM15020110101~ DTM15120110102~ CASCO4550~
Health Plan claim:	CLM3CL300**11:B:1~ REFF82011092600003~ SV3AD:A300**3~ DTP472RD820101231-20110102~ SVD<Related SBR01 value>75AD:A1~ CASCO4525~ SVD<Related SBR01 value>150AD:A2~ CASCO4550~

1.4.2.4 Bundled Lines

Submitted lines combined into a single line for processing and pricing.
The original claim from the provider included two line items the payer considers payable as a single service. As a result, the payer adds a code that represents those combined services to the adjudication system.

Provider claim:	CLM4CL200**11:B:1~ SV3AD:A100**1~ SV3AD:B100***1~
835 example:	CLP4CL120010020122011092600004~ SVCAD:C100100**AD:A~ CASOA94-100~ CASCO4580~ CASPR220~ SVCAD:C10000AD:B1~ CASOA97100~
Health Plan Claim:	CLM4CL300**11:B:1~ REFF82011092600004~ SV3AD:A100**1~ SVD<Related SBR01 value>100AD:C*1~ CASOA94-100~ CASCO4580~ CASPR220~ SV2AD:B100***1~ SVD<Related SBR01 value>0AD:C*1~ CASOA97100~

1.4.2.5 Split Claims

Submitted lines split into multiple claims for processing.
The original claim from the provider included two line items. For processing reasons, the payer created two separate claims with a single line.

Provider Claim:	CLM5CL220**11:B:1~ SV3AD:A100**1~ DTP472D820101231~ SV2AD:B**1~AD:~ DTP472D820110101~
835 to provider:	CLP5CL110050*122011092600005~ SVCAD:A10050~ DTM47220101231~ CASCO45500~ CLP5CL110050*122011092600015~ SVCAD:B12060~ DTM47220110101~ CASCO4560~
Health Plan claim:	CLM5CL100**11:B:1~ REFF82011092600005~ SV3AD:A100**1~ DTP472D820101231~ SVD<Related SBR01 value>50AD:A1~ CASCO4550~ CLM5CL120**11:B:1~ REFF82011092600015~ SV3AD:A100**1~ DTP472D820110101~ SVD<Related SBR01 value>60AD:B2~ CASCO4560~

1.4.2.6 Unbundled Lines

Submitted lines split into multiple lines for processing and pricing.
The original claim from the provider included a single line items the payer considers payable as multiple services. As a result, the payer adds line items and adjudicates using procedure codes that represent the independent services to the adjudication system.

Provider Claim:	CLM6CL200**11:B:1~ SV3AD:A100**1~ DTP472D820110926~
835 to provider:	CLP6CL1200120*122011092600006~ SVCAD:B20060*AD:A~ CASCO45140~ SVCAD:C060*AD:A~ CASOA94-60~
Health Plan claim:	CLM6CL200**11:B:1~ REFF82011092600006~ SV3AD:A100**1~ SVD<Related SBR01 value>60AD:B*1AD:A~ CASCO45140~ SVD<Related SBR01 value>60AD:C*1AD:A~ CASOA94*-60~

1.4.3 Subscriber / Patient Information

The structure of this implementation guide is different from a "normal" provider submitted claim in that, as an entity, the Data Receiver does not always assign subscriber or patient identifier of their own. With the exception of Medicare and Medicaid encounters, the desire of the receiver is to retain the subscriber/patient relationship as known to the submitting entity.

Header Level Subscriber/Patient Information (Loops 2010BA and 2010CA)
For submissions directed to entities such as an All Payer Claims Database or Health Insurance Exchange, the Subscriber identified in loop 2010BA is the actual subscriber as known to the submitting plan, and report identifiers as assigned by the receiving entity and social security numbers when allowed by applicable law and properly secured.

Since the Data Receiver is not serving in the role of a payer, things like the Payer Responsibility Sequence Code (SBR01) and others are not applicable. Where able, these elements have been changed to Not Used. If the element is defined as Mandatory in the standard (SBR01 for example), a default has been defined.

In the case of submissions to Medicare and Medicaid agencies, the Subscriber identified in loop 2010BA is the patient and therefore the patient loop is never used.

Other Payer Level Subscriber/Patient Information (Loops 2330A and 2330C)
Subscriber and Patient information reported at this level will need to be viewed in two different ways. The difference is based upon whether this is the information related to the submitting payer, or Coordination of Benefits information extracted from the claim submitted to the payer requesting payment.

Submitting Payer (Identified by SBR06 = 6)
In this scenario, the subscriber is the actual subscriber as defined by the payer's enrollment files. The patient information is used when the patient is a dependent of the subscriber as defined by the payer's enrollment files.

Coordination of Benefits Submission (Identified by SBR06 = 1)
In this scenario, the subscriber and patient information is reported as received on the claim submitted to the payer requesting payment.

1.4.4 Provider Taxonomy Code Reporting

Provider Taxonomy Codes describe provider type, classification, and area of specialization and are maintained by the National Uniform Claims Committee. For use in post adjudication reporting, the taxonomy reported is determined by the payer's adjudication process. When the payer does not use taxonomies in their processing, the taxonomy may not be included in the transaction.

1.4.5 Balancing

In order to ensure internal claim integrity, amounts reported in the 837 MUST balance at two different levels — the claim and the service line.

1.4.5.1 Claim Level

There are two different ways the claim information must balance. They are as follows.

1) Claim Charge Amounts
The total claim charge amount reported in Loop ID-2300 CLM02 must balance to the sum of all service line charge amounts reported in Loop ID-2400 SV302.

2) Claim Payment Amounts
Balancing of claim payment information is done payer by payer. For a given payer that has service line adjudication data, the sum of all line level payment amounts (Loop ID-2430 SVD02) less any claim level adjustment amounts (Loop ID-2320 CAS adjustments) must balance to the claim level payment amount (Loop ID-2320 AMT02).

When a previous payer's adjudication data is only at the claim level, the claim level payment amount for a payer (Loop ID-2320 AMT02) must equal the Total Claim Charge Amount (Loop ID-2300 CLM02) less any claim level adjustment amounts for that payer (Loop ID-2320 CAS adjustments).

Expressed as a calculation for given payer that has service line adjudication data: {Loop ID-2320 AMT02 payer payment} = {sum of Loop ID-2430 SVD02 payment amounts} minus {sum of Loop ID-2320 CAS adjustment amounts}.

Line Level Payment Amounts
Line level payment information is reported in Loop ID-2430 SVD02. In order to perform the balancing function, the receiver must know which payer the line payment belongs to. This is accomplished using the identifier reported in Loop ID-2430 SVD01.This identifier must match the identifier of the corresponding payer identifier reported in Loop ID-2320 SBR01.

Adjustment Calculations
Adjustments are reported in the CAS segments of Loop ID-2320 (claim level) and Loop ID-2430 (line level). Adjustment amounts DECREASE the payment amount when the adjustment amount is POSITIVE, and INCREASE the payment amount when the adjustment amount is NEGATIVE.

Claim Level Payment Amount
At the claim level, the payer's total claim payment is reported within the Loop ID-2320 Coordination of Benefits (COB) Payer Paid Amount AMT segment with a D qualifier in AMT01. The associated payer is defined within the Loop ID-2330B child loop. Note that this example includes adjustments at both the service line and a separate claim level adjustment. Claim adjustments ARE NOT the sum of the line adjustments.

Example:

Claim Charge = 100.00
Claim Payment = 80.00
Claim Adjustment = 5.00

Line 1 Charge = 80.00
Line 1 Payment = 70.00
Line 1 Adjustment = 10.00

Line 2 Charge = 20.00
Line 2 Payment = 15.00
Line 2 Adjustment = 5.00

Claim payment ($80) = Line 1 payment ($70) plus Line 2 payment ($15) minus claim adjustment ($5).

1.4.5.2 Service Line

Service line balancing applies independently for each Payer's Line Adjudication Information loop, Loop ID-2430. In order to balance, the sum of all service line adjustments and the service line payment within a Payer's 2430 Line Adjudication Information loop must balance to the Line Item Charge Amount for that service line.

When a single service line has multiple 2430 loops for the same Payer, balancing logic must be modified. In the case of 2430 loops from two benefit plans from the same Payer, each SVD loop must balance independently as described above. Whereas, in the case of a single payer's adjudication unbundling services resulting in multiple 2430 loops, one for each unbundled service, the payments and adjustments for all such loops for that Payer must be summed together to balance to the Line Item Charge.

The balancing calculation for each 2430 loop (other than the exceptions listed above) is as follows:

{Sum of all Loop-ID 2430 CAS Adjustment Amounts},
plus
{Loop-ID 2430 SVD02 Service Line Paid Amount}
=
{Loop ID-2400 SV203 Line Item Charge Amount}

Example:

Line 1 Charge = 80.00
Line 1 Payment = 70.00
Line 1 Adjustment = 10.00

Line 2 Charge = 20.00
Line 2 Payment = 15.00
Line 2 Adjustment = 5.00
Line 1 adjustment ($10) plus Line 1 payment ($70) = Line 1 charge ($80).
Line 2 adjustment ($5) plus Line 2 payment ($15) = Line 2 charge ($20)

1.5 Business Terminology

This section defines terms used in this implementation guide that are not included in the Data Dictionary Appendix. See the Data Dictionary Appendix for additional terms and definitions.

All Payer Claims Database
The APCD is a database, typically created by state mandate, generally comprised of medical, pharmacy, and dental claims, and information from the member eligibility, provider, and product files encompassing fully-insured, self-insured, Medicare, and Medicaid data.

Bundling
Bundling occurs when a provider reports two or more procedure codes, but the payer adjudicates them together using a single (possibly different) procedure code.

Claim
For the purposes of this implementation guide, claim is intended to be an all-inclusive term to represent adjudicated claims and encounter reporting. When there are differences, they are specifically noted.

Encounter
For the purposes of this implementation guide, the following definitions apply:

When the word "encounter" is used by itself: pre-adjudicated health care service information submitted by the provider to the payer for the purpose of reporting the service rather than requesting payment.
When an encounter is referred to as a "Medicare Encounter", "Medicaid Encounter" or "Medicare/Medicaid encounter": post adjudicated claim data reported from the payer to the Medicare or Medicaid agency.

Health Insurance Exchange
As defined by the Affordable Care Act a Health Insurance Exchange is an organization that provides a marketplace for health insurance coverage options to affordable quality health care and other related functions.

Payer
A payer may be an insurance company, health maintenance organization (HMO), government agency (Medicare, Medicaid, TRICARE, 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.

Payer's System
Reference to the "payer's system" is referenced throughout this implementation guide. The reference is intended to broadly represent the various databases within a payer environment. It is intended to include any data stored in a normalized, retrievable structure. It is not intended to include storage of raw transaction data that is not parsed and maintained in a normalized, retreivable database.

Provider
A provider is either a person or organizational entity who has either provided or participated in some aspect of the service(s) described in the transaction. Specific types of providers are identified in this implementation guide (for example billing provider, referring provider).

Regulatory Agency
A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific segment of the health care/insurance industry.

Transmission Intermediary
A transmission intermediary is any entity that handles the transaction between the payer (originator of the transmission) and the reporting destination. The term 'intermediary' is not referring to a Part A Medicare contractor.

Unbundling
Unbundling occurs when a provider submits one procedure code which the payer adjudicates and reports back as two or more different procedure codes.

1.6 Transaction Acknowledgments

The purpose of transaction acknowledgments is to report to the sender whether the transaction being acknowledged was accepted or rejected.

The ASC X12 Technical Report Type 2, Acknowledgment Reference Model provides guidance on several control structures and transaction set standards intended to augment EDI auditing and control systems.

1.7 Related Transactions

There are one or more transactions related to the transactions described in this implementation guide.

1.7.1 Health Care Claim Payment/Advice (835)

Information in the Health Care Claim Payment/Advice (835) transaction is generated by the payer's adjudication system. Some of the information reported in the 835 must be included in the Post Adjudicated Claims Data Reporting 837.

1.8 Trading Partner Agreements

Trading partner agreements are used to establish and document the relationship between trading partners. A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide.

1.9 HIPAA Role in Implementation Guides

Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (PL 104-191 - known as HIPAA) direct the Secretary of Health and Human Services to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard.

This implementation guide has been developed for use as an insurance industry implementation guide. At the time of publication it has not been adopted as a HIPAA standard. Should the Secretary adopt this implementation guide as a standard, the Secretary will establish compliance dates for its use by HIPAA covered entities.

2. Transaction Set

NOTE
See Appendix B, Nomenclature, to review the transaction set structure, including descriptions of segments, data elements, levels, and loops.

2.1 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 insurance industry-specific implementation. In this implementation guide, IMPLEMENTATION specifies the requirements for this implementation. X12 STANDARD is included as a reference only.

The transaction set presentation is comprised of two main sections with subsections within the main sections:

2.3 Transaction Set Listing

There are two sub-sections under this general title. The first sub-section concerns this implementation of a generic X12 transaction set. The second sub-section concerns the generic X12 standard itself.

This section lists the levels, loops, and segments contained in this implementation. It also serves as an index to the segment detail.

This section is included as a reference.

2.4 Segment Detail

There are three sub-sections under this general title. This section repeats once for each segment used in this implementation providing segment specific detail and X12 standard detail.

This section is included as a reference.

This section is included as a reference. It provides a pictorial view of the standard and shows which elements are used in this implementation.

This section specifies the implementation details of each data element.

These illustrations (Figures 2.1 through 2.5) are examples and are not extracted from the Section 2 detail in this implementation guide. Annotated illustrations, presented below in the same order they appear in this implementation guide, describe the format of the transaction set that follows.

Figure 2.1 - Transaction Set Key - Implementation

Transaction Set Key - Implementation

Figure 2.2 - Transaction Set Key - Standard

Transaction Set Key - Standard

Figure 2.3 - Segment Key - Implementation

Segment Key - Implementation

Figure 2.4 - Segment Key - Diagram

Segment Key - Diagram

Figure 2.5 - Segment Key - Element Summary

Segment Key - Element Summary

2.2.1 Industry Usage

Industry Usage describes when loops, segments, and elements are to be sent when complying with this implementation guide. The three choices for Usage are required, not used, and situational. To avoid confusion, these are named differently than the X12 standard Condition Designators (mandatory, optional, and relational).

Required

This loop/segment/element must always be sent.

Required segments in Situational loops only occur when the loop is used.

Required elements in Situational segments only occur when the segment is used.

Required component elements in Situational composite elements only occur when the composite element is used.

Not Used

This element must never be sent.

Situational

Use of this loop/segment/element varies, depending on data content and business context as described in the defining rule. The defining rule is documented in a Situational Rule attached to the item.

There are two forms of Situational Rules.

The first form is "Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver." The data qualified by such a situational rule cannot be required or requested by the receiver, transmission of this data is solely at the sender's discretion.

The alternative form is "Required when <explicit condition statement>. If not required by this implementation guide, do not send." The data qualified by such a situational rule cannot be sent except as described in the explicit condition statement.

2.2.1.1 Transaction Compliance Related to Industry Usage

A transmitted transaction complies with an implementation guide when it satisfies the requirements as defined within the implementation guide. The presence or absence of an item (loop, segment, or element) complies with the industry usage specified by this implementation guide according to the following table.

Industry Usage	Business Condition is	Item is	Transaction Complies with Implementation Guide?
Required	N/A	Sent	Yes
Required	N/A	Not Sent	No
Not Used	N/A	Sent	No
Not Used	N/A	Not Sent	Yes
Situational (Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.)	True	Sent	Yes
	True	Not Sent	No
	Not True	Sent	Yes
	Not True	Not Sent	Yes
Situational (Required when <explicit condition statement>. If not required by this implementation guide, do not send.)	True	Sent	Yes
	True	Not Sent	No
	Not True	Sent	No
	Not True	Not Sent	Yes

This table specifies how an entity is to evaluate a transmitted transaction for compliance with industry usage. It is not intended to require or imply that the receiver must reject non-compliant transactions. The receiver will handle non-compliant transactions based on its business process and any applicable regulations.

2.2.2 Loops

Loop requirements depend on the context or location of the loop within the transaction. See Appendix B for more information on loops.

A nested loop can be used only when the associated higher level loop is used.
The usage of a loop is the same as the usage of its beginning segment.
- If a loop's beginning segment is Required, the loop is Required and must occur at least once unless it is nested in a loop that is not being used.
- If a loop's beginning segment is Situational, the loop is Situational.
Subsequent segments within a loop can be sent only when the beginning is used.
Required segments in Situational loops occur only when the loop is used.

2.4 837 - Health Care Claim: Dental

This section specifies the segments, data elements, and codes for this implementation. Refer to Section 2.1 - Presentation Examples for detailed information on the components of the Segment Detail section.

SEGMENT DETAIL

ST - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

ST✱837✱987654✱005010X300A1~


DIAGRAM

✱

ST01		143
TS ID Code
M 1	ID	3/3

✱

ST02		329
TS Control Number
M 1	AN	4/9

✱

ST03		1705
Imple Conv Reference
O 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

ST01

143

Transaction Set Identifier Code

M 1

3/3

Code uniquely identifying a Transaction Set

CODE

DEFINITION

837

Health Care Claim

REQUIRED

ST02

329

Transaction Set Control Number

M 1

4/9

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

The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.

REQUIRED

ST03

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

INDUSTRY NAME: Implementation Guide Version Name

This element must be populated with the guide identifier named in Section 1.2.

This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.

SEGMENT DETAIL

BHT - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 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

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

BHT✱0019✱00✱44445✱20120213✱0345✱RP~


DIAGRAM

BHT

✱

BHT01		1005
Hierarch Struct Code
M 1	ID	4/4

✱

BHT02		353
TS Purpose Code
M 1	ID	2/2

✱

BHT03		127
Reference Ident
O 1	AN	1/50

✱

BHT04		373
Date
O 1	DT	8/8

✱

BHT05		337
Time
O 1	TM	4/8

✱

BHT06		640
Transaction Type Code
O 1	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

BHT01

1005

Hierarchical Structure Code

M 1

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

REQUIRED

BHT02

353

Transaction Set Purpose Code

M 1

2/2

Code identifying purpose of transaction set

CODE

DEFINITION

Original

Original transmissions are transmissions which have never been sent to the receiver.

Reissue

If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent.

REQUIRED

BHT03

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.

INDUSTRY NAME: Originator Application Transaction Identifier

The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.

REQUIRED

BHT04

373

Date

O 1

8/8

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

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

INDUSTRY NAME: Transaction Set Creation Date

REQUIRED

BHT05

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

REQUIRED

BHT06

640

Transaction Type Code

O 1

2/2

Code specifying the type of transaction

INDUSTRY NAME: Claim or Encounter Identifier

CODE

DEFINITION

Reporting

SEGMENT DETAIL

NM1 - SUBMITTER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

1000A — SUBMITTER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The submitter is the entity responsible for the creation and formatting of this transaction.

TR3 Example:

NM1✱41✱2✱ABC SUBMITTER✱✱✱✱✱46✱999999999~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
~~Name~~ ~~First~~
O 1	AN	1/35

✱

NM105		1037
~~Name~~ ~~Middle~~
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
~~Name~~ ~~Suffix~~
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Submitter Last or Organization Name

NOT USED

NM104

1036

Name First

O 1

1/35

NOT USED

NM105

1037

Name Middle

O 1

1/25

NOT USED

NM106

1038

Name Prefix

O 1

1/10

NOT USED

NM107

1039

Name Suffix

O 1

1/10

REQUIRED

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Submitter Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

PER - SUBMITTER EDI CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 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.

Loop:

1000A — SUBMITTER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 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 must 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

2.	The contact information in this segment identifies 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 combinations of communication numbers including extensions.

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~


DIAGRAM

PER

✱

PER01		366
Contact Funct Code
M 1	ID	2/2

✱

PER02		93
Name
O 1	AN	1/60

✱

PER03		365
Comm Number Qual
X 1	ID	2/2

✱

PER04		364
Comm Number
X 1	AN	1/256

✱

PER05		365
Comm Number Qual
X 1	ID	2/2

✱

PER06		364
Comm Number
X 1	AN	1/256

✱

PER07		365
Comm Number Qual
X 1	ID	2/2

✱

PER08		364
Comm Number
X 1	AN	1/256

✱

PER09		443
~~Contact Inq~~ ~~Reference~~
O 1	AN	1/20

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PER01

366

Contact Function Code

M 1

2/2

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

CODE

DEFINITION

Information Contact

SITUATIONAL

PER02

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the contact name is different than the name contained in the Submitter Name (NM1) segment of this loop
AND
it is the first iteration of the Submitter EDI Contact Information (PER) segment.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter Contact Name

REQUIRED

PER03

365

Communication Number Qualifier

X 1

2/2

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

REQUIRED

PER04

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL

PER05

365

Communication Number Qualifier

X 1

2/2

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

SITUATIONAL

PER06

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

SITUATIONAL

PER07

365

Communication Number Qualifier

X 1

2/2

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

SITUATIONAL

PER08

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

NOT USED

PER09

443

Contact Inquiry Reference

O 1

1/20

SEGMENT DETAIL

NM1 - RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

1000B — RECEIVER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

NM1✱40✱2✱XYZ RECEIVER✱✱✱✱✱46✱111222333~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
~~Name~~ ~~First~~
O 1	AN	1/35

✱

NM105		1037
~~Name~~ ~~Middle~~
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
~~Name~~ ~~Suffix~~
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Receiver

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Receiver Name

NOT USED

NM104

1036

Name First

O 1

1/35

NOT USED

NM105

1037

Name Middle

O 1

1/25

NOT USED

NM106

1038

Name Prefix

O 1

1/10

NOT USED

NM107

1039

Name Suffix

O 1

1/10

REQUIRED

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Receiver Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

HL - BILLING PROVIDER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000A — BILLING PROVIDER HIERARCHICAL LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

HL✱1✱✱20✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
~~Hierarch~~ ~~Parent ID~~
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope 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.

NOT USED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Source

REQUIRED

HL04

736

Hierarchical Child Code

O 1

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

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

PRV - BILLING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2000A — BILLING PROVIDER HIERARCHICAL LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱BI✱PXC✱1223G0001X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/50

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Billing

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

CUR - FOREIGN CURRENCY INFORMATION

X12 Name:

Currency

X12 Purpose:

To specify the currency (dollars, pounds, francs, etc.) used in a transaction

X12 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.
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.

X12 Comments:

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

Loop:

2000A — BILLING PROVIDER HIERARCHICAL LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.

TR3 Notes:


1.	It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.

TR3 Example:

CUR✱85✱CAD~


DIAGRAM

CUR

✱

CUR01		98
Entity ID Code
M 1	ID	2/3

✱

CUR02		100
Currency Code
M 1	ID	3/3

✱

CUR03		280
~~Exchange~~ ~~Rate~~
O 1	R	4/10

✱

CUR04		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

CUR05		100
~~Currency~~ ~~Code~~
O 1	ID	3/3

✱

CUR06		669
~~Curr Market~~ ~~/Exchg Code~~
O 1	ID	3/3

✱

CUR07		374
~~Date/Time~~ ~~Qualifier~~
X 1	ID	3/3

✱

CUR08		373
~~Date~~
O 1	DT	8/8

✱

CUR09		337
~~Time~~
O 1	TM	4/8

✱

CUR10		374
~~Date/Time~~ ~~Qualifier~~
X 1	ID	3/3

✱

CUR11		373
~~Date~~
X 1	DT	8/8

✱

CUR12		337
~~Time~~
X 1	TM	4/8

✱

CUR13		374
~~Date/Time~~ ~~Qualifier~~
X 1	ID	3/3

✱

CUR14		373
~~Date~~
X 1	DT	8/8

✱

CUR15		337
~~Time~~
X 1	TM	4/8

✱

CUR16		374
~~Date/Time~~ ~~Qualifier~~
X 1	ID	3/3

✱

CUR17		373
~~Date~~
X 1	DT	8/8

✱

CUR18		337
~~Time~~
X 1	TM	4/8

✱

CUR19		374
~~Date/Time~~ ~~Qualifier~~
X 1	ID	3/3

✱

CUR20		373
~~Date~~
X 1	DT	8/8

✱

CUR21		337
~~Time~~
X 1	TM	4/8

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

CUR01

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

REQUIRED

CUR02

100

Currency Code

M 1

3/3

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

The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

CUR03

280

Exchange Rate

O 1

4/10

NOT USED

CUR04

Entity Identifier Code

O 1

2/3

NOT USED

CUR05

100

Currency Code

O 1

3/3

NOT USED

CUR06

669

Currency Market/Exchange Code

O 1

3/3

NOT USED

CUR07

374

Date/Time Qualifier

X 1

3/3

NOT USED

CUR08

373

Date

O 1

8/8

NOT USED

CUR09

337

Time

O 1

4/8

NOT USED

CUR10

374

Date/Time Qualifier

X 1

3/3

NOT USED

CUR11

373

Date

X 1

8/8

NOT USED

CUR12

337

Time

X 1

4/8

NOT USED

CUR13

374

Date/Time Qualifier

X 1

3/3

NOT USED

CUR14

373

Date

X 1

8/8

NOT USED

CUR15

337

Time

X 1

4/8

NOT USED

CUR16

374

Date/Time Qualifier

X 1

3/3

NOT USED

CUR17

373

Date

X 1

8/8

NOT USED

CUR18

337

Time

X 1

4/8

NOT USED

CUR19

374

Date/Time Qualifier

X 1

3/3

NOT USED

CUR20

373

Date

X 1

8/8

NOT USED

CUR21

337

Time

X 1

4/8

SEGMENT DETAIL

NM1 - BILLING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010AA — BILLING PROVIDER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI.

2.	When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment.

3.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

NM1✱85✱1✱SMITH✱JOHN✱B✱✱✱✱XX✱1234567890~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Billing Provider Last or Organizational Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

If, for whatever reason, the data is not stored within the payer's system, do not use.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

N3 - BILLING PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2010AA — BILLING PROVIDER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Billing Provider Address Line

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Address Line

SEGMENT DETAIL

N4 - BILLING PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	C0605 If N406 is present, then N405 is required.
3.	C0704 If N407 is present, then N404 is required.

Loop:

2010AA — BILLING PROVIDER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
O 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Billing Provider City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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

SEGMENT SYNTAX: E0207

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Billing Provider Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

SEGMENT DETAIL

REF - BILLING PROVIDER TAX IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010AA — BILLING PROVIDER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This is the tax identification number (TIN) of the entity paid for the submitted services.

TR3 Example:

REF✱EI✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Employer's Identification Number

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Tax Identification Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - BILLING PROVIDER LICENSE INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010AA — BILLING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱0B✱654321~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider License Information

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - BILLING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010AA — BILLING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

HL - SUBSCRIBER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000B — SUBSCRIBER HIERARCHICAL LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.

TR3 Example:

HL✱2✱1✱22✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope 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.

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

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

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

REQUIRED

HL04

736

Hierarchical Child Code

O 1

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.

The claim (Loop ID-2300) can be used 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 for one or more dependents of the subscriber are being sent under the same billing provider HL (for example, a spouse and son are both treated by the same provider). In that case, the subscriber HL04 = 1 because there is at least one dependent to this subscriber. The dependent HL (spouse) would then be sent followed by the Loop ID-2300 for the spouse. The next HL would be the dependent HL for the son followed by the Loop ID-2300 for the son.

In order to send claims for the subscriber and one or more dependents, the Subscriber HL, with Relationship Code SBR02=18 (Self), would be followed by the Subscriber's Loop ID-2300 for the Subscriber's claims. Then the Subscriber HL would be repeated, followed by one or more Patient HL loops for the dependents, with the proper Relationship Code in PAT01, each followed by their respective Loop ID-2300 for each dependent's claims.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

SBR - SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

To record information specific to the primary insured and the insurance carrier for that insured

Loop:

2000B — SUBSCRIBER HIERARCHICAL LEVEL

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

SBR✱N✱18~


DIAGRAM

SBR

✱

SBR01		1138
Payer Resp Seq No Code
M 1	ID	1/1

✱

SBR02		1069
Individual Relat Code
O 1	ID	2/2

✱

SBR03		127
~~Reference~~ ~~Ident~~
O 1	AN	1/50

✱

SBR04		93
~~Name~~
O 1	AN	1/60

✱

SBR05		1336
~~Insurance~~ ~~Type Code~~
O 1	ID	1/3

✱

SBR06		1143
~~Benefits~~ ~~Coord Code~~
O 1	ID	1/1

✱

SBR07		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SBR08		584
~~Employment~~ ~~Status Code~~
O 1	ID	2/2

✱

SBR09		1032
~~Claim File~~ ~~Ind Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SBR01

1138

Payer Responsibility Sequence Number Code

M 1

1/1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

CODE

DEFINITION

Unconfirmed

SITUATIONAL

SBR02

1069

Individual Relationship Code

O 1

2/2

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

SITUATIONAL RULE: Requried when the patient is the subscriber. If not required by this implementation guide, do not send.

CODE

DEFINITION

Self

NOT USED

SBR03

127

Reference Identification

O 1

1/50

NOT USED

SBR04

Name

O 1

1/60

NOT USED

SBR05

1336

Insurance Type Code

O 1

1/3

NOT USED

SBR06

1143

Coordination of Benefits Code

O 1

1/1

NOT USED

SBR07

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SBR08

584

Employment Status Code

O 1

2/2

NOT USED

SBR09

1032

Claim Filing Indicator Code

O 1

1/2

SEGMENT DETAIL

NM1 - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010BA — SUBSCRIBER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.

2.	When submitting to an All Payer Claims Database or Health Benefit Exchange, this is the Subscriber as defined within the payers enrollment files. When submitting Medicare or Medicaid encounters, the patient is always the subscriber.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when an identifier has been assigned by the receiver. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when an identifier has been assigned by the receiver. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2010BA — SUBSCRIBER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Address Line

SEGMENT DETAIL

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	C0605 If N406 is present, then N405 is required.
3.	C0704 If N407 is present, then N404 is required.

Loop:

2010BA — SUBSCRIBER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
O 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Subscriber City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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

SEGMENT SYNTAX: E0207

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

SEGMENT DETAIL

DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

1.	P0102 If either DMG01 or DMG02 is present, then the other is required.
2.	P1011 If either DMG10 or DMG11 is present, then the other is required.
3.	C1105 If DMG11 is present, then DMG05 is required.

Loop:

2010BA — SUBSCRIBER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

DMG✱D8✱19690815✱M~


DIAGRAM

DMG

✱

DMG01		1250
Date Time Format Qual
X 1	ID	2/3

✱

DMG02		1251
Date Time Period
X 1	AN	1/35

✱

DMG03		1068
Gender Code
O 1	ID	1/1

✱

DMG04		1067
~~Marital~~ ~~Status Code~~
O 1	ID	1/1

✱

DMG05		C056
~~Comp Race~~ ~~or Ethn Inf~~
X 10

✱

DMG06		1066
~~Citizenship~~ ~~Status Code~~
O 1	ID	1/2

✱

DMG07		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

DMG08		659
~~Basis of~~ ~~Verif Code~~
O 1	ID	1/2

✱

DMG09		380
~~Quantity~~
O 1	R	1/15

✱

DMG10		1270
~~Code List~~ ~~Qual Code~~
X 1	ID	1/3

✱

DMG11		1271
~~Industry~~ ~~Code~~
X 1	AN	1/30

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DMG02

1251

Date Time Period

X 1

1/35

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

SEGMENT SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

INDUSTRY NAME: Subscriber Birth Date

REQUIRED

DMG03

1068

Gender Code

O 1

1/1

Code indicating the sex of the individual

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

NOT USED

DMG04

1067

Marital Status Code

O 1

1/1

NOT USED

DMG05

C056

Composite Race or Ethnicity Information

X 10

NOT USED

DMG06

1066

Citizenship Status Code

O 1

1/2

NOT USED

DMG07

Country Code

O 1

2/3

NOT USED

DMG08

659

Basis of Verification Code

O 1

1/2

NOT USED

DMG09

380

Quantity

O 1

1/15

NOT USED

DMG10

1270

Code List Qualifier Code

X 1

1/3

NOT USED

DMG11

1271

Industry Code

X 1

1/30

SEGMENT DETAIL

REF - SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010BA — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010BA — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱Y4✱4445555~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - DATA RECEIVER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010BB — DATA RECEIVER
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

NM1✱ZD✱2✱Medicaid Agency~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
~~Name~~ ~~First~~
O 1	AN	1/35

✱

NM105		1037
~~Name~~ ~~Middle~~
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
~~Name~~ ~~Suffix~~
O 1	AN	1/10

✱

NM108		66
~~ID Code~~ ~~Qualifier~~
X 1	ID	1/2

✱

NM109		67
ID ~~Code~~
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Party to Receive Reports

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Data Receiver Name

NOT USED

NM104

1036

Name First

O 1

1/35

NOT USED

NM105

1037

Name Middle

O 1

1/25

NOT USED

NM106

1038

Name Prefix

O 1

1/10

NOT USED

NM107

1039

Name Suffix

O 1

1/10

NOT USED

NM108

Identification Code Qualifier

X 1

1/2

NOT USED

NM109

Identification Code

X 1

2/80

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

HL - PATIENT HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000C — PATIENT HIERARCHICAL LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the data receiver is a reporting entity, such as an APCD or Health Insurance Exchange, AND the patient is not the subscriber.

TR3 Notes:


1.	The information reported in this loop describes the patient as known by the payer's system.

2.	When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.

3.	There are no HLs subordinate to the Patient HL.

TR3 Example:

HL✱3✱2✱23✱0~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

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

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

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

REQUIRED

HL04

736

Hierarchical Child Code

O 1

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.

SEGMENT DETAIL

PAT - PATIENT INFORMATION

X12 Name:

Patient Information

X12 Purpose:

To supply patient information

X12 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.

Loop:

2000C — PATIENT HIERARCHICAL LEVEL

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

PAT✱01~


DIAGRAM

PAT

✱

PAT01		1069
Individual Relat Code
O 1	ID	2/2

✱

PAT02		1384
~~Patient Loc~~ ~~Code~~
O 1	ID	1/1

✱

PAT03		584
~~Employment~~ ~~Status Code~~
O 1	ID	2/2

✱

PAT04		1220
~~Student~~ ~~Status Code~~
O 1	ID	1/1

✱

PAT05		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

PAT06		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

PAT07		355
~~Unit/Basis~~ ~~Meas Code~~
X 1	ID	2/2

✱

PAT08		81
~~Weight~~
X 1	R	1/10

✱

PAT09		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PAT01

1069

Individual Relationship Code

O 1

2/2

Code indicating the relationship between two individuals or entities

Specifies the patient's relationship to the person insured.

CODE

DEFINITION

Spouse

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

NOT USED

PAT02

1384

Patient Location Code

O 1

1/1

NOT USED

PAT03

584

Employment Status Code

O 1

2/2

NOT USED

PAT04

1220

Student Status Code

O 1

1/1

NOT USED

PAT05

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

PAT06

1251

Date Time Period

X 1

1/35

NOT USED

PAT07

355

Unit or Basis for Measurement Code

X 1

2/2

NOT USED

PAT08

Weight

X 1

1/10

NOT USED

PAT09

1073

Yes/No Condition or Response Code

O 1

1/1

SEGMENT DETAIL

NM1 - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010CA — PATIENT NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient has been assigned an identifier that is different than the subscriber identifier reported in Loop ID 2010BA NM109.

If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient has been assigned an identifier that is different than the subscriber identifier reported in Loop ID 2010BA NM109.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

N3 - PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2010CA — PATIENT NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Address Line

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Address Line

SEGMENT DETAIL

N4 - PATIENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	C0605 If N406 is present, then N405 is required.
3.	C0704 If N407 is present, then N404 is required.

Loop:

2010CA — PATIENT NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
O 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Patient City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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

SEGMENT SYNTAX: E0207

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Patient Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

SEGMENT DETAIL

DMG - PATIENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

1.	P0102 If either DMG01 or DMG02 is present, then the other is required.
2.	P1011 If either DMG10 or DMG11 is present, then the other is required.
3.	C1105 If DMG11 is present, then DMG05 is required.

Loop:

2010CA — PATIENT NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The information provided in this segment is intended to be representative of the information as known to the payer's system.

TR3 Example:

DMG✱D8✱19690815✱M~


DIAGRAM

DMG

✱

DMG01		1250
Date Time Format Qual
X 1	ID	2/3

✱

DMG02		1251
Date Time Period
X 1	AN	1/35

✱

DMG03		1068
Gender Code
O 1	ID	1/1

✱

DMG04		1067
~~Marital~~ ~~Status Code~~
O 1	ID	1/1

✱

DMG05		C056
~~Comp Race~~ ~~or Ethn Inf~~
X 10

✱

DMG06		1066
~~Citizenship~~ ~~Status Code~~
O 1	ID	1/2

✱

DMG07		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

DMG08		659
~~Basis of~~ ~~Verif Code~~
O 1	ID	1/2

✱

DMG09		380
~~Quantity~~
O 1	R	1/15

✱

DMG10		1270
~~Code List~~ ~~Qual Code~~
X 1	ID	1/3

✱

DMG11		1271
~~Industry~~ ~~Code~~
X 1	AN	1/30

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DMG02

1251

Date Time Period

X 1

1/35

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

SEGMENT SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

INDUSTRY NAME: Patient Birth Date

REQUIRED

DMG03

1068

Gender Code

O 1

1/1

Code indicating the sex of the individual

INDUSTRY NAME: Patient Gender Code

CODE

DEFINITION

Female

Male

Unknown

NOT USED

DMG04

1067

Marital Status Code

O 1

1/1

NOT USED

DMG05

C056

Composite Race or Ethnicity Information

X 10

NOT USED

DMG06

1066

Citizenship Status Code

O 1

1/2

NOT USED

DMG07

Country Code

O 1

2/3

NOT USED

DMG08

659

Basis of Verification Code

O 1

1/2

NOT USED

DMG09

380

Quantity

O 1

1/15

NOT USED

DMG10

1270

Code List Qualifier Code

X 1

1/3

NOT USED

DMG11

1271

Industry Code

X 1

1/30

SEGMENT DETAIL

REF - PATIENT SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010CA — PATIENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Social Security Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2010CA — PATIENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱Y4✱4445555~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

CLM - CLAIM INFORMATION

X12 Name:

Health Claim

X12 Purpose:

To specify basic data about the claim

Loop:

2300 — CLAIM INFORMATION
Loop Repeat: 100

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:

TR3 Example:

CLM✱013193000001✱500✱✱✱11:B:1✱Y✱A✱Y✱Y~


DIAGRAM

CLM

✱

CLM01		1028
Claim Submt Identifier
M 1	AN	1/38

✱

CLM02		782
Monetary Amount
O 1	R	1/18

✱

CLM03		1032
~~Claim File~~ ~~Ind Code~~
O 1	ID	1/2

✱

CLM04		1343
~~Non-Inst~~ ~~Claim Code~~
O 1	ID	1/2

✱

CLM05		C023
Health Care Serv Loc.
O 1

✱

CLM06		1073
Yes/No Cond Resp Code
O 1	ID	1/1

✱

CLM07		1359
Provider Accept Code
O 1	ID	1/1

✱

CLM08		1073
Yes/No Cond Resp Code
O 1	ID	1/1

✱

CLM09		1363
Release of Info Code
O 1	ID	1/1

✱

CLM10		1351
~~Patient Sig~~ ~~Source Code~~
O 1	ID	1/1

✱

CLM11		C024
Related Causes Info
O 1

✱

CLM12		1366
Special Prog Code
O 1	ID	2/3

✱

CLM13		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

CLM14		1338
~~Level of~~ ~~Serv Code~~
O 1	ID	1/3

✱

CLM15		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

CLM16		1360
~~Provider~~ ~~Agree Code~~
O 1	ID	1/1

✱

CLM17		1029
~~Claim~~ ~~Status Code~~
O 1	ID	1/2

✱

CLM18		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

CLM19		1383
~~Claim Submt~~ ~~Reason Code~~
O 1	ID	2/2

✱

CLM20		1514
Delay Reason Code
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

CLM01

1028

Claim Submitter's Identifier

M 1

1/38

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

INDUSTRY NAME: Patient Control Number

The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.

REQUIRED

CLM02

782

Monetary Amount

O 1

1/18

Monetary amount

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

INDUSTRY NAME: Total Claim Charge Amount

The Total Claim Charge Amount must be greater than or equal to zero.

The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.

This amount represents the sum of the line charge amounts included in this portion of the claim.

NOT USED

CLM03

1032

Claim Filing Indicator Code

O 1

1/2

NOT USED

CLM04

1343

Non-Institutional Claim Type Code

O 1

1/2

REQUIRED

CLM05

C023

Health Care Service Location Information

O 1

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

CLM05 applies to all service lines unless it is over written at the line level.

REQUIRED

CLM05-01

1331

Facility Code Value

1/2

INDUSTRY NAME: Place of Service Code

REQUIRED

CLM05-02

1332

Facility Code Qualifier

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Place of Service Codes for Professional or Dental Services

CODE SOURCE 237: Place of Service Codes for Professional Claims

REQUIRED

CLM05-03

1325

Claim Frequency Type Code

1/1

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

INDUSTRY NAME: Claim Frequency Code

CODE SOURCE 235: Claim Frequency Type Code

SITUATIONAL

CLM06

1073

Yes/No Condition or Response Code

O 1

1/1

Code indicating a Yes or No condition or response

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

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider or Supplier Signature Indicator

CODE

DEFINITION

Yes

SITUATIONAL

CLM07

1359

Provider Accept Assignment Code

O 1

1/1

Code indicating whether the provider accepts assignment

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assignment or Plan Participation Code

Within this element the context of the word assignment is related to the relationship between the provider and the payer.

CODE

DEFINITION

Assigned

Not Assigned

SITUATIONAL

CLM08

1073

Yes/No Condition or Response Code

O 1

1/1

Code indicating a Yes or No condition or response

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefits Assignment Certification Indicator

This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.

CODE

DEFINITION

Not Applicable

Use code `W' when the patient refuses to assign benefits.

Yes

SITUATIONAL

CLM09

1363

Release of Information Code

O 1

1/1

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

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

NOT USED

CLM10

1351

Patient Signature Source Code

O 1

1/1

SITUATIONAL

CLM11

C024

Related Causes Information

O 1

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

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required.

REQUIRED

CLM11-01

1362

Related-Causes Code

2/3

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

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

SITUATIONAL

CLM11-02

1362

Related-Causes Code

2/3

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

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Related Causes Code

NOT USED

CLM11-03

1362

Related-Causes Code

2/3

SITUATIONAL

CLM11-04

156

State or Province Code

2/2

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

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Auto Accident State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

CLM11-05

Country Code

2/3

Code identifying the country

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE SOURCE 5: Countries, Currencies and Funds

SITUATIONAL

CLM12

1366

Special Program Code

O 1

2/3

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

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Special Program Indicator

CODE

DEFINITION

Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)

Physically Handicapped Children's Program

Special Federal Funding

Disability

NOT USED

CLM13

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

CLM14

1338

Level of Service Code

O 1

1/3

NOT USED

CLM15

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

CLM16

1360

Provider Agreement Code

O 1

1/1

NOT USED

CLM17

1029

Claim Status Code

O 1

1/2

NOT USED

CLM18

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

CLM19

1383

Claim Submission Reason Code

O 1

2/2

SITUATIONAL

CLM20

1514

Delay Reason Code

O 1

1/2

Code indicating the reason why a request was delayed

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

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

Natural Disaster

SEGMENT DETAIL

DTP - DATE - ACCIDENT

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱439✱D8✱20120108~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Accident Date

SEGMENT DETAIL

DTP - DATE - APPLIANCE PLACEMENT

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱452✱D8✱20120108~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

452

Appliance Placement

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Orthodontic Banding Date

SEGMENT DETAIL

DTP - DATE - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱472✱D8✱20120108~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

SEGMENT DETAIL

DN1 - ORTHODONTIC TOTAL MONTHS OF TREATMENT

X12 Name:

Orthodontic Information

X12 Purpose:

To supply orthodontic information

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	When reporting this segment, at least one of DN101, DN102 or DN104 must be present.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DN1✱36✱27~

TR3 Example:

DN1✱✱✱Y~


DIAGRAM

DN1

✱

DN101		380
Quantity
O 1	R	1/15

✱

DN102		380
Quantity
O 1	R	1/15

✱

DN103		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

DN104		352
Description
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

SITUATIONAL

DN101

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DN101 is the estimated number of treatment months.

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Months Count

SITUATIONAL

DN102

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DN102 is the number of treatment months remaining.

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Months Remaining Count

NOT USED

DN103

1073

Yes/No Condition or Response Code

O 1

1/1

SITUATIONAL

DN104

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: DN104 is the appliance description.

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Indicator

The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.

SEGMENT DETAIL

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

1.	P0405 If either DN204 or DN205 is present, then the other is required.

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DN2✱8✱E✱✱✱✱JP~


DIAGRAM

DN2

✱

DN201		127
Reference Ident
M 1	AN	1/50

✱

DN202		1368
Tooth Status Code
O 1	ID	1/2

✱

DN203		380
~~Quantity~~
O 1	R	1/15

✱

DN204		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

DN205		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

DN206		1270
Code List Qual Code
M 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DN201

127

Reference Identification

M 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: DN201 is the tooth number.

INDUSTRY NAME: Tooth Number

The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.

REQUIRED

DN202

1368

Tooth Status Code

O 1

1/2

Code specifying the status of the tooth

CODE

DEFINITION

To Be Extracted

Missing

NOT USED

DN203

380

Quantity

O 1

1/15

NOT USED

DN204

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

DN205

1251

Date Time Period

X 1

1/35

REQUIRED

DN206

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

SEMANTIC: DN206 designates the code set used to identify the tooth in DN201.

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE 135: American Dental Association

SEGMENT DETAIL

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

TR3 Example:

CN1✱02✱550~


DIAGRAM

CN1

✱

CN101		1166
Contract Type Code
M 1	ID	2/2

✱

CN102		782
Monetary Amount
O 1	R	1/18

✱

CN103		332
Allow/Chrg Percent
O 1	R	1/6

✱

CN104		127
Reference Ident
O 1	AN	1/50

✱

CN105		338
Terms Disc Percent
O 1	R	1/6

✱

CN106		799
Version ID
O 1	AN	1/30

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

CN101

1166

Contract Type Code

M 1

2/2

Code identifying a contract type

CODE

DEFINITION

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

SITUATIONAL

CN102

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Amount

SITUATIONAL

CN103

332

Percent, Decimal Format

O 1

1/6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

SEMANTIC: CN103 is the allowance or charge percent.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Percentage

SITUATIONAL

CN104

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: CN104 is the contract code.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Code

SITUATIONAL

CN105

338

Terms Discount Percent

O 1

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

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Terms Discount Percentage

SITUATIONAL

CN106

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Version Identifier

SEGMENT DETAIL

AMT - PATIENT AMOUNT PAID

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

AMT✱F5✱152.45~


DIAGRAM

AMT

✱

AMT01		522
Amount Qual Code
M 1	ID	1/3

✱

AMT02		782
Monetary Amount
M 1	R	1/18

✱

AMT03		478
~~Cred/Debit~~ ~~Flag Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Patient Amount Paid

REQUIRED

AMT02

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Patient Amount Paid

NOT USED

AMT03

478

Credit/Debit Flag Code

O 1

1/1

SEGMENT DETAIL

REF - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱9F✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referral Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G1✱13579~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior Authorization Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Authorization Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	The data conveyed in this segment is not related to the provider submission to the payer. This segment is used only when the payer is submitting this transaction to the Data Receiver through an intermediary that assigns their own unique claim number.

TR3 Example:

REF✱D9✱TJ98UU321~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Number assigned by clearinghouse, van, etc.

CODE

DEFINITION

Claim Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Claim Identifier for Transmission Intermediaries

The value carried in this element is limited to a maximum of 20 positions.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.

2.	Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.

3.	X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

4.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

K3✱STATE DATA REQUIREMENT~


DIAGRAM

✱

K301		449
Fixed Form Information
M 1	AN	1/80

✱

K302		1333
~~Record~~ ~~Format Code~~
O 1	ID	1/2

✱

K303		C001
~~Composite~~ ~~Unit of Mea~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

K301

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

NOT USED

K302

1333

Record Format Code

O 1

1/2

NOT USED

K303

C001

Composite Unit of Measure

O 1

SEGMENT DETAIL

HI - HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

2300 — CLAIM INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	Do not transmit the decimal point for ICD codes. The decimal point is implied.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

HI✱BK:52403✱BF:52404~


DIAGRAM

✱

HI01		C022
Health Care Code Info.
M 1

✱

HI02		C022
Health Care Code Info.
O 1

✱

HI03		C022
Health Care Code Info.
O 1

✱

HI04		C022
Health Care Code Info.
O 1

✱

HI05		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI06		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI07		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI08		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI09		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI10		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI11		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI12		C022
~~Health Care~~ ~~Code Info.~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HI01

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

The diagnosis listed in this element is assumed to be the principal diagnosis.

REQUIRED

HI01-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

CODE

DEFINITION

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE 135: American Dental Association

REQUIRED

HI01-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Principal Diagnosis Code

NOT USED

HI01-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI01-04

1251

Date Time Period

1/35

NOT USED

HI01-05

782

Monetary Amount

1/18

NOT USED

HI01-06

380

Quantity

1/15

NOT USED

HI01-07

799

Version Identifier

1/30

NOT USED

HI01-08

1271

Industry Code

1/30

NOT USED

HI01-09

1073

Yes/No Condition or Response Code

1/1

SITUATIONAL

HI02

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

REQUIRED

HI02-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE 135: American Dental Association

REQUIRED

HI02-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

NOT USED

HI02-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI02-04

1251

Date Time Period

1/35

NOT USED

HI02-05

782

Monetary Amount

1/18

NOT USED

HI02-06

380

Quantity

1/15

NOT USED

HI02-07

799

Version Identifier

1/30

NOT USED

HI02-08

1271

Industry Code

1/30

NOT USED

HI02-09

1073

Yes/No Condition or Response Code

1/1

SITUATIONAL

HI03

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

REQUIRED

HI03-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

See element HI02-1 for a list of valid values.

REQUIRED

HI03-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

NOT USED

HI03-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI03-04

1251

Date Time Period

1/35

NOT USED

HI03-05

782

Monetary Amount

1/18

NOT USED

HI03-06

380

Quantity

1/15

NOT USED

HI03-07

799

Version Identifier

1/30

NOT USED

HI03-08

1271

Industry Code

1/30

NOT USED

HI03-09

1073

Yes/No Condition or Response Code

1/1

SITUATIONAL

HI04

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

REQUIRED

HI04-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

See element HI02-1 for a list of valid values.

REQUIRED

HI04-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

NOT USED

HI04-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI04-04

1251

Date Time Period

1/35

NOT USED

HI04-05

782

Monetary Amount

1/18

NOT USED

HI04-06

380

Quantity

1/15

NOT USED

HI04-07

799

Version Identifier

1/30

NOT USED

HI04-08

1271

Industry Code

1/30

NOT USED

HI04-09

1073

Yes/No Condition or Response Code

1/1

NOT USED

HI05

C022

Health Care Code Information

O 1

NOT USED

HI06

C022

Health Care Code Information

O 1

NOT USED

HI07

C022

Health Care Code Information

O 1

NOT USED

HI08

C022

Health Care Code Information

O 1

NOT USED

HI09

C022

Health Care Code Information

O 1

NOT USED

HI10

C022

Health Care Code Information

O 1

NOT USED

HI11

C022

Health Care Code Information

O 1

NOT USED

HI12

C022

Health Care Code Information

O 1

SEGMENT DETAIL

NM1 - REFERRING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2310A — REFERRING PROVIDER NAME
Loop Repeat: 2

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	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 patient's episode of care being billed/reported in this transaction.

2.	When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.

3.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DN✱1✱WELBY✱MARCUS✱W✱✱JR✱XX✱1234567891~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Referring Provider Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

PRV - REFERRING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2310A — REFERRING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱RF✱PXC✱1223G0001X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/50

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Referring

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

REF - REFERRING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2310A — REFERRING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referring Provider Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - RENDERING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2310B — RENDERING PROVIDER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 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.	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 substitute provider (locum tenens) was used, enter that provider's information here.

3.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

PRV - RENDERING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2310B — RENDERING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/50

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

REF - RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2310B — RENDERING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - SERVICE FACILITY LOCATION NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2310C — SERVICE FACILITY LOCATION NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 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.	This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

TR3 Example:

NM1✱77✱2✱A-OK MOBILE CLINIC✱✱✱✱✱XX✱1112233301~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
~~Name~~ ~~First~~
O 1	AN	1/35

✱

NM105		1037
~~Name~~ ~~Middle~~
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
~~Name~~ ~~Suffix~~
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Service Location

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Laboratory or Facility Name

NOT USED

NM104

1036

Name First

O 1

1/35

NOT USED

NM105

1037

Name Middle

O 1

1/25

NOT USED

NM106

1038

Name Prefix

O 1

1/10

NOT USED

NM107

1039

Name Suffix

O 1

1/10

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when received on the provider's original claim submission; the Service Location information originates from the 2310 Service Location loop of the provider submitted claim; and the NPI is different than the NPI reported in NM109 of Loop ID 2010AA (Billing Provider).

If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when received on the provider's original claim submission; the Service Location information originates from the 2310 Service Location loop of the provider submitted claim; and the NPI is different than the NPI reported in NM109 of Loop ID 2010AA (Billing Provider).

If not required by this implementation guide, do not send.

INDUSTRY NAME: Laboratory or Facility Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

N3 - SERVICE FACILITY LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2310C — SERVICE FACILITY LOCATION NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Laboratory or Facility Address Line

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Laboratory or Facility Address Line

SEGMENT DETAIL

N4 - SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	C0605 If N406 is present, then N405 is required.
3.	C0704 If N407 is present, then N404 is required.

Loop:

2310C — SERVICE FACILITY LOCATION NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
O 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Laboratory or Facility City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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

SEGMENT SYNTAX: E0207

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Laboratory or Facility State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Laboratory or Facility Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

SEGMENT DETAIL

REF - SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2310C — SERVICE FACILITY LOCATION NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Laboratory or Facility Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - ASSISTANT SURGEON NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2310D — ASSISTANT SURGEON NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DD✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567899~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Assistant Surgeon

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Assistant Surgeon Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Name Suffix

Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Primary Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

PRV - ASSISTANT SURGEON SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2310D — ASSISTANT SURGEON NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱AS✱PXC✱1223S0112X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/50

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

REF - ASSISTANT SURGEON SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2310D — ASSISTANT SURGEON NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱0B✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Assistant Surgeon Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - SUPERVISING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2310E — SUPERVISING PROVIDER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 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.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DQ✱1✱SMITH✱JOHN✱A✱✱✱XX✱2223334444~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Use this code for the supervising dentist or physician.

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

REF - SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2310E — SUPERVISING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Supervising Provider Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

SBR - OTHER SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

To record information specific to the primary insured and the insurance carrier for that insured

X12 Set Notes:

1.	NOTE: 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.

Loop:

2320 — OTHER SUBSCRIBER INFORMATION
Loop Repeat: 10

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.

2.	Loop ID 2320 and its suboordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by both the submitting payer and other payers who have previously adjudicated the claim. This loop is not to be provided for payers who have not adjudicated the claim. For example, the provider submitted claim includes payer information that is subsequent to the payer submitting this transaction. SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer. When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider. When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.

TR3 Example:

SBR✱P✱18✱G00786✱✱✱6✱✱✱CI~


DIAGRAM

SBR

✱

SBR01		1138
Payer Resp Seq No Code
M 1	ID	1/1

✱

SBR02		1069
Individual Relat Code
O 1	ID	2/2

✱

SBR03		127
Reference Ident
O 1	AN	1/50

✱

SBR04		93
Name
O 1	AN	1/60

✱

SBR05		1336
~~Insurance~~ ~~Type Code~~
O 1	ID	1/3

✱

SBR06		1143
Benefits Coord Code
O 1	ID	1/1

✱

SBR07		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SBR08		584
~~Employment~~ ~~Status Code~~
O 1	ID	2/2

✱

SBR09		1032
Claim File Ind Code
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SBR01

1138

Payer Responsibility Sequence Number Code

M 1

1/1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

When this field is populated based upon the adjudication of the submitting payer, the selection of this code value is similar to how CLP02 in the 835 transaction is performed.

CODE

DEFINITION

Payer Responsibility Four

Payer Responsibility Five

Payer Responsibility Six

Payer Responsibility Seven

Payer Responsibility Eight

Payer Responsibility Nine

Payer Responsibility Ten

Payer Responsibility Eleven

Primary

Secondary

Tertiary

Unknown

REQUIRED

SBR02

1069

Individual Relationship Code

O 1

2/2

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

CODE

DEFINITION

Spouse

Self

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

SITUATIONAL

SBR03

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: SBR03 is policy or group number.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer has assigned a group identifier to this benefit plan.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Insured Group or Policy Number

This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.

SITUATIONAL

SBR04

Name

O 1

1/60

Free-form name

SEMANTIC: SBR04 is plan name.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer has assigned a group name to this benefit plan; and SBR03 is not used.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Group Name

NOT USED

SBR05

1336

Insurance Type Code

O 1

1/3

REQUIRED

SBR06

1143

Coordination of Benefits Code

O 1

1/1

Code identifying whether there is a coordination of benefits

CODE

DEFINITION

Coordination of Benefits

Use this code when the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 was submitted on the original claim from the provider.

No Coordination of Benefits

Use this code when the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication of the payer submitting this transaction.

NOT USED

SBR07

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SBR08

584

Employment Status Code

O 1

2/2

REQUIRED

SBR09

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

CODE

DEFINITION

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Blue Cross/Blue Shield

Champus

Commercial Insurance Co.

Disability

Federal Employees Program

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Other Federal Program

Use code OF when submitting Medicare Part D claims.

Title V

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Use Code ZZ when Type of Insurance is not known.

SEGMENT DETAIL

CAS - CLAIM LEVEL ADJUSTMENTS

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 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.
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.

X12 Comments:

1.	Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid.

Loop:

2320 — OTHER SUBSCRIBER INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the claim has claim level adjustment information. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Submitters must 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.

3.	A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

4.	When the payer identified is not the submitting payer, codes and associated amounts must be reported as submitted by the provider. When the payer identified is the submitting payer, codes and amounts must be reported the same as if creating the 835 to send to the provider.

TR3 Example:

CAS✱PR✱1✱7.93~

TR3 Example:

CAS✱OA✱93✱15.06~


DIAGRAM

CAS

✱

CAS01		1033
Claim Adj Group Code
M 1	ID	1/2

✱

CAS02		1034
Claim Adj Reason Code
M 1	ID	1/5

✱

CAS03		782
Monetary Amount
M 1	R	1/18

✱

CAS04		380
Quantity
O 1	R	1/15

✱

CAS05		1034
Claim Adj Reason Code
X 1	ID	1/5

✱

CAS06		782
Monetary Amount
X 1	R	1/18

✱

CAS07		380
Quantity
X 1	R	1/15

✱

CAS08		1034
Claim Adj Reason Code
X 1	ID	1/5

✱

CAS09		782
Monetary Amount
X 1	R	1/18

✱

CAS10		380
Quantity
X 1	R	1/15

✱

CAS11		1034
Claim Adj Reason Code
X 1	ID	1/5

✱

CAS12		782
Monetary Amount
X 1	R	1/18

✱

CAS13		380
Quantity
X 1	R	1/15

✱

CAS14		1034
Claim Adj Reason Code
X 1	ID	1/5

✱

CAS15		782
Monetary Amount
X 1	R	1/18

✱

CAS16		380
Quantity
X 1	R	1/15

✱

CAS17		1034
Claim Adj Reason Code
X 1	ID	1/5

✱

CAS18		782
Monetary Amount
X 1	R	1/18

✱

CAS19		380
Quantity
X 1	R	1/15

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

CAS01

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

CODE

DEFINITION

Contractual Obligations

Correction and Reversals

Other adjustments

Payor Initiated Reductions

Patient Responsibility

REQUIRED

CAS02

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

REQUIRED

CAS03

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

SITUATIONAL

CAS04

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the number of service units has been adjusted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

SITUATIONAL

CAS05

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

SITUATIONAL

CAS06

782

Monetary Amount

X 1

1/18

Monetary amount

SEGMENT SYNTAX: L050607, C0605

SEMANTIC: CAS06 is the amount of the adjustment.

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

SITUATIONAL

CAS07

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: L050607, C0705

SEMANTIC: CAS07 is the units of service being adjusted.

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

SITUATIONAL

CAS08

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

SITUATIONAL

CAS09

782

Monetary Amount

X 1

1/18

Monetary amount

SEGMENT SYNTAX: L080910, C0908

SEMANTIC: CAS09 is the amount of the adjustment.

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

SITUATIONAL

CAS10

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: L080910, C1008

SEMANTIC: CAS10 is the units of service being adjusted.

SITUATIONAL RULE: Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

SITUATIONAL

CAS11

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

SITUATIONAL

CAS12

782

Monetary Amount

X 1

1/18

Monetary amount

SEGMENT SYNTAX: L111213, C1211

SEMANTIC: CAS12 is the amount of the adjustment.

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

SITUATIONAL

CAS13

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: L111213, C1311

SEMANTIC: CAS13 is the units of service being adjusted.

SITUATIONAL RULE: Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

SITUATIONAL

CAS14

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

SITUATIONAL

CAS15

782

Monetary Amount

X 1

1/18

Monetary amount

SEGMENT SYNTAX: L141516, C1514

SEMANTIC: CAS15 is the amount of the adjustment.

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

SITUATIONAL

CAS16

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: L141516, C1614

SEMANTIC: CAS16 is the units of service being adjusted.

SITUATIONAL RULE: Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

SITUATIONAL

CAS17

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

SITUATIONAL

CAS18

782

Monetary Amount

X 1

1/18

Monetary amount

SEGMENT SYNTAX: L171819, C1817

SEMANTIC: CAS18 is the amount of the adjustment.

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

SITUATIONAL

CAS19

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: L171819, C1917

SEMANTIC: CAS19 is the units of service being adjusted.

SITUATIONAL RULE: Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

SEGMENT DETAIL

AMT - COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

2320 — OTHER SUBSCRIBER INFORMATION

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

AMT✱D✱411~


DIAGRAM

AMT

✱

AMT01		522
Amount Qual Code
M 1	ID	1/3

✱

AMT02		782
Monetary Amount
M 1	R	1/18

✱

AMT03		478
~~Cred/Debit~~ ~~Flag Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Payor Amount Paid

REQUIRED

AMT02

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Payer Paid Amount

It is acceptable to show "0" as the amount paid.

When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.

NOT USED

AMT03

478

Credit/Debit Flag Code

O 1

1/1

SEGMENT DETAIL

AMT - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

2320 — OTHER SUBSCRIBER INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

AMT✱EAF✱75~


DIAGRAM

AMT

✱

AMT01		522
Amount Qual Code
M 1	ID	1/3

✱

AMT02		782
Monetary Amount
M 1	R	1/18

✱

AMT03		478
~~Cred/Debit~~ ~~Flag Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AMT01

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

EAF

Amount Owed

REQUIRED

AMT02

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Remaining Patient Liability

NOT USED

AMT03

478

Credit/Debit Flag Code

O 1

1/1

SEGMENT DETAIL

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Medicare Outpatient Adjudication

X12 Purpose:

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Loop:

2320 — OTHER SUBSCRIBER INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

MOA✱✱✱A4~


DIAGRAM

MOA

✱

MOA01		954
Percent
O 1	R	1/10

✱

MOA02		782
Monetary Amount
O 1	R	1/18

✱

MOA03		127
Reference Ident
O 1	AN	1/50

✱

MOA04		127
Reference Ident
O 1	AN	1/50

✱

MOA05		127
Reference Ident
O 1	AN	1/50

✱

MOA06		127
Reference Ident
O 1	AN	1/50

✱

MOA07		127
Reference Ident
O 1	AN	1/50

✱

MOA08		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

MOA09		782
Monetary Amount
O 1	R	1/18

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

SITUATIONAL

MOA01

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SEMANTIC: MOA01 is the reimbursement rate.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Reimbursement Rate

SITUATIONAL

MOA02

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: HCPCS Payable Amount

SITUATIONAL

MOA03

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA03 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

SITUATIONAL

MOA04

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA04 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

SITUATIONAL

MOA05

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA05 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

SITUATIONAL

MOA06

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA06 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

SITUATIONAL

MOA07

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: MOA07 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

NOT USED

MOA08

782

Monetary Amount

O 1

1/18

SITUATIONAL

MOA09

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA09 is the professional component amount billed but not payable.

SITUATIONAL RULE: Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Non-Payable Professional Component Billed Amount

SEGMENT DETAIL

NM1 - OTHER SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2330A — OTHER SUBSCRIBER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	When SBR06 = 1, the information in this segment represents the Subscriber as submitted by the provider for the payer identified in Loop ID 2330B. When SBR06 = 6, the information in this segment represents the Subscriber as known by the submitting payer.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Insured Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Name Suffix

REQUIRED

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Insured Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

N3 - OTHER SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2330A — OTHER SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Insured Address Line

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Address Line

If, for whatever reason, the data is not stored within the payer's system, do not use.

SEGMENT DETAIL

N4 - OTHER SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	C0605 If N406 is present, then N405 is required.
3.	C0704 If N407 is present, then N404 is required.

Loop:

2330A — OTHER SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
O 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Other Insured City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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

SEGMENT SYNTAX: E0207

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Other Insured Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

SEGMENT DETAIL

REF - OTHER SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2330A — OTHER SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Insured Additional Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - OTHER PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2330B — OTHER PAYER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

NM1✱PR✱2✱ABC INSURANCE CO✱✱✱✱✱PI✱11122333~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
~~Name~~ ~~First~~
O 1	AN	1/35

✱

NM105		1037
~~Name~~ ~~Middle~~
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
~~Name~~ ~~Suffix~~
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Payer Last or Organization Name

NOT USED

NM104

1036

Name First

O 1

1/35

NOT USED

NM105

1037

Name Middle

O 1

1/25

NOT USED

NM106

1038

Name Prefix

O 1

1/10

NOT USED

NM107

1039

Name Suffix

O 1

1/10

REQUIRED

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Payer Primary Identifier

When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

DTP - CLAIM CHECK OR REMITTANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2330B — OTHER PAYER NAME

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

DTP✱573✱D8✱20120503~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

573

Date Claim Paid

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Adjudication or Payment Date

SEGMENT DETAIL

REF - OTHER PAYER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2330B — OTHER PAYER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱2U✱98765~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Employer's Identification Number

Claim Office Number

National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE 245: National Association of Insurance Commissioners (NAIC) Code

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - OTHER PAYER CLAIM ADJUSTMENT INDICATOR

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2330B — OTHER PAYER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when SBR06 = 6; and this claim is a void or adjustment of a previously adjudicated claim.

If not required by this implementation guide, do not send.

TR3 Example:

REF✱T4✱Y~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Signal Code

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Claim Adjustment Indicator

The only valid value for this element is `Y'.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - OTHER PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2330B — OTHER PAYER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when SBR06 = 6.
OR
Required when available in the payer's system.

If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱F8✱R555588~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer's Claim Control Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - OTHER PAYER ADJUSTED CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2330B — OTHER PAYER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when SBR06 = 6 and the submitting payer has adjusted this claim.
OR
Required when available in the payer's system.

If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱BP✱R5555589~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Adjustment Control Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer's Adjusted Claim Control Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - OTHER PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2330C — OTHER PATIENT NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the entity reported in Loop ID 2330A (Other Payer Subscriber) is not the patient.

TR3 Notes:


1.	When SBR06 = 1, the information in this segment represents the Patient as submitted by the provider for the payer identified in Loop ID 2330B. When SBR06 = 6, the information in this segment represents the Patient as known by the submitting payer.

TR3 Example:

NM1✱QC✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Insured Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient has been assigned an identifier that is different than the subscriber identifier reported in Loop ID 2330A NM109.

If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient has been assigned an identifier that is different than the subscriber identifier reported in Loop ID 2330A NM109.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

N3 - OTHER PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2330C — OTHER PATIENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Patient Address Line

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Patient Address Line

If, for whatever reason, the data is not stored within the payer's system, do not use.

SEGMENT DETAIL

N4 - OTHER PATIENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	C0605 If N406 is present, then N405 is required.
3.	C0704 If N407 is present, then N404 is required.

Loop:

2330C — OTHER PATIENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
O 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Other Patient City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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

SEGMENT SYNTAX: E0207

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

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Patient State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Other Patient Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

SEGMENT DETAIL

REF - OTHER PATIENT SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2330C — OTHER PATIENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

TR3 Example:

REF✱SY✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Insured Additional Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

LX - SERVICE LINE NUMBER

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

1.	NOTE: Loop 2400 contains Service Line information.

Loop:

2400 — SERVICE LINE NUMBER
Loop Repeat: 50

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	The LX functions as a line counter.

2.	The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.

3.	LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.2.4 for more information on bundling and section 1.4.2.6 for more information on unbundling.

TR3 Example:

LX✱1~


DIAGRAM

✱

LX01		554
Assigned Number
M 1	N0	1/6

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

LX01

554

Assigned Number

M 1

1/6

Number assigned for differentiation within a transaction set

SEGMENT DETAIL

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

SV3✱AD:D2150✱80✱✱✱✱1~


DIAGRAM

SV3

✱

SV301		C003
Comp. Med. Proced. ID
M 1

✱

SV302		782
Monetary Amount
O 1	R	1/18

✱

SV303		1331
Facility Code
O 1	AN	1/2

✱

SV304		C006
Oral Cavity Designat.
O 1

✱

SV305		1358
Prosthesis/ Inlay Code
O 1	ID	1/1

✱

SV306		380
Quantity
O 1	R	1/15

✱

SV307		352
~~Description~~
O 1	AN	1/80

✱

SV308		1327
~~Copay~~ ~~Status Code~~
O 1	ID	1/1

✱

SV309		1360
~~Provider~~ ~~Agree Code~~
O 1	ID	1/1

✱

SV310		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV311		C004
Comp. Diag. Code Point.
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SV301

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

REQUIRED

SV301-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CDT = Current Dental Terminology

CODE SOURCE 135: American Dental Association

REQUIRED

SV301-02

234

Product/Service ID

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

SITUATIONAL

SV301-03

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

SITUATIONAL

SV301-04

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

SITUATIONAL

SV301-05

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

SITUATIONAL

SV301-06

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.

SITUATIONAL

SV301-07

352

Description

1/80

A free-form description to clarify the related data elements and their content

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

NOT USED

SV301-08

234

Product/Service ID

1/48

REQUIRED

SV302

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

INDUSTRY NAME: Line Item Charge Amount

This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.

Zero "0" is an acceptable value for this element.

SITUATIONAL

SV303

1331

Facility Code Value

O 1

1/2

SEMANTIC: SV303 is the place of service code representing the location where the dental treatment was rendered.

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Place of Service Code

See CODE SOURCE 237: Place of Service Codes for Professional Claims

SITUATIONAL

SV304

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

Do not use this element for reporting of individual teeth. If it is necessary to report one or more individual teeth, use the Tooth Information (TOO) segment in this loop.

If, for whatever reason, the data is not stored within the payer's system, do not use.

REQUIRED

SV304-01

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-02

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-03

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-04

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-05

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV305

1358

Prosthesis, Crown or Inlay Code

O 1

1/1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

If, for whatever reason, the data is not stored within the payer's system, do not use.

CODE

DEFINITION

Initial Placement

Replacement

When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.

SITUATIONAL

SV306

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Count

Number of procedures

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

SV307

352

Description

O 1

1/80

NOT USED

SV308

1327

Copay Status Code

O 1

1/1

NOT USED

SV309

1360

Provider Agreement Code

O 1

1/1

NOT USED

SV310

1073

Yes/No Condition or Response Code

O 1

1/1

SITUATIONAL

SV311

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 4, and correspond to Composite Data Elements 01 through 04 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300.

If, for whatever reason, the data is not stored within the payer's system, do not use.

REQUIRED

SV311-01

1328

Diagnosis Code Pointer

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL

SV311-02

1328

Diagnosis Code Pointer

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

SITUATIONAL

SV311-03

1328

Diagnosis Code Pointer

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

SITUATIONAL

SV311-04

1328

Diagnosis Code Pointer

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

SEGMENT DETAIL

TOO - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

1.	P0102 If either TOO01 or TOO02 is present, then the other is required.

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

TOO✱JP✱12✱L:O~


DIAGRAM

TOO

✱

TOO01		1270
Code List Qual Code
X 1	ID	1/3

✱

TOO02		1271
Industry Code
X 1	AN	1/30

✱

TOO03		C005
Tooth Surface
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TOO01

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE 135: American Dental Association

REQUIRED

TOO02

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

See Appendix A for code source 135: American Dental Association Codes.

This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.

SITUATIONAL

TOO03

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

REQUIRED

TOO03-01

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

SITUATIONAL

TOO03-02

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.

SITUATIONAL

TOO03-03

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

SITUATIONAL

TOO03-04

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

SITUATIONAL

TOO03-05

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

SEGMENT DETAIL

DTP - DATE - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱472✱D8✱20120108~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

SEGMENT DETAIL

DTP - DATE - PRIOR PLACEMENT

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱441✱D8✱20120401~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

139

Estimated

Required when the exact Prior Placement Date is not known.

441

Prior Placement

Required when the exact Prior Placement Date is known.

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Prior Placement Date

SEGMENT DETAIL

DTP - DATE - APPLIANCE PLACEMENT

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱452✱D8✱20120108~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

452

Appliance Placement

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Orthodontic Banding Date

SEGMENT DETAIL

DTP - DATE - REPLACEMENT

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱446✱D8✱20120127~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

446

Replacement

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Replacement Date

SEGMENT DETAIL

DTP - DATE - TREATMENT START

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	When the Treatment Start Date is used, the Date of Service must not be used.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱196✱D8✱20120115~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

196

Start

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Treatment Start Date

SEGMENT DETAIL

DTP - DATE - TREATMENT COMPLETION

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	When the Treatment Completion Date is used, the Date of Service must not be used.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱198✱D8✱20120129~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

198

Completion

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Treatment Completion Date

SEGMENT DETAIL

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

TR3 Example:

CN1✱02✱550~


DIAGRAM

CN1

✱

CN101		1166
Contract Type Code
M 1	ID	2/2

✱

CN102		782
Monetary Amount
O 1	R	1/18

✱

CN103		332
Allow/Chrg Percent
O 1	R	1/6

✱

CN104		127
Reference Ident
O 1	AN	1/50

✱

CN105		338
Terms Disc Percent
O 1	R	1/6

✱

CN106		799
Version ID
O 1	AN	1/30

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

CN101

1166

Contract Type Code

M 1

2/2

Code identifying a contract type

CODE

DEFINITION

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

SITUATIONAL

CN102

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Amount

SITUATIONAL

CN103

332

Percent, Decimal Format

O 1

1/6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

SEMANTIC: CN103 is the allowance or charge percent.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Percentage

SITUATIONAL

CN104

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: CN104 is the contract code.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Code

SITUATIONAL

CN105

338

Terms Discount Percent

O 1

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

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Terms Discount Percentage

SITUATIONAL

CN106

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.

SITUATIONAL RULE: Required when this information is necessary to satisfy contract requirements.

If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Version Identifier

SEGMENT DETAIL

REF - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G1✱13579~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior Authorization Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Authorization or Referral Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱9F✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referral Number

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

2400 — SERVICE LINE NUMBER

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.

2.	Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.

3.	X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

4.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

K3✱STATE DATA REQUIREMENT~


DIAGRAM

✱

K301		449
Fixed Form Information
M 1	AN	1/80

✱

K302		1333
~~Record~~ ~~Format Code~~
O 1	ID	1/2

✱

K303		C001
~~Composite~~ ~~Unit of Mea~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

K301

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

NOT USED

K302

1333

Record Format Code

O 1

1/2

NOT USED

K303

C001

Composite Unit of Measure

O 1

SEGMENT DETAIL

NM1 - RENDERING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2420A — RENDERING PROVIDER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	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 substitute provider (locum tenens) was used, enter that provider's information here.

2.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

PRV - RENDERING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2420A — RENDERING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/50

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

REF - RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2420A — RENDERING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - ASSISTANT SURGEON NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2420B — ASSISTANT SURGEON NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DD✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567899~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Assistant Surgeon

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Assistant Surgeon Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Assistant Surgeon Primary Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

PRV - ASSISTANT SURGEON SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2420B — ASSISTANT SURGEON NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱AS✱PXC✱1223S0112X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/50

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

REF - ASSISTANT SURGEON SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2420B — ASSISTANT SURGEON NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G2✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Assistant Surgeon Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - SUPERVISING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Set Notes:

1.	NOTE: 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.

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2420C — SUPERVISING PROVIDER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱DQ✱1✱SMITH✱JOHN✱A✱✱✱XX✱2223334444~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/60

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/60

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Use this code for the supervising dentist or physician.

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

REQUIRED

NM103

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare & Medicaid Services National Provider Identifier

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available in the payer's system.
If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Identifier

If, for whatever reason, the data is not stored within the payer's system, do not use.

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/60

SEGMENT DETAIL

REF - SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

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

Loop:

2420C — SUPERVISING PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when available in the payer's system.
If not required by this implementation guide, do not send.

TR3 Notes:


1.	If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱0B✱12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/50

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

REQUIRED

REF02

127

Reference Identification

X 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Supervising Provider Secondary Identifier

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

SVD - LINE ADJUDICATION INFORMATION

X12 Name:

Service Line Adjudication

X12 Purpose:

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

X12 Set Notes:

1.	NOTE: SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.

Loop:

2430 — LINE ADJUDICATION INFORMATION
Loop Repeat: 15

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:

TR3 Example:

SVD✱43✱55✱AD:D0330✱✱1~


DIAGRAM

SVD

✱

SVD01		67
ID Code
M 1	AN	2/80

✱

SVD02		782
Monetary Amount
M 1	R	1/18

✱

SVD03		C003
Comp. Med. Proced. ID
O 1

✱

SVD04		234
~~Product/~~ ~~Service ID~~
O 1	AN	1/48

✱

SVD05		380
Quantity
O 1	R	1/15

✱

SVD06		554
Assigned Number
O 1	N0	1/6

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SVD01

Identification Code

M 1

2/80

Code identifying a party or other code

SEMANTIC: SVD01 is the payer identification code.

INDUSTRY NAME: Other Payer Primary Identifier

REQUIRED

SVD02

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVD02 is the amount paid for this service line.

INDUSTRY NAME: Service Line Paid Amount

Zero "0" is an acceptable value for this element.

REQUIRED

SVD03

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

COMMENT: SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.