277 Transaction Set Listing

006020X313 Health Care Claim Request For Additional Information
Usage
Repeats

ISA - INTERCHANGE CONTROL HEADER

X12 Name:
Interchange Control Header
X12 Purpose:
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
  1. All positions within each of the data elements must be filled.
  2. For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
  3. The first element separator defines the element separator to be used through the entire interchange.
  4. The ISA segment terminator defines the segment terminator used throughout the entire interchange.
  5. Spaces in the example interchanges are represented by "." for clarity.
TR3 Example:
ISA✱00✱..........✱01✱SECRET....✱ZZ✱SUBMITTERS.ID..✱ZZ✱RECEIVERS.ID...✱030101✱1253✱^✱00602✱000000905✱0✱T✱:~
ISA
✱
1
I01
Author Info
Qualifier
M 1
ID
2
✱
2
I02
Author
Information
M 1
AN
10
✱
3
I03
Security
Info Qual
M 1
ID
2
✱
4
I04
Security
Information
M 1
AN
10
✱
5
I05
Interchange
ID Qual
M 1
ID
2
✱
6
I06
Interchange
Sender ID
M 1
AN
15
✱
7
I05
Interchange
ID Qual
M 1
ID
2
✱
8
I07
Interchange
Receiver ID
M 1
AN
15
✱
9
I08
Interchange
Date
M 1
DT
6
✱
10
I09
Interchange
Time
M 1
TM
4
✱
11
I65
Repetition
Separator
M 1
✱
12
I11
Inter Ctrl
Version Num
M 1
ID
5
✱
13
I12
Inter Ctrl
Number
M 1
N
9
✱
14
I13
Ack
Requested
M 1
ID
1
✱
15
I14
Usage
Indicator
M 1
ID
1
✱
16
I15
Component
Elem Sepera
M 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
I01
Authorization Information Qualifier
M 1
ID
2
Code identifying the type of information in the Authorization Information
CODE
DEFINITION
00
No Authorization Information Present (No Meaningful Information in I02)
03
Additional Data Identification
Required
2
I02
Authorization Information
M 1
AN
10
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
3
I03
Security Information Qualifier
M 1
ID
2
Code identifying the type of information in the Security Information
CODE
DEFINITION
00
No Security Information Present (No Meaningful Information in I04)
01
Password
Required
4
I04
Security Information
M 1
AN
10
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
5
I05
Interchange ID Qualifier
M 1
ID
2
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
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
CODE SOURCE: 121: Health Industry Number
27
Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
28
Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
29
Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
Required
6
I06
Interchange Sender ID
M 1
AN
15
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
7
I05
Interchange ID Qualifier
M 1
ID
2
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
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
CODE SOURCE: 121: Health Industry Number
27
Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
28
Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
29
Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
Required
8
I07
Interchange Receiver ID
M 1
AN
15
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
9
I08
Interchange Date
M 1
DT
6
Date of the interchange
The date format is YYMMDD.
Required
10
I09
Interchange Time
M 1
TM
4
Time of the interchange
The time format is HHMM.
Required
11
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
12
I11
Interchange Control Version Number
M 1
ID
5
Code specifying the version number of the interchange control segments
CODE
DEFINITION
00602
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2009
Required
13
I12
Interchange Control Number
M 1
N
9
A control number assigned by the interchange sender
  1. The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
  2. Must be a positive unsigned number and must be identical to the value in IEA02.
Required
14
I13
Acknowledgment Requested
M 1
ID
1
Code indicating sender's request for an interchange acknowledgment
X12.5 - Interchange Control Structure, provides the purpose of the TA1 segment. The X12 Acknowledgment Reference Model provides considerable information about the TA1 segment.
CODE
DEFINITION
0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
Required
15
I14
Interchange Usage Indicator
M 1
ID
1
Code indicating whether data enclosed by this interchange envelope is test, production or information
CODE
DEFINITION
P
Production Data
T
Test Data
Required
16
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*HN - 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:
1
TR3 Example:
GS✱XX✱SENDER CODE✱RECEIVER CODE✱19991231✱0802✱1✱X✱006020X313~
GS
✱
1
479
Functional
ID Code
M 1
ID
2
✱
2
142
Application
Send's Code
M 1
AN
2/15
✱
3
124
Application
Rec's Code
M 1
AN
2/15
✱
4
373
Date
M 1
DT
8
✱
5
337
Time
M 1
TM
4/8
✱
6
28
Group Ctrl
Number
M 1
N
1/9
✱
7
455
Responsible
Agency Code
M 1
ID
1/2
✱
8
480
Ver/Release
ID Code
M 1
AN
1/12
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
479
Functional Identifier Code
M 1
ID
2
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
HN
Health Care Information Status Notification (277)
Required
2
142
Application Sender's Code
M 1
AN
2/15
Code identifying party sending transmission; codes agreed to by trading partners
Use this code to identify the unit sending the information.
Required
3
124
Application Receiver's Code
M 1
AN
2/15
Code identifying party receiving transmission; codes agreed to by trading partners
Use this code to identify the unit receiving the information.
Required
4
373
Date
M 1
DT
8
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
5
337
Time
M 1
TM
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: GS05 is the group time.
Use this time for the creation time. The recommended format is HHMM.
Required
6
28
Group Control Number
M 1
N
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
7
455
Responsible Agency Code
M 1
ID
1/2
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
CODE
DEFINITION
X
Accredited Standards Committee X12
Required
8
480
Version / Release / Industry Identifier Code
M 1
AN
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
006020X313
Health Care Claim Request For Additional Information

ST*277 - 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:
1
TR3 Example:
ST✱277✱0001✱006020X313~
ST
✱
1
143
TS ID
Code
M 1
ID
3
✱
2
329
TS Control
Number
M 1
AN
4/9
✱
3
1705
Imple Conv
Reference
O 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
143
Transaction Set Identifier Code
M 1
ID
3
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
277
Health Care Information Status Notification
Required
2
329
Transaction Set Control Number
M 1
AN
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 Numbers in ST02 and SE02 must be identical and must be a numeric value. The number (i.e. numeric value) is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the numeric value 0001 and increment from there. The Transaction Set Control Number also aids in error resolution research.
Required
3
1705
Implementation Convention Reference
O 1
AN
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: Version, Release, or Industry Identifier
  1. This element must be populated with the implementation guide Version/Release/Industry Identifier Code named in Section 1.2.
  2. This element 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 utilized at translation time.
CODE
DEFINITION
006020X313
Health Care Claim Request For Additional Information

BHT*0085 - 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:
1
TR3 Example:
BHT✱0085✱48✱277RFI000001✱20110801✱1211✱RQ~
BHT
✱
1
1005
Hierarch
Struct Code
M 1
ID
4
✱
2
353
TS Purpose
Code
M 1
ID
2
✱
3
127
Reference
Ident
O 1
AN
1/80
✱
4
373
Date
O 1
DT
8
✱
5
337
Time
O 1
TM
4/8
✱
6
640
Transaction
Type Code
O 1
ID
2
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1005
Hierarchical Structure Code
M 1
ID
4
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
Used to specify the sequential order of HL segments. The HL loops in the data stream must comply with this sequential order. An HL parent loop must be followed by any subordinate child loops prior to commencing a new HL parent loop at the same hierarchical level.
CODE
DEFINITION
0085
Information Source, Information Receiver, Provider of Service, Patient
Required
2
353
Transaction Set Purpose Code
M 1
ID
2
Code identifying purpose of transaction set
CODE
DEFINITION
48
Suspended
Required
3
127
Reference Identification
O 1
AN
1/80
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
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Required
4
373
Date
O 1
DT
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
5
337
Time
O 1
TM
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: BHT05 is the time the transaction was created within the business application system.
INDUSTRY NAME: Transaction Set Creation Time
Required
6
640
Transaction Type Code
O 1
ID
2
Code specifying the type of transaction
CODE
DEFINITION
RQ
Request

HL - INFORMATION SOURCE 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:
Loop 2000A - INFORMATION SOURCE LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
The entity requesting this information is the payer.
TR3 Example:
HL✱1✱✱20✱1~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
1/12
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Not Used
2
734
Hierarchical Parent ID Number
O 1
AN
1/12
Required
3
735
Hierarchical Level Code
M 1
ID
1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
CODE
DEFINITION
20
Information Source
Required
4
736
Hierarchical Child Code
O 1
ID
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
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:
Individual or Organizational Name
X12 Purpose:
To supply the full name of an individual or organizational entity
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:
Loop 2100A - PAYER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱PR✱2✱ABC INSURANCE CO✱✱✱✱✱XV✱11122333~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/60
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/60
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
PR
Payer
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/60
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Payer Name
Not Used
4
1036
Name First
O 1
AN
1/35
Not Used
5
1037
Name Middle
O 1
AN
1/25
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code designating the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
PI
Payor Identification
Use when XV is not used.
XV
Centers for Medicare and Medicaid Services PlanID
Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID
Required
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Payer Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/60

PER*IC - PAYER 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:
Loop 2100A - PAYER NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the payer has contact data that may provide medical or other policy information that may apply to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
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. This PER Segment provides general payer customer support information and is not returned in the 275.
TR3 Example:
PER✱IC✱✱UR✱www.anyhealthplan.com/policies.html~
PER
✱
1
366
Contact
Funct Code
M 1
ID
2
✱
2
93
Name
O 1
AN
1/60
✱
3
365
Comm
Number Qual
X 1
ID
2
✱
4
364
Comm
Number
X 1
AN
1/256
✱
5
365
Comm
Number Qual
X 1
ID
2
✱
6
364
Comm
Number
X 1
AN
1/256
✱
7
365
Comm
Number Qual
X 1
ID
2
✱
8
364
Comm
Number
X 1
AN
1/256
✱
9
443
Contact Inq
Reference
O 1
AN
1/20
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
IC
Information Contact
Situational
2
93
Name
O 1
AN
1/60
Free-form name
SITUATIONAL RULE: Required when it is necessary to identify a contact name or department for questions or general information related to the payer's additional information requests. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
INDUSTRY NAME: Payer Contact Name
Situational
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
CODE
DEFINITION
EM
Electronic Mail
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
Situational
4
364
Communication Number
X 1
AN
1/256
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
INDUSTRY NAME: Payer Contact Communication Number
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
CODE
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
Situational
6
364
Communication Number
X 1
AN
1/256
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
INDUSTRY NAME: Payer Contact Communication Number
Situational
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
CODE
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
Situational
8
364
Communication Number
X 1
AN
1/256
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
INDUSTRY NAME: Payer Contact Communication Number
Not Used
9
443
Contact Inquiry Reference
O 1
AN
1/20

HL - INFORMATION RECEIVER 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:
Loop 2000B - INFORMATION RECEIVER LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
HL✱2✱1✱21✱1~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
1/12
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Required
2
734
Hierarchical Parent ID Number
O 1
AN
1/12
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Required
3
735
Hierarchical Level Code
M 1
ID
1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
CODE
DEFINITION
21
Information Receiver
Required
4
736
Hierarchical Child Code
O 1
ID
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
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:
Individual or Organizational Name
X12 Purpose:
To supply the full name of an individual or organizational entity
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:
Loop 2100B - INFORMATION RECEIVER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
Recipient of the request from the Information Source. For this business use, this entity can be a provider, a provider group, a clearinghouse, a service bureau, an agency, etc.
TR3 Example:
NM1✱41✱2✱ABC SUBMITTER✱✱✱✱✱46✱999999999~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/60
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/60
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
This is the submitter of the original claim or the entity designated to receive the request for additional information.
CODE
DEFINITION
41
Submitter
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/60
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Information Receiver Last or Organization Name
Situational
4
1036
Name First
O 1
AN
1/35
Individual first name
SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Information Receiver First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Information Receiver Middle Name
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code designating the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
46
Electronic Transmitter Identification Number (ETIN)
Required
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Information Receiver Identification Number
The ETIN is established through Trading Partner agreement.
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/60

HL - SERVICE PROVIDER 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:
Loop 2000C - SERVICE PROVIDER LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
HL✱3✱2✱19✱1~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
1/12
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Required
2
734
Hierarchical Parent ID Number
O 1
AN
1/12
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Required
3
735
Hierarchical Level Code
M 1
ID
1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
CODE
DEFINITION
19
Provider of Service
Required
4
736
Hierarchical Child Code
O 1
ID
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
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*1P - SERVICE PROVIDER NAME

X12 Name:
Individual or Organizational Name
X12 Purpose:
To supply the full name of an individual or organizational entity
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:
Loop 2100C - SERVICE PROVIDER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱1P✱2✱HOME MEDICAL✱✱✱✱✱XX✱1666666666~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/60
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/60
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
1P
Provider
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/60
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Provider Last or Organization Name
Situational
4
1036
Name First
O 1
AN
1/35
Individual first name
SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Middle Name
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when NM102 = 1 and the person has a name suffix that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Name Suffix
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code designating the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
FI
Federal Taxpayer's Identification Number
SV
Service Provider Number
XX
Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers in the United States or its territories when the provider is eligible to receive a National Provider Identifier (NPI).
OR
Required for providers not in the United States or its territories when the provider has received an NPI. If not required by this implementation guide, do not send.
CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier
Required
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Provider Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/60

HL - PATIENT 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:
Loop 2000D - PATIENT LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
HL✱4✱3✱PT~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
1/12
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Required
2
734
Hierarchical Parent ID Number
O 1
AN
1/12
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Required
3
735
Hierarchical Level Code
M 1
ID
1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
CODE
DEFINITION
PT
Patient
Not Used
4
736
Hierarchical Child Code
O 1
ID
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:
  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:
Loop 2100D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱QC✱1✱SMITH✱JOHN✱Q✱✱IV✱MI✱99887777~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/60
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/60
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
QC
Patient
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
Required
3
1035
Name Last or Organization Name
X 1
AN
1/60
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Patient Last Name
Situational
4
1036
Name First
O 1
AN
1/35
Individual first name
SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Patient First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Patient Middle Name or Initial
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when NM102 = 1 and the person has a name suffix that is known. If not required by this implementation guide, do not send.
INDUSTRY NAME: Patient Name Suffix
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code designating the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
II
Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated for use. If not required, use value "MI" instead.
MI
Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.
Required
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Patient Primary Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/60

TRN*1 - PAYER CLAIM CONTROL NUMBER

X12 Name:
Trace
X12 Purpose:
To uniquely identify a transaction to an application
Loop:
Loop 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
This is the payer's claim control number.
TR3 Example:
TRN✱1✱0612991010987~
TRN
✱
1
481
Trace Type
Code
M 1
ID
1/2
✱
2
127
Reference
Ident
M 1
AN
1/80
✱
3
509
Originating
Company ID
O 1
AN
10
✱
4
127
Reference
Ident
O 1
AN
1/80
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
481
Trace Type Code
M 1
ID
1/2
Code identifying which transaction is being referenced
CODE
DEFINITION
1
Current Transaction Trace Numbers
Required
2
127
Reference Identification
M 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEMANTIC: TRN02 provides unique identification for the transaction.
INDUSTRY NAME: Payer Claim Control Number
  1. This is the Control Number assigned by the payer. This number is used by the Payer to connect the request to the response. This number must be returned in the 275 response in the 2000A TRN02 data element.
  2. Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
509
Originating Company Identifier
O 1
AN
10
Not Used
4
127
Reference Identification
O 1
AN
1/80

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:
Status Information
X12 Purpose:
To report the status, required action, and paid information of a claim or service line
Loop:
Loop 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
>1
Situational Rule:
Required when requesting additional information at the claim level. If not required by this implementation guide, do not send.
TR3 Notes:
  1. See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
  2. The codes in this STC segment must be returned in the 275 response in the 2000A STC.
TR3 Example:
STC✱RO:18682-5::LOI✱20110824~ orSTC✱R4:18660-1::LOI✱20110824✱✱✱✱✱✱✱✱R4:19790-6::LOI~
STC
✱
1
C043
Health Care
Stat Claim
M 1
✱
2
373
Date
O 1
DT
8
✱
3
306
Action
Code
O 1
ID
1/2
✱
4
782
Monetary
Amount
O 1
R
1/18
✱
5
782
Monetary
Amount
O 1
R
1/18
✱
6
373
Date
O 1
DT
8
✱
7
591
Payment
Method Code
O 1
ID
3
✱
8
373
Date
O 1
DT
8
✱
9
429
Check
Number
O 1
AN
1/16
✱
10
C043
Health Care
Stat Claim
O 1
✱
11
C043
Health Care
Stat Claim
O 1
✱
12
933
Free-Form
Message Txt
O 1
AN
1/264
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
C043
Health Care Claim Status
M 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
Required
1-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. Use Requests for Additional Information "R" type Category Codes only.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
1-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Additional Information Request Code
This is the LOINC® Code that defines the additional information being requested.
Not Used
1-3
98
Entity Identifier Code
O 1
ID
2/3
Required
1-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
This value indicates that STC01-02, STC10-02, STC11-02 are Logical Observation Identifier Names and Codes (LOINC®).
CODE
DEFINITION
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)
Required
2
373
Date
O 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: STC02 is the effective date of the status information.
INDUSTRY NAME: Status Information Effective Date
This is the date the claim was placed in this status by the Information Source's adjudication process.
Not Used
3
306
Action Code
O 1
ID
1/2
Not Used
4
782
Monetary Amount
O 1
R
1/18
Not Used
5
782
Monetary Amount
O 1
R
1/18
Not Used
6
373
Date
O 1
DT
8
Not Used
7
591
Payment Method Code
O 1
ID
3
Not Used
8
373
Date
O 1
DT
8
Not Used
9
429
Check Number
O 1
AN
1/16
Situational
10
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.
Required
10-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. Use Requests for Additional Information "R" type Category Codes only.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
10-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Additional Information Request Code
This will be the LOINC® Code that further specifies the request for information.
Not Used
10-3
98
Entity Identifier Code
O 1
ID
2/3
Required
10-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)
Situational
11
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.
Required
11-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. Use Requests for Additional Information "R" type Category Codes only.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
11-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Additional Information Request Code
This will be the LOINC® Code that further specifies the request for information.
Not Used
11-3
98
Entity Identifier Code
O 1
ID
2/3
Required
11-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)
Not Used
12
933
Free-form Message Text
O 1
AN
1/264

REF*X1 - PROVIDER'S ASSIGNED CLAIM 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Provider's Assigned Claim Identifier was submitted on the claim. If not required by this implementation guide, do not send.
TR3 Notes:
This segment is the Provider's Assigned Claim Identifier submitted in the CLM01 of the 837.
TR3 Example:
REF✱X1✱PT12345~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
X1
Provider Claim Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Provider's Assigned Claim Identifier
  1. Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
  2. The maximum number of characters to be supported for this field is '35'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

REF*BLT - INSTITUTIONAL BILL TYPE 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required for Institutional claims when Institutional Type of Bill was received on the claim. If not required by this implementation guide, do not send.
TR3 Example:
REF✱BLT✱111~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
BLT
Billing Type
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
  1. Concatenate the 837I CLM05-01 (Facility Type Code) and CLM05-03 (Claim Frequency Code) values.
    Code Source 236: Uniform Billing Claim Form Bill Type
    Code Source 235: Claim Frequency Type Code
  2. Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

REF*EA - MEDICAL RECORD IDENTIFICATION 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Medical Record Identification Number was submitted on the original claim. If not required by this implementation guide, do not send.
TR3 Notes:
The Medical Record Identification Number is reported in the 837, 2300 Loop REF02 (REF01 = EA).
TR3 Example:
REF✱EA✱44444TH56~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
EA
Medical Record Identification Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Medical Record Identification Number
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a transmission intermediary (clearinghouse or other) needs to attach their own unique tracking number. If not required by this implementation guide, do not send.
TR3 Example:
REF✱D9✱TJ98UU321~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
D9
Claim Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Clearinghouse Trace Number
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

REF*Y4 - PROPERTY & 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when requesting information related to a Property & Casualty claim. If not required by this implementation guide, do not send.
TR3 Example:
REF✱Y4✱4445555~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
Y4
Agency Claim Number
Required
2
127
Reference Identification
X 1
AN
1/80
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
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

REF*3H - CASE REFERENCE 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a case reference identifier is assigned by the payer and necessary for tracking related attachment requests. If not required by this implementation guide, do not send.
TR3 Notes:
A case reference identifier may be assigned by the payer to link related attachment requests which may involve single or multiple patients and/or providers.
TR3 Example:
REF✱3H✱XRAY123~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
3H
Case Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Case Reference Identifier
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

REF*X9 - ATTACHMENT REQUEST TRACKING 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when an attachment request tracking identifier is assigned by the payer to this attachment request and is necessary for tracking purposes. If not required by this implementation guide, do not send.
TR3 Notes:
This identifier is used to track an individual attachment request for a single claim.
TR3 Example:
REF✱X9✱DOC234~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
X9
Internal Control Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Attachment Request Tracking Identifier
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

REF*Q4 - PRIOR ATTACHMENT REQUEST TRACKING 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a previously issued attachment request tracking identifier has been terminated and replaced with the current attachment request tracking identifier (REF01=X9). If not required by this implementation guide, do not send.
TR3 Example:
REF✱Q4✱DOC123~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
Q4
Prior Identifier Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Prior Attachment Request Tracking Identifier
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the claim is not a predetermination and service level dates are not reported. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
TR3 Notes:
For Institutional claims, it is the statement period in loop 2300 (DTP01=434). For Professional claims this information is derived from the earliest service level dates in loop 2400 (DTP01=472) to the latest service level date. For Dental claims it is the service date at the claim loop 2300 (DTP01=472) or when not reported at Loop 2300, it is derived from the earliest service level date in loop 2400 (DTP01=472) to the latest service level date.
TR3 Example:
DTP✱472✱D8✱20110201~ ORDTP✱472✱RD8✱20110201-20110205~
DTP
✱
1
374
Date/Time
Qualifier
M 1
ID
3
✱
2
1250
Date Time
Format Qual
M 1
ID
2/3
✱
3
1251
Date Time
Period
M 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
472
Service
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Claim Service Period

DTP*106 - RESPONSE DUE 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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
This date is supplied to indicate the date the requested information is to be returned by the Information Receiver.

Should this date pass without the requested information being supplied by the Information Receiver, the payer may decide to allow the claim to proceed through the adjudication process based upon the information already received.
TR3 Example:
DTP✱106✱D8✱20110228~
DTP
✱
1
374
Date/Time
Qualifier
M 1
ID
3
✱
2
1250
Date Time
Format Qual
M 1
ID
2/3
✱
3
1251
Date Time
Period
M 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
106
Required By
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Response Due Date

PWK*OZ - CLAIM SUPPLEMENTAL INFORMATION

X12 Name:
Paperwork
X12 Purpose:
To identify the type or transmission or both of paperwork or supporting information
X12 Syntax:
  1. P0506
    If either PWK05 or PWK06 is present, then the other is required.
  2. P1011
    If either PWK10 or PWK11 is present, then the other is required.
X12 Set Notes:
COMMENT: The 2210 loop may be used when there is a status notification or a request for additional information about a particular claim.
Loop:
Loop 2210D - CLAIM SUPPLEMENTAL INFORMATION
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when the payer must have the requested information returned to a specific contact person, number or location. If not required by this implementation guide, do not send.
TR3 Notes:
The PWK segment is syntactically required in order to use the Payer Response Contact data in the 2210D Loop.
TR3 Example:
PWK✱OZ~
PWK
✱
1
755
Report Type
Code
M 1
ID
2
✱
2
756
Report
Transm Code
O 1
ID
1/2
✱
3
757
Report
Copies Need
O 1
N
1/2
✱
4
98
Entity ID
Code
O 1
ID
2/3
✱
5
66
ID Code
Qualifier
X 1
ID
1/2
✱
6
67
ID
Code
X 1
AN
2/80
✱
7
352
Description
O 1
AN
1/80
✱
8
C002
Actions
Indicated
O 1
✱
9
1525
Request
Categ Code
O 1
ID
1/2
✱
10
1270
Code List
Qual Code
X 1
ID
1/3
✱
11
1271
Industry
Code
X 1
AN
1/30
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
755
Report Type Code
M 1
ID
2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY NAME: Report Transmission Code
CODE
DEFINITION
OZ
Support Data for Claim
Not Used
2
756
Report Transmission Code
O 1
ID
1/2
Not Used
3
757
Report Copies Needed
O 1
N
1/2
Not Used
4
98
Entity Identifier Code
O 1
ID
2/3
Not Used
5
66
Identification Code Qualifier
X 1
ID
1/2
Not Used
6
67
Identification Code
X 1
AN
2/80
Not Used
7
352
Description
O 1
AN
1/80
Not Used
8
C002
Actions Indicated
O 1
Not Used
9
1525
Request Category Code
O 1
ID
1/2
Not Used
10
1270
Code List Qualifier Code
X 1
ID
1/3
Not Used
11
1271
Industry Code
X 1
AN
1/30

PER*RE - PAYER RESPONSE 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:
Loop 2210D - CLAIM SUPPLEMENTAL INFORMATION
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
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 data in this PER is used by the payer for routing the requested information within their system. This data must be returned by the provider. In the 275 Transaction, this data is returned in the 1000A loop PER Segment, Payer Response Contact Information.
TR3 Example:
PER✱RE✱MEDICAL REVIEW DEPARTMENT✱ED✱MRD123✱FX✱3135554321~
PER
✱
1
366
Contact
Funct Code
M 1
ID
2
✱
2
93
Name
O 1
AN
1/60
✱
3
365
Comm
Number Qual
X 1
ID
2
✱
4
364
Comm
Number
X 1
AN
1/256
✱
5
365
Comm
Number Qual
X 1
ID
2
✱
6
364
Comm
Number
X 1
AN
1/256
✱
7
365
Comm
Number Qual
X 1
ID
2
✱
8
364
Comm
Number
X 1
AN
1/256
✱
9
443
Contact Inq
Reference
O 1
AN
1/20
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
RE
Receiving Contact
Situational
2
93
Name
O 1
AN
1/60
Free-form name
SITUATIONAL RULE: Required when it is necessary to identify a contact name or department for questions or general information related to the payer's additional information requests. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
INDUSTRY NAME: Payer Contact Name
Situational
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.
The presence of the communications qualifiers does not imply the method for which data must be returned.
CODE
DEFINITION
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
FX
Facsimile
TE
Telephone
Situational
4
364
Communication Number
X 1
AN
1/256
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.
INDUSTRY NAME: Payer Contact Communication Number
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.
The presence of the communications qualifiers does not imply the method for which data must be returned.
CODE
DEFINITION
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Situational
6
364
Communication Number
X 1
AN
1/256
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.
INDUSTRY NAME: Payer Contact Communication Number
Situational
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.
The presence of the communications qualifiers does not imply the method for which data must be returned.
CODE
DEFINITION
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Situational
8
364
Communication Number
X 1
AN
1/256
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.
INDUSTRY NAME: Payer Contact Communication Number
Not Used
9
443
Contact Inquiry Reference
O 1
AN
1/20

N3 - PAYER RESPONSE CONTACT ADDRESS

X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop 2210D - CLAIM SUPPLEMENTAL INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the payer needs to identify a specific mailing location for the return of attachment data in the event the 275 transaction will not be used. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
TR3 Notes:
This data is not returned in the 275 transaction.
TR3 Example:
N3✱123 MAIN STREET~
N3
✱
1
166
Address
Information
M 1
AN
1/55
✱
2
166
Address
Information
O 1
AN
1/55
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Response Contact Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.
INDUSTRY NAME: Response Contact Additional Address Line

N4 - PAYER RESPONSE CONTACT 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:
Loop 2210D - CLAIM SUPPLEMENTAL INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the payer needs to identify a specific mailing location for the return of attachment data in the event the 275 transaction will not be used. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
TR3 Notes:
This data is not returned in the 275 transaction.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
1
19
City
Name
O 1
AN
2/30
✱
2
156
State or
Prov Code
X 1
ID
2
✱
3
116
Postal
Code
O 1
ID
3/15
✱
4
26
Country
Code
X 1
ID
2/3
✱
5
309
Location
Qualifier
X 1
ID
1/2
✱
6
310
Location
Identifier
O 1
AN
1/30
✱
7
1715
Country Sub
Code
X 1
ID
1/3
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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: Response Contact City Name
Situational
2
156
State or Province Code
X 1
ID
2
Code (Standard State/Province) as defined by appropriate government agency
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: Response Contact State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
O 1
ID
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: Response Contact Postal Zone or ZIP Code
  • CODE SOURCE 51: ZIP Code
  • CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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.
INDUSTRY NAME: Response Contact Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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.
INDUSTRY NAME: Response Contact Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds

SVC - SERVICE LINE INFORMATION

X12 Name:
Service Information
X12 Purpose:
To supply payment and control information to a provider for a particular service
Loop:
Loop 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when the request for additional information is about a service line. If not required by this implementation guide, do not send.
TR3 Notes:
For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-02 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-02.
TR3 Example:
SVC✱NU:0710✱15.61~ ORSVC✱HC:99213✱35~
SVC
✱
1
C003
Comp. Med.
Proced. ID
M 1
✱
2
782
Monetary
Amount
M 1
R
1/18
✱
3
782
Monetary
Amount
O 1
R
1/18
✱
4
234
Product/
Service ID
O 1
AN
1/80
✱
5
380
Quantity
O 1
R
1/15
✱
6
C003
Comp. Med.
Proced. ID
O 1
✱
7
380
Quantity
O 1
R
1/15
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
C003
Composite Medical Procedure Identifier
M 1
To identify a medical procedure by its standardized codes and applicable modifiers
SEMANTIC: SVC01 is the medical procedure upon which adjudication is based.
COMMENT: For Medicare Part A claims, SVC01 would be the Healthcare Common Procedure Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
X12 COMPOSITE SEMANTIC NOTES:
  1. C003-01 qualifies C003-02 and C003-08.
  2. If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
  3. C003-03 modifies the value in C003-02 and C003-08.
  4. C003-04 modifies the value in C003-02 and C003-08.
  5. C003-05 modifies the value in C003-02 and C003-08.
  6. C003-06 modifies the value in C003-02 and C003-08.
  7. C003-07 is the description of the procedure identified in C003-02.
  8. C003-08 represents the ending value in the range in which the code occurs.
  9. C003-09 modifies the value in C003-02 and C003-08.
  10. C003-10 modifies the value in C003-02 and C003-08.
  11. C003-11 modifies the value in C003-02 and C003-08.
  12. C003-12 modifies the value in C003-02 and C003-08.
Required
1-1
235
Product/Service ID Qualifier
M 1
ID
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
AD
American Dental Association Codes
CODE SOURCE: 135: American Dental Association
ER
Jurisdiction Specific Procedure and Supply Codes
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 Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.
CODE SOURCE: 576: Workers Compensation Specific Procedure and Supply Codes
HC
Healthcare Common Procedure Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HCPCS consists of codes from multiple sources including AMA's CPT codes and ADA's CDT codes.
CODE SOURCE: 130: Healthcare Common Procedure Coding System
HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities
N4
National Drug Code in 5-4-2 Format
CODE SOURCE: 240: National Drug Code by Format
NU
National Uniform Billing Committee (NUBC) UB92 Codes
This code is the NUBC Revenue Code.
CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes
WK
Advanced Billing Concepts (ABC) Codes
At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA:
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.
CODE SOURCE: 843: Advanced Billing Concepts (ABC) Codes
Required
1-2
234
Product/Service ID
M 1
AN
1/80
Identifying number for a product or service
INDUSTRY NAME: Service Identification Code
If the value in SVC01-01 is "NU", then this element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-02, then SVC04 is not used.
Situational
1-3
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-4
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-5
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-6
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Not Used
1-7
352
Description
O 1
AN
1/80
Not Used
1-8
234
Product/Service ID
O 1
AN
1/80
Situational
1-9
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-10
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-11
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-12
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Required
2
782
Monetary Amount
M 1
R
1/18
Monetary amount
SEMANTIC: SVC02 is the submitted service charge.
INDUSTRY NAME: Line Item Charge Amount
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.
Not Used
3
782
Monetary Amount
O 1
R
1/18
Situational
4
234
Product/Service ID
O 1
AN
1/80
Identifying number for a product or service
SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.
SITUATIONAL RULE: Required on institutional claims to report a NUBC revenue code when a HCPCS or HIPPS code is reported in the SVC01-02. If not required by this implementation guide, do not send.
INDUSTRY NAME: Revenue Code
Not Used
5
380
Quantity
O 1
R
1/15
Not Used
6
C003
Composite Medical Procedure Identifier
O 1
Not Used
7
380
Quantity
O 1
R
1/15

STC - SERVICE LINE STATUS INFORMATION

X12 Name:
Status Information
X12 Purpose:
To report the status, required action, and paid information of a claim or service line
Loop:
Loop 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
>1
TR3 Notes:
  1. See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
  2. The codes in this STC segment must be returned in the 275 response in the 2000A STC.
TR3 Example:
STC✱R3:18682-5::LOI✱20110501~ orSTC✱R3:18660-1::LOI✱20110501✱✱✱✱✱✱✱✱R4:18790-6::LOI~
STC
✱
1
C043
Health Care
Stat Claim
M 1
✱
2
373
Date
O 1
DT
8
✱
3
306
Action
Code
O 1
ID
1/2
✱
4
782
Monetary
Amount
O 1
R
1/18
✱
5
782
Monetary
Amount
O 1
R
1/18
✱
6
373
Date
O 1
DT
8
✱
7
591
Payment
Method Code
O 1
ID
3
✱
8
373
Date
O 1
DT
8
✱
9
429
Check
Number
O 1
AN
1/16
✱
10
C043
Health Care
Stat Claim
O 1
✱
11
C043
Health Care
Stat Claim
O 1
✱
12
933
Free-Form
Message Txt
O 1
AN
1/264
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
C043
Health Care Claim Status
M 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
Required
1-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. Use Requests for Additional Information "R" type Category Codes only.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
1-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Additional Information Request Code
This is the LOINC® Code that defines the additional information being requested.
Not Used
1-3
98
Entity Identifier Code
O 1
ID
2/3
Required
1-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)
Required
2
373
Date
O 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: STC02 is the effective date of the status information.
INDUSTRY NAME: Status Information Effective Date
This is the date the claim was placed in this status by the Information Source's adjudication process.
Not Used
3
306
Action Code
O 1
ID
1/2
Not Used
4
782
Monetary Amount
O 1
R
1/18
Not Used
5
782
Monetary Amount
O 1
R
1/18
Not Used
6
373
Date
O 1
DT
8
Not Used
7
591
Payment Method Code
O 1
ID
3
Not Used
8
373
Date
O 1
DT
8
Not Used
9
429
Check Number
O 1
AN
1/16
Situational
10
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.
Required
10-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. Use Requests for Additional Information "R" type Category Codes only.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
10-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Additional Information Request Code
This will be the LOINC® Code that further specifies the request for information.
Not Used
10-3
98
Entity Identifier Code
O 1
ID
2/3
Required
10-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)
Situational
11
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.
Required
11-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. Use Requests for Additional Information "R" type Category Codes only.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
11-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Additional Information Request Code
This will be the LOINC® Code that further specifies the request for information.
Not Used
11-3
98
Entity Identifier Code
O 1
ID
2/3
Required
11-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)
Not Used
12
933
Free-form Message Text
O 1
AN
1/264

REF*6R - SERVICE LINE ITEM 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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a Service Line Item Control Number was submitted on the claim. If not required by this implementation guide, do not send.
TR3 Example:
REF✱6R✱54321~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
6R
Provider Control Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Line Item Control Number
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1

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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a service level date was submitted on the claim for this service. If not required by this implementation guide, do not send.
TR3 Example:
DTP✱472✱D8✱20110201~ ORDTP✱472✱RD8✱20110201-20110205~
DTP
✱
1
374
Date/Time
Qualifier
M 1
ID
3
✱
2
1250
Date Time
Format Qual
M 1
ID
2/3
✱
3
1251
Date Time
Period
M 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
472
Service
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Service Line Date

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:
P0102
If either TOO01 or TOO02 is present, then the other is required.
Loop:
Loop 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
32
Situational Rule:
Required when tooth information is needed to further define the service. If not required by this implementation guide, do not send.
TR3 Example:
TOO✱JP✱12✱L:O~
TOO
✱
1
1270
Code List
Qual Code
X 1
ID
1/3
✱
2
1271
Industry
Code
X 1
AN
1/30
✱
3
C005
Tooth
Surface
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1270
Code List Qualifier Code
X 1
ID
1/3
Code identifying a specific industry code list
SEGMENT SYNTAX: P0102
CODE
DEFINITION
JO
International Standard Designation System for Teeth and Areas of the Oral Cavity
Required when reporting areas of the oral cavity; do not use to report individual teeth.
CODE SOURCE: 135: American Dental Association
JP
Universal National Tooth Designation System
Required when reporting individual teeth; do not use when reporting areas of the oral cavity.
CODE SOURCE: 135: American Dental Association
Required
2
1271
Industry Code
X 1
AN
1/30
Code indicating a code from a specific industry code list
SEGMENT SYNTAX: P0102
INDUSTRY NAME: Tooth Code
Situational
3
C005
Tooth Surface
O 1
To identify one or more tooth surface codes
SITUATIONAL RULE: Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.
Required
3-1
1369
Tooth Surface Code
M 1
ID
1/2
Code identifying the area of the tooth that was treated
CODE
DEFINITION
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-2
1369
Tooth Surface Code
O 1
ID
1/2
Code identifying the area of the tooth that was treated
SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.
Additional tooth surface codes can be carried in TOO03-02 through TOO03-05. The code values are the same as in TOO03-01.
CODE
DEFINITION
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-3
1369
Tooth Surface Code
O 1
ID
1/2
Code identifying the area of the tooth that was treated
SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.
CODE
DEFINITION
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-4
1369
Tooth Surface Code
O 1
ID
1/2
Code identifying the area of the tooth that was treated
SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.
CODE
DEFINITION
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-5
1369
Tooth Surface Code
O 1
ID
1/2
Code identifying the area of the tooth that was treated
SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.
CODE
DEFINITION
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal

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:
1
TR3 Example:
SE✱24✱0001~
SE
✱
1
96
Number of
Inc Segs
M 1
N
1/10
✱
2
329
TS Control
Number
M 1
AN
4/9
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
96
Number of Included Segments
M 1
N
1/10
Total number of segments included in a transaction set including ST and SE segments
INDUSTRY NAME: Transaction Segment Count
Required
2
329
Transaction Set Control Number
M 1
AN
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.

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:
1
TR3 Example:
GE✱1✱1~
GE
✱
1
97
Number of
TS Included
M 1
N
1/6
✱
2
28
Group Ctrl
Number
M 1
N
1/9
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
97
Number of Transaction Sets Included
M 1
N
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
2
28
Group Control Number
M 1
N
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:
1
TR3 Example:
IEA✱1✱000000905~
IEA
✱
1
I16
Num of Incl
Funct Group
M 1
N
1/5
✱
2
I12
Inter Ctrl
Number
M 1
N
9
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
I16
Number of Included Functional Groups
M 1
N
1/5
A count of the number of functional groups included in an interchange
Required
2
I12
Interchange Control Number
M 1
N
9
A control number assigned by the interchange sender
logo

277 Health Care Claim Request For Additional Information (006020X313)

SEPTEMBER 2014

Copyright © 2008-21, X12 Incorporated, Format © 2008-21 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.

All rights reserved.

Abstract

The Health Care Claim Request for Additional Information Implementation Guide describes the use of the ASC X12 Health Care Claim Status Notification (277) transaction set to request additional information to support a health care claim or encounter.

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

For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

The purpose of this implementation guide is to provide standardized data requirements and content for all users of the ASC X12 Health Care Claim Request for Additional Information (277). This implementation guide focuses on the use of the 277 by a health care payer to request additional information to support a health care claim or encounter. The use of the 277 for this specific business purpose is the reason for this separate implementation guide.

This implementation guide provides a detailed explanation of the transaction set by defining uniform data content, identifying valid code tables, and specifying values applicable for the business focus of the 277 Request for Additional Information. The intention of the developers of the 277 is represented in the guide.

This implementation guide is designed to assist those who request or who receive requests to supplement claim review using the 277 format. The entities requesting additional health care information include, but are not limited to, insurance companies, Third Party Administrators (TPAs), managed care service organizations, state and federal agencies and their contractors, plan purchasers, and any other entity that processes health care claims or manages the delivery of health care services.

Other business partners affiliated with the 277 include billing services, health care providers, consulting services, vendors of systems, software and EDI translators, and EDI network intermediaries such as Automated Clearing Houses (ACHs), Value-Added Net-works (VANs), and telecommunications services.

1.2 Version Information

This implementation guide is based on the October 2009 ASC X12 standards, referred to as Version 6, Release 2, Sub-release 0 (006020).

The unique Version/Release/Industry Identifier Code for transaction sets that are defined by this implementation guide is 006020X313.

The two-character Functional Identifier Code for the transaction set included in this implementation guide:

  • HN   Health Care Information Status Notification (277)

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 EDI Control Directory.

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

There are no other usage limitations.

1.4 Business Usage

The ASC X12 Health Care Claim Request for Additional Information (277) implementation guide addresses usage of the 277 as a request for additional information to support a health care claim or encounter. The 277 transaction provides the mechanism for asking questions or making requests for information about specific claims or service lines. The actual answer or additional information response is provided in the ASC X12 Additional Information to Support a Health Care Claim or Encounter (275).

The 277 has the capability to request information for multiple claims and patients. However the 275 transaction structure only allows the submitter to send one claim in each 275. A separate Transaction Set Header/Trailer (ST/SE) must be sent for each claim. The LX segment within the 275 can be repeated to respond to multiple questions on an individual claim.

Figure 1.1 - General Claim Status Information Flow

General Claim Status Information Flow

1.4.1 Health Care Transaction Flow

Each X12 implementation guide explains how to use X12 transaction sets to meet a single defined business purpose. The diagrams found at https://www.x12.org/flow depict the business functions supported by the X12 health care implementation guides.

1.4.2 Transaction Participants

The hierarchical level structure is used to identify and relate the participants involved in the transaction. The relationships between the hierarchical levels are described by the hierarchical level code data elements, also known as HL01 and HL02. The data element, HL03, identifies the participants within the transaction. The participants described are as follows:

When HL03 = 20, the hierarchical level contains the Information Source. This entity is the decision maker in the business transaction. For this business use, this entity is the payer who is requesting additional information for the specified claims.

When HL03 = 21, the hierarchical level contains the Information Receiver. This entity is the recipient of the request for additional information from Information Source. This entity will be identified via their electronic ID. For this business use, this entity can be a provider, a provider group, a claims clearinghouse, a service bureau, etc.

When HL03 = 19, the hierarchical level contains the Provider of Service. This entity delivered the health care service. Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider).

When HL03 = PT the hierarchical level contains the Patient information. This entity is the recipient of the health care service rendered for which additional information is being requested.

The Information Receiver and the Service Provider hierarchical levels have a unique relationship. Information Receiver refers to the entity that processes the detailed information contained within the transaction set. In some cases, the Information Receiver is an entity acting on behalf of the Service Provider. When this occurs, the entity is described when HL03 = 21, and the Provider of Service is described when HL03 = 19. In other instances, the Information Receiver is also the Service Provider. When this occurs, the same entity is described at two hierarchical levels - when HL03 = 21 and when HL03 = 19.

The coding examples are presented sequentially as found within an actual transaction set. However, for reading ease each segment begins on a new line.

The following example demonstrates the coding of the segments and data elements within the Information Source hierarchical level:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~

The following is a coding example of the Information Receiver hierarchical level:

HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~

The following is a coding example of the Service Provider hierarchical level:

HL*3*2*19*1~
NM1*1P*2*HOME MEDICAL*****XX*1666666666~

The following is a coding example of the Patient Hierarchical level level:

HL*4*3*PT~
NM1*QC*1*MANN*JOHN****MI*345678901~

1.4.3 Claim and Service Information

Unlike the Transaction Participants, specific claim and service detail information is not given a hierarchical level. Claim and service information is positioned in the Patient hierarchical level. The specific claim(s) for which information is being requested is described in Loop 2200, while the service information follows the claim data in Loop 2220.

A payer may request additional information in support of a claim at the claim level, service line level, or at both locations. The STC segments at the claim and service level are used to express the specific information the payer requires from the provider to complete the adjudication process for the identified claim.

See Section 1.4.4.1 - STC Composite and Code Use Rules for additional information.

1.4.3.1 The Claim

When a request for additional information is made, the payer supplies the parameters that assist providers in locating the claim and data within their system. These parameters are frequently the Provider's Assigned Claim Identifier, medical record number, and dates of service which are sent in Loop 2200.

1.4.3.1.1 Claim Association of the 277 with the 275

The 277 transaction is used for requesting additional information about a specific claim. The additional information response must be able to be associated with the original request in the payer's adjudication system. The association of the request and additional information is accomplished with a trace number identified in the TRN Segment (TRN02).

The 277 Request for Additional Information, Loop 2200D TRN segment conveys the payer's claim control number. This identification number is assigned by the payer's system. This identifier is used by the payer to associate the additional information response to the appropriate claim.

When the additional information response is sent in an ASC X12 275 transaction, this number is returned in the 2000A TRN segment. The payer needs to receive this number back with the response to complete the association process.

1.4.3.1.2 Claim Level Identifiers

Within the 2200D loop, various identifiers can be sent by the payer to help providers identify the patient's claim or services within their system. These identifiers are reported in REF segments.

The following are examples of these REF segment identifiers:

REF*X1*SMITH123~

 Provider's Assigned Claim Identifier

REF*EA*JS980503LAB~

 Medical Record Number

REF*D9*123456789~

 Claim Identification Number for Clearinghouses and other Transmission Intermediaries

1.4.3.1.3 Claim Level Dates

The DTP segment occurs twice at the 2200D level and specifies the claim service dates and the response due date.

The response due date is supplied by the Information Source (Payer) to indicate the date the requested information must be returned. Should this date pass without the requested information being supplied by the Information Receiver, the payer may decide to allow the claim to proceed through the adjudication process based upon the information already received in the claim.

1.4.3.1.4 Claim Supplemental Information

The 2210D Loop, Claim Supplemental Information, is situational and can be used for internal work flow routing by the Information Source. The payer uses the segments within this loop to identify the entity who is expecting to receive the additional information from the provider. When the additional information is returned using the 275, only the Payer Response Contact Information, PER segment, is returned in the 1000A Loop of the 275. Payers may optionally decide to provide information on other methods (non EDI) such as fax, email address, mailing address, etc. for the return of attachment data.

1.4.3.2 The Service

When the requested information is more clearly identified by specifying the claim service line, Loop 2220 is used. The service information follows the Loop 2200 claim data. Some payers' adjudication systems support service line information requests.

For service line requests for additional information, the SVC segment is used to report the actual service (procedure) data. A specific service date is also required when requesting additional information at the service line level.

1.4.4 277 Status Information (STC) Segment Usage

The STC segment is used to express the specific information the payer requires from the provider to complete the adjudication process for the identified claim. A payer may request additional information in support of a claim, at the claim level, service line level, or at both locations.

See Section 1.4.4.1 - STC Composite and Code Use Rules for additional information.

The STC segment contains three iterations of the C043 (Health Care Claim Status) composite within STC01, STC10 and STC11.

The Health Care Claim Status composite (C043) consists of four elements:

  • The first element in the C043 composite (C043-01) is the Health Care Claim Status Category Code, Code Source 507. The Category Code indicates the type of request for additional information. While the code source includes multiple values, the only valid codes for this business use are the Request for Additional Information Codes (R-prefix).
  • The second element in the C043 composite (C043-02) is the Logical Observation Identifier Names and Codes (LOINC®), Code Source 663. The LOINC® codes contain the detail information about the actual question and modifiers. Refer to the HL7 specifications for additional information on LOINC® codes and their modifiers.
    Note: The dash "-" character displayed in a LOINC® code (e.g., 18657-7) is part of the LOINC® code. Please refer to Section B.1.1.2 - Delimiters for further information.
  • The third element in the C043 composite (C043-03) is the Entity Identifier Code (ASC X12 data element 98). This element is not used within this implementation.
  • The fourth element in the C043 composite (C043-04) is the Code List Qualifier Code (ASC X12 data element 1270). The Code List Qualifier Code is used to identify that the second element of the composite contains a LOINC® code. For the purposes of this implementation, this element must always contain the value "LOI".

The Category Codes and LOINC® codes are code lists external to the ASC X12 standards. See Appendix A, External Code Sources, for more information on these code sources.

A committee of healthcare industry representatives from payer, provider and vendor organizations maintains the Health Care Claim Status Category Codes, Code Source 507. The code list is updated after each ASC X12 trimester meeting. Version specific code additions or deactivations are noted on the code lists.

The Blue Cross Blue Shield Association (BCBSA) is the owner of the Health Care Claim Status Category Code list. The primary distribution source is the Washington Publishing Company web site (www.wpc-edi.com). This web site offers an online conferencing facility that allows interested parties to submit requests for new codes, changes to existing codes, or simply view comments on pending requests. Individuals who are unable to access the Internet may contact BCBSA directly.

LOINC® codes provide a standard set of universal names and codes for identifying individual laboratory and clinical results as well as other clinical information. LOINC® codes are maintained by Regenstrief Institute, Inc.

1.4.4.1 STC Composite and Code Use Rules

The following rules apply to use of the composites and codes within the STC segment:

  • Each STC segment defines a single request for additional information. A maximum of three LOINC® codes can be used to define the request.
  • The STC segment at the 2200D claim level is situational; it is required when requesting information at the claim level.
  • The request for additional information can be asked at the claim level, service line level, or at both levels.
  • Multiple requests for additional information for the same claim and/or line must be conveyed with separate STC segments.
  • STC01 is required and describes the question or the requested information. For example, LOINC® code 18657-7 is requesting the Rehabilitation treatment plan, plan of treatment (narrative).
  • LOINC® codes entered in STC10 and STC11 are situational and are used to provide greater specificity.
  • General versus specific: When requesting additional information, payers are strongly encouraged to be as specific as possible in their LOINC® code assignment to avoid general requests for additional information.
    For example: 'operative report' versus 'medical records'.

1.4.5 277 Transaction Uses

The Health Care Information Status Notification (277) transaction set has multiple implementation conventions to meet various business needs of the health care industry. The transaction set can be used to provide healthcare claim information in the following business scenarios:

  • ASC X12 Health Care Claim Request for Additional information (277), which is a payer's request for additional information to support a health care claim. This function is supported in this implementation guide.
  • ASC X12 Health Care Claim Status Request and Response (276/277), where the 277 is a response to a request for claim status information. This function is not supported in this implementation guide.
  • ASC X12 Health Care Claim Acknowledgement (277), which is a business application response to the ASC X12 837 claim/encounter transactions. This function is not supported in this implementation guide.
  • ASC X12 Health Care Claim Pending Status Information (277), which is used as a listing of pended claims in a payer's system. This function is not supported in this implementation guide.

Figure 1.2 - General ASC X12 Health Care Claim Information Flow illustrates the flow of information related to several usages of the 277. The multiple uses of the 277 claim status are differentiated by values in the ST and BHT Segments of Table 1 data. Element BHT06, in addition to the ST03 and GS08 values, is used to distinguish between these varied business functions. The various 277 - BHT06 code values are:

  • DG - Response (Health Care Claim Status Request and Response)
  • NO - Notice (Health Care Claim Pending Status Information)
  • RQ - Request (Health Care Claim Request for Additional Information)
  • TH - Receipt Acknowledgment Advice (Health Care Claim Acknowledgment)

Figure 1.2 - General ASC X12 Health Care Claim Information Flow

General ASC X12 Health Care Claim Information Flow

1.5 Business Terminology

To ensure consistent use of terms, definitions, and acronyms across X12 products, X12 maintains the Wordbook, a comprehensive corporate glossary. The included terms are either proprietary to X12, cite definitions published by another authority, or represent common terms and definitions that are relevant to X12's work. The terms and definitions defined in the Wordbook are used in X12 work products when applicable, without modification or revision. The Wordbook can be referenced online at wordbook.x12.org.

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 The Claim (837)

Submitting a claim using the 837 is the first step in the claim adjudication process. The data elements found on the original claim have their source from the provider's billing system. When additional supporting information is required for a claim to complete the payer's adjudication process, the payer can request the information from the provider using the 277 Request for Additional Information. Data from the original claim is returned to the provider on the 277 to facilitate locating the claim or the supporting information.

1.7.2 The Health Care Patient Information (275)

When a claim requires supporting medical documentation to complete the payer's adjudication process, the payer can electronically request the information using the 277 transaction. Data from the original claim is included on the 277 to assist the provider with locating the claim or the supporting information. The provider may return the supporting medical documentation by sending the 275 transaction, Additional Information to Support a Health Care Claim or Encounter. The provider will return the medical documentation along with various data elements from the 277 to facilitate association of the response to the request within the payer's adjudication system.

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 Transaction Compliance

There are three types of compliance that may be relevant to a transmitted transaction.

Compliance with implementation guide requirements

Compliance with state and federal regulation

Compliance with trading partner contractual agreements

1.9.1 Transaction Compliance with Implementation Guide Requirements

A transaction complies with ASC X12 implementation guide requirements if the transaction satisfies all format and content rules and constraints specified in the applicable ASC X12 standards and the implementation guide (also known as a TR3) itself.

Should additional clarification of an ASC X12 implementation guide requirement be desired, two options are available.

ASC X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that are not TR3-compliant based on its own business process.

A receiver may specify its business rules in a trading partner agreement or companion document. As stated in §1.8, these documents do not override TR3 requirements, nor change how transaction compliance with this TR3 is determined.

1.9.2 Transaction Compliance with State and Federal Regulations

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 state or federal standard. Should this implementation guide be adopted as a standard, the adopting authority will establish compliance dates for its use by impacted entities.

ASC X12 is not the authority for determining compliance with regulatory requirements that might further constrain implementation guide requirements. Questions of compliance for regulatory requirements should be directed to the governing authority.

ASC X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with applicable regulatory requirements as specified by the applicable regulation(s) or governing authority.

1.9.3 Transaction Compliance with State and Federal Regulations

ASC X12 is not the authority for determining compliance with contractual requirements that might further constrain implementation guide requirements. Questions of compliance for contractual requirements should be directed to the contracting entity.

ASC X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with contractual requirements as specified by the applicable contract or contracting entity.

1.10 Data Overview

This section introduces the structures of the 277. Familiarity with ASC X12 nomenclature, segments, data elements, hierarchical levels, and looping structure is recommended. For a review, see Appendix B, X12 Control and Guidance, and Appendix C, EDI Control Directory.

1.10.1 Overall Data Architecture

Two formats, or views, are used to present the transaction set: the implementation view and the standard view. The intent of the implementation view is to clarify the purpose and use of the segments by restricting the view to display only those segments used with their assigned health care names. The implementation view for the 277 is presented in Section 2.3.1, Implementation. The standard view for the 277 displays all segments available within the transaction set with their assigned ASC X12 names. This view is presented in Section 2.3.2, X12 Standard.

The transaction set is divided into two levels, or tables, Table 1 and Table 2.

Table 1
Table 1 is named the Header Level and contains the transaction control information. The ST segment identifies the start of a transaction and the specific transaction set. The BHT identifies the transactions business purpose and the hierarchical structure used in Table 2.

Table 2
Table 2 is named the Detail Level because it contains the detail information for the business function of the transactions. This table uses the hierarchical level structure. Each hierarchical level (HL) is a series of loops, which are identified by numbers and letters. The hierarchical level that identifies the patient is Loop ID-2000D. The patient name is contained in Loop ID-2100D. Specific claim details begin with Loop ID-2200D.

The following are HL segment coding examples and the data element significance within the HL segments:

HL*1**20*1~

 Information Source Level

HL*2*1*21*1~

 Information Receiver Level

HL*3*2*19*1~

 Service Provider Level

HL*4*3*PT~

 Patient Level
  • HLs are sequentially numbered. The sequential number is found in HL01, which is the first data element in the HL segment.
  • The second element, HL02, indicates the sequential number of the parent hierarchical level to which this hierarchical level is subordinate. The absence of a data value in HL02, indicates it is the highest hierarchical level. In this example, the Information Source is the highest parent. The Information Receiver level is subordinate to the Information Source hierarchical level numbered 1 (HL01 = 1). The Provider Service Level is subordinate to the Information Receiver hierarchical level numbered 2 (HL01 = 2), etc.
  • The data value in data element HL03 describes the hierarchical level entity. For example, when HL03 = 20, the hierarchical level is the Information Source. When HL03 = PT, the hierarchical level is the Patient.
  • Data element HL04 indicates whether or not child (subordinate) hierarchical levels exist. A value of "1" indicates subordinate hierarchical levels exist. A value of "0" or the absence of a data value indicates that no subordinate hierarchical levels exist.

2. Transaction Set

NOTE
See X12 documents X12.5, X12.6, and X12.59 to review transaction set structure, including descriptions of segments, 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:

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.

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.

"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, requested or rejected by the receiver when the condition is not applicable. Transmission of this data is solely at the sender's discretion when the stated condition does not apply.

"Required when <explicit condition statement>. If not required by this implementation guide, do not send."

The data qualified by such a situational rule must not be sent except as described in the explicit condition statement.

2.2.1.1 Determining Transaction Compliance with Industry Usage Requirements

A transmitted transaction complies with the governing implementation guide when it satisfies the requirements as defined within the implementation guide. Specifically, 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

Not Sent

No

Not Used

N/A

Sent

No

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

Not Sent

No

Not True

Sent

Yes

Not Sent

Yes

Situational (Required when <explicit condition statement>. If not required by this implementation guide, do not send.)

True

Sent

Yes

Not Sent

No

Not True

Sent

No

Not Sent

Yes

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 segment is used.
  • Required segments in Situational loops occur only when the loop is used.

3. Examples

Business scenario examples for use of this transaction can be found on the ASC X12 Examples website at http://examples.x12.org. The ASC X12 Examples website provides convenient access to examples of ASC X12 transaction transmissions, including the data stream and a description of the associated scenario.

Appendix A. External Code Sources

Prior to this publication, X12 TR3s contained a subset of the overall Code Source Directory, formerly known as Appendix A of X12.3. External code lists are not part of the X12 standard and are provided for information purposes only. The full listing is available in Glass, X12's On-Line viewer.

Read more about Glass here: https://products.x12.org/.

Where an external code source is referenced in this publication, the implementer is required to use only the codes from that list. Codes must be reported as listed in the code source (e.g. with leading zeroes). Implementers must follow the instructions for code use that are supplied by the code set owner.

B.1.1 X12 Referenced and Related Standards

This technical report is based on the X12 EDI standard which comprises a series of interdependent publications. Implementers are advised to consult these publications when using this technical report.

The following standards are required to interpret, understand, and use this technical report:

  • X12.5 - Interchange Control Structure
  • X12.6 - Application Control Structure

The following guideline is useful to interpret, understand, and use this technical report:

  • Compliance in X12

The following reference model is useful to interpret, understand, and use this technical report:

  • Acknowledgment Reference Model

All of the documents above are available online using links to X12's Online Viewer.

B.1.1.1 Transmission Control Schematic

Refer to X12.5 - Interchange Control Structures, Section 3.5 - Order of Control Segments, and Chapter 5 Interchange Segment Specifications.

Similar transaction sets, called "functional groups," can be sent together within a transmission. Each functional group is prefaced by a group start segment; and a functional group is terminated by a group end segment. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer. Figure B.1 - Transmission Control Schematic, illustrates this interchange control.

Figure B.1 - Transmission Control Schematic

Transmission Control Schematic

B.1.1.2 Constraints applicable to the suite of TR3s

Refer to X12.6 - Application Control Structure, Section 3.2.8 - Minimums/Maximums.

Data element minimum and maximum lengths are set by the ASC X12 standard. This implementation guide may further restrict minimum and maximum lengths within the bounds set by the standard. Such restrictions may occur implicitly by virtue of the allowed qualifier for the data element, or they may be stated explicitly in a note attached to the element or in the general limitations below.

B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification

The current ASC X12 standard allows a maximum length greater than 50 characters for data element 127. For implementations governed by this implementation guide, unless another value is specified in an attached note, the maximum length of each occurrence of this data element is constrained to 50 characters.

B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount

For implementations governed by this implementation guide, unless another value is specified for an instance of Data Element 782 within Section 2 (Transaction Set), each occurrence of Data Element 782 (Monetary Amount) will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). Note that the decimal point and leading sign, if sent, are not part of the character count.

EXAMPLE

  • The following transmitted value represents the largest positive dollar amount that can be sent: 99999999.99
  • The following transmitted value is the longest string of characters that can be sent representing whole dollars. 99999999
  • The following transmitted value is the longest string of characters that can be sent representing negative dollars and cents. -99999999.99
  • The following transmitted value is the longest string of characters that can be sent representing negative whole dollars. -99999999

B.1.1.3 Decimal

While the ASC X12 standard supports usage of exponential notation, this guide prohibits that usage.

Appendix D. Change Summary

This Implementation Guide (006020X313) defines the X12 requirements for the Health Care Claim Request For Additional Information. It is based on version/release/subrelease 006020 of the ASC X12 standards.