275 Transaction Set Listing

006020X314 Additional Information to Support a Health Care Claim or Encounter
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*PI - 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✱006020X314~
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
PI
Patient Information (275)
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
006020X314
Additional Information to Support a Health Care Claim or Encounter

ST*275 - 275 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✱275✱1234✱006020X314~
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).
Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set.
CODE
DEFINITION
275
Patient Information
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
This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
CODE
DEFINITION
006020X314
Additional Information to Support a Health Care Claim or Encounter

BGN - BEGINNING SEGMENT

X12 Name:
Beginning Segment
X12 Purpose:
To indicate the beginning of a transaction set
X12 Syntax:
C0504
If BGN05 is present, then BGN04 is required.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
BGN✱11✱123456✱20111001~
BGN
✱
1
353
TS Purpose
Code
M 1
ID
2
✱
2
127
Reference
Ident
M 1
AN
1/80
✱
3
373
Date
M 1
DT
8
✱
4
337
Time
X 1
TM
4/8
✱
5
623
Time
Code
O 1
ID
2
✱
6
127
Reference
Ident
O 1
AN
1/80
✱
7
640
Transaction
Type Code
O 1
ID
2
✱
8
306
Action
Code
O 1
ID
1/2
✱
9
786
Security
Level Code
O 1
ID
2
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
353
Transaction Set Purpose Code
M 1
ID
2
Code identifying purpose of transaction set
CODE
DEFINITION
02
Add
Used when submitting an unsolicited attachment.
11
Response
Used when responding to a solicited attachment request.
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: BGN02 is the transaction set reference number.
INDUSTRY NAME: Transaction Set Reference Number
  1. The originator of the transaction set assigns the unique reference number in BGN02 and the date of creation in BGN03.
  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.
Required
3
373
Date
M 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: BGN03 is the transaction set date.
INDUSTRY NAME: Transaction Set Creation Date
Not Used
4
337
Time
X 1
TM
4/8
Not Used
5
623
Time Code
O 1
ID
2
Not Used
6
127
Reference Identification
O 1
AN
1/80
Not Used
7
640
Transaction Type Code
O 1
ID
2
Not Used
8
306
Action Code
O 1
ID
1/2
Not Used
9
786
Security Level Code
O 1
ID
2

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.
X12 Set Notes:
NOTE: Loop NM1 identifies a single patient; it also identifies other entities or individuals which include the requester, responder or other organizations.
Loop:
Loop 1000A - PAYER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱PR✱2✱HOLLY HILLS HOSPITAL✱✱✱✱✱PI✱1234567890~
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 1000A - PAYER NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the value in BGN01 is 11 and the Payer Response Contact Information (PER Segment) was reported in the 2210D loop of the 277 Health Care Claim Request for Additional Information. If not required by this implementation guide, do not send.
TR3 Notes:
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
TR3 Example:
PER✱IC✱MEDICAL REVIEW DEPARTMENT✱TE✱5552221212✱EX✱6593✱FX✱5553332121~
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 the PER segment in the 2210D loop of the 277 includes this information. If not required by this implementation guide, do not send.
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 PER segment in the 2210D loop of the 277 includes this information. If not required by this implementation guide, do not send.
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 PER segment in the 2210D loop of the 277 includes this information. 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 PER segment in the 2210D loop of the 277 includes this information. If not required by this implementation guide, do not send.
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 PER segment in the 2210D loop of the 277 includes this information. 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 PER segment in the 2210D loop of the 277 includes this information. If not required by this implementation guide, do not send.
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 PER segment in the 2210D loop of the 277 includes this information. 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

NM1*41 - SUBMITTER INFORMATION

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.
X12 Set Notes:
NOTE: Loop NM1 identifies a single patient; it also identifies other entities or individuals which include the requester, responder or other organizations.
Loop:
Loop 1000B - SUBMITTER INFORMATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
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
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: Submitter 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: Submitter 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: Submitter Middle Name or Initial
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: Submitter 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

NM1*1P - PROVIDER NAME INFORMATION

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.
X12 Set Notes:
NOTE: Loop NM1 identifies a single patient; it also identifies other entities or individuals which include the requester, responder or other organizations.
Loop:
Loop 1000C - PROVIDER NAME INFORMATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
  1. In the solicited 275 model, the information from the 2100C NM1 segment of the 277 must be returned in this segment.
  2. In the unsolicited 275 model, the billing provider information must be sent in this segment.
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
Situational
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
SITUATIONAL RULE: Required when the NPI was reported on the original claim or the NPI was present in the 2100C NM109 of the 277.
CODE
DEFINITION
XX
Centers for Medicare and Medicaid Services National Provider Identifier
Required when the National Provider Identifier is mandated for use and the provider is a covered health care provider under the mandate.
CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: This is required, if NM108 is used. If not required by this implementation guide, do not send.
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

PRV*BI - PROVIDER TAXONOMY INFORMATION

X12 Name:
Provider Information
X12 Purpose:
To specify the identifying characteristics of a provider
X12 Syntax:
P0203
If either PRV02 or PRV03 is present, then the other is required.
X12 Set Notes:
NOTE: The PRV segment is only used in Loop NM1 when identifying a requestor or responder who is also a provider.
Loop:
Loop 1000C - PROVIDER NAME INFORMATION
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
TR3 Example:
PRV✱BI✱PXC✱1223G0001X~
PRV
✱
1
1221
Provider
Code
M 1
ID
1/3
✱
2
128
Reference
Ident Qual
X 1
ID
2/3
✱
3
127
Reference
Ident
X 1
AN
1/80
✱
4
156
State or
Prov Code
O 1
ID
2
✱
5
C035
Provider
Spec. Inf.
O 1
✱
6
1223
Provider
Org Code
O 1
ID
3
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1221
Provider Code
M 1
ID
1/3
Code identifying the type of provider
CODE
DEFINITION
BI
Billing
Required
2
128
Reference Identification Qualifier
X 1
ID
2/3
Code qualifying the Reference Identification
SEGMENT SYNTAX: P0203
CODE
DEFINITION
PXC
Health Care Provider Taxonomy Code
CODE SOURCE: 682: Health Care Provider Taxonomy
Required
3
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: P0203
INDUSTRY NAME: Provider Taxonomy Code
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
4
156
State or Province Code
O 1
ID
2
Not Used
5
C035
Provider Specialty Information
O 1
Not Used
6
1223
Provider Organization Code
O 1
ID
3

REF - PROVIDER SECONDARY IDENTIFICATION

X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
Loop:
Loop 1000C - PROVIDER NAME INFORMATION
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the provider is not covered under the NPI mandate. If not required by this implementation guide, do not send.
TR3 Example:
REF✱A6✱12345~
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
A6
Provider Identifier
LU
Location 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 Secondary 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

NX1*1P - PROVIDER IDENTIFICATION

X12 Name:
Property or Entity Identification
X12 Purpose:
To define the attributes of a property or an entity
Loop:
Loop 1100C - PROVIDER IDENTIFICATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
The provider address information in this loop applies to the provider information listed in the 1000C loop.
TR3 Example:
NX1✱1P~
NX1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
98
Entity ID
Code
O 1
ID
2/3
✱
3
98
Entity ID
Code
O 1
ID
2/3
✱
4
98
Entity ID
Code
O 1
ID
2/3
✱
5
98
Entity ID
Code
O 1
ID
2/3
~
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
Not Used
2
98
Entity Identifier Code
O 1
ID
2/3
Not Used
3
98
Entity Identifier Code
O 1
ID
2/3
Not Used
4
98
Entity Identifier Code
O 1
ID
2/3
Not Used
5
98
Entity Identifier Code
O 1
ID
2/3

N3 - PROVIDER ADDRESS

X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop 1100C - PROVIDER IDENTIFICATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
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: Provider Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when the providers street address includes a second line. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Address Line

N4 - PROVIDER CITY, STATE, ZIP CODE

X12 Name:
Geographic Location
X12 Purpose:
To specify the geographic place of the named party
X12 Syntax:
  1. E0207
    Only one of N402 or N407 may be present.
  2. C0605
    If N406 is present, then N405 is required.
  3. C0704
    If N407 is present, then N404 is required.
Loop:
Loop 1100C - PROVIDER IDENTIFICATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
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: Provider 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: Provider 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: Provider 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: Provider 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: Provider Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds

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.
X12 Set Notes:
NOTE: Loop NM1 identifies a single patient; it also identifies other entities or individuals which include the requester, responder or other organizations.
Loop:
Loop 1000D - 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 person has a first name. 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 the middle name or initial of the person is needed to identify the individual. 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 the name suffix is needed to identify the individual. 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. Otherwise, another listed code must be used.
MI
Member Identification Number
The code "MI" is intended to be the patient's identification number as assigned by the payer. Payers use different terminology to convey the same number. The Member Identification Number is used 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

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 1000D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Provider's Assigned Claim Identifier was submitted on the claim or in the 277 Request for Information. If not required by this implementation guide, do not send.
TR3 Notes:
When the value in BGN01 of the 275 is 02, the Provider's Assigned Claim Identifier must be the same number as reported in CLM01 of the 2300 loop in the 837. When the value in BGN01 is 11, the Provider's Assigned Claim Identifier must be the same number as reported in REF02 of the 2200D loop in the 277.
TR3 Example:
REF✱X1✱ME1234~
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. The maximum number of characters to be supported for this data element is "35". A provider may submit fewer characters depending upon their needs.
  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*BLT - INSTITUTIONAL TYPE OF BILL

X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
Loop:
Loop 1000D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Institutional Type of Bill is submitted in the associated 837 or is included in the 2200D REF segment of the 277. 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
INDUSTRY NAME: Bill Type Identifier
  1. The value in REF02 corresponds to a concatenation of Facility Type Code (CLM05-01) and Claim Frequency Type Code (CLM05-03) from the ASC X12N 837 claim transaction or this is the value from REF02 in the 2200D loop of the 277.
  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 1000D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Medical Record Identification Number is submitted on the original claim. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
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
  1. This is the Medical Record Identification Number from the original claim.
  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*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 1000D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when this claim identification number is sent in the 2200D REF segment of the 277. If not required by this implementation guide, may be provided at the sender's discretion but can not be required by the receiver.
TR3 Notes:
Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, trading partners are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
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 1000D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the additional information is submitted in support of a Property and Casualty claim. If not required by this implementation guide, do not send.
TR3 Notes:
  1. This is the Property & Casualty Claim Number assigned by the payer for the claim event.
  2. If the Property and Casualty payer assigned Claim Number is submitted in the bill for service (e.g 837) or in the Request for Additional Information (277), then the number in this REF must be the number submitted in the bill or request for additional information.
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

DTP*472 - CLAIM 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 1000D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the information submitted or requested applies to the entire claim. If not required by this implementation guide, may be provided at the sender's discretion but can not be required by the receiver.
TR3 Example:
DTP✱472✱RD8✱20100720-20100724~
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
RD8 is required only when the To and From dates are different.
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

LX - ASSIGNED NUMBER

X12 Name:
Transaction Set Line Number
X12 Purpose:
To reference a line number in a transaction set
Loop:
Loop 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
  1. The LX segment can be repeated to respond to multiple questions on an individual claim. 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.
  2. Within the LX, LX01 is the sequence number of the LX Loop. It is required that the LX01 sequence number start at 1 and increment by 1.
TR3 Example:
LX✱1~
LX
✱
1
554
Assigned
Number
M 1
N
1/6
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
554
Assigned Number
M 1
N
1/6
Number assigned for differentiation within a transaction set

TRN - PAYER CLAIM CONTROL TRACE NUMBER/PROVIDER ATTACHMENT CONTROL TRACE NUMBER

X12 Name:
Trace
X12 Purpose:
To uniquely identify a transaction to an application
X12 Set Notes:
NOTE: The TRN segment in Loop LX identifies a previously sent transaction set. The LX loop provides supporting or additional information for that item when TRN is used.
Loop:
Loop 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
  1. Payer Claim Control Number is the value from the 277 TRN segment of the 2200D loop, when in response to a solicited request.
  2. For the unsolicited 275, if the attachment applies to entire 837, the Provider Attachment Control Number is the value from the 837 PWK06 of the 2300 loop. If the attachment applies to a specific service line, the Provider Attachment Control Number is the value from the 837 PWK06 for that service line in the 2400 loop. This is the main matching criteria and must be unique on a per attachment basis.
  3. The TRN02 value must be the same in each iteration of the 2000A loop when the value in TRN02 is the Payer claim control number.
TR3 Example:
TRN✱2✱1234567~
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
Used when sending an unsolicited 275 to support an 837.
2
Referenced Transaction Trace Numbers
Used when responding to a 277.
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 or Provider Attachment Control Number
  1. When the value in BGN01 is 11, this number will be the payer claim control number that is in TRN02 of the 2200D loop, in the 277. This value must be the same in each LX loop.
  2. When the value in BGN01 is 02, this number is the unique control number that the provider assigned for the attachment. It must match the number in PWK06 loop 2300 of the 837. This is the main matching criteria and must be unique on a per attachment basis. When using the Attachment Control Number the minimum length requirement is 2. For the unsolicited 275, payers and clearinghouses may ensure a match of the 275 attachment to the claim by concatenating other data in this transaction to the value in TRN02.
  3. The payer does not set the format for the Attachment Control Number. However, the payer may have some system constraints, e.g. maximum readable length, that the provider needs to take into account when formatting this Control Number.
  4. 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 - STATUS INFORMATION

X12 Name:
Status Information
X12 Purpose:
To report the status, required action, and paid information of a claim or service line
X12 Set Notes:
NOTE: The STC segment in LX loop identifies the status and action requested in a prior transaction when the response is provided in this transaction.
Loop:
Loop 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the value in BGN01 is 11 (Response). If not required by this implementation guide, do not send.
TR3 Example:
STC✱R4:19002-5::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.
This data element contains the values found in the STC in the 277.
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
For this implementation, the value must be a Category Code beginning with R.
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
  1. This will be the LOINC® Code that defines the additional information that was requested.
  2. See Code Source 663: Logical Observation Identifier Names and Codes (LOINC®)
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)
Not Used
2
373
Date
O 1
DT
8
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 the 277 STC10 is used. 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
For this implementation, the value must be a Category Code beginning with R.
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
  1. See Code Source 663: Logical Observation Identifier Names and Codes (LOINC®)
  2. 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 the 277 STC11 is used. 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
For this implementation, the value must be a Category Code beginning with R.
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
  1. See Code Source 663: Logical Observation Identifier Names and Codes (LOINC®)
  2. 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 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the additional information is associated with the service line or revenue line information. If not required by this implementation guide, do not send.
TR3 Notes:
If this segment is used, then there will be a SVC segment that contains the Procedure Code or Revenue Code.
TR3 Example:
REF✱6R✱1234~
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

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 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when sent on the 277 Request for Information. 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 attachments 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 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required if sent on the 277 Request for Information. If not required by this implementation guide, do not send.
TR3 Notes:
This identifier is assigned by the payer to this attachment and is necessary for tracking purposes.
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

HI - HEALTH CARE INFORMATION CODES

X12 Name:
Health Care Information Codes
X12 Purpose:
To supply information related to the delivery of health care
Loop:
Loop 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
2
Situational Rule:
Required when a diagnosis is specifically related to the attachment information being sent. If not required by this implementation guide, do not send.
TR3 Notes:
Do not transmit the decimal point for ICD codes. The decimal point is implied.
TR3 Example:
HI✱ABK:H25032✱ABF:I10✱ABF:R9431✱ABF:H59312~
HI
✱
1
C022
Health Care
Code Info.
M 1
✱
2
C022
Health Care
Code Info.
O 1
✱
3
C022
Health Care
Code Info.
O 1
✱
4
C022
Health Care
Code Info.
O 1
✱
5
C022
Health Care
Code Info.
O 1
✱
6
C022
Health Care
Code Info.
O 1
✱
7
C022
Health Care
Code Info.
O 1
✱
8
C022
Health Care
Code Info.
O 1
✱
9
C022
Health Care
Code Info.
O 1
✱
10
C022
Health Care
Code Info.
O 1
✱
11
C022
Health Care
Code Info.
O 1
✱
12
C022
Health Care
Code Info.
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
C022
Health Care Code Information
M 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
Required
1-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
Required
1-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
1-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
1-4
1251
Date Time Period
X 1
AN
1/35
Not Used
1-5
782
Monetary Amount
O 1
R
1/18
Not Used
1-6
380
Quantity
O 1
R
1/15
Not Used
1-7
799
Version Identifier
O 1
AN
1/30
Not Used
1-8
1271
Industry Code
X 1
AN
1/30
Not Used
1-9
1271
Industry Code
X 1
AN
1/30
Situational
2
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
2-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
2-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
2-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
2-4
1251
Date Time Period
X 1
AN
1/35
Not Used
2-5
782
Monetary Amount
O 1
R
1/18
Not Used
2-6
380
Quantity
O 1
R
1/15
Not Used
2-7
799
Version Identifier
O 1
AN
1/30
Not Used
2-8
1271
Industry Code
X 1
AN
1/30
Not Used
2-9
1271
Industry Code
X 1
AN
1/30
Situational
3
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
3-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
3-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
3-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
3-4
1251
Date Time Period
X 1
AN
1/35
Not Used
3-5
782
Monetary Amount
O 1
R
1/18
Not Used
3-6
380
Quantity
O 1
R
1/15
Not Used
3-7
799
Version Identifier
O 1
AN
1/30
Not Used
3-8
1271
Industry Code
X 1
AN
1/30
Not Used
3-9
1271
Industry Code
X 1
AN
1/30
Situational
4
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
4-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
4-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
4-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
4-4
1251
Date Time Period
X 1
AN
1/35
Not Used
4-5
782
Monetary Amount
O 1
R
1/18
Not Used
4-6
380
Quantity
O 1
R
1/15
Not Used
4-7
799
Version Identifier
O 1
AN
1/30
Not Used
4-8
1271
Industry Code
X 1
AN
1/30
Not Used
4-9
1271
Industry Code
X 1
AN
1/30
Situational
5
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
5-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
5-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
5-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
5-4
1251
Date Time Period
X 1
AN
1/35
Not Used
5-5
782
Monetary Amount
O 1
R
1/18
Not Used
5-6
380
Quantity
O 1
R
1/15
Not Used
5-7
799
Version Identifier
O 1
AN
1/30
Not Used
5-8
1271
Industry Code
X 1
AN
1/30
Not Used
5-9
1271
Industry Code
X 1
AN
1/30
Situational
6
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
6-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
6-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
6-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
6-4
1251
Date Time Period
X 1
AN
1/35
Not Used
6-5
782
Monetary Amount
O 1
R
1/18
Not Used
6-6
380
Quantity
O 1
R
1/15
Not Used
6-7
799
Version Identifier
O 1
AN
1/30
Not Used
6-8
1271
Industry Code
X 1
AN
1/30
Not Used
6-9
1271
Industry Code
X 1
AN
1/30
Situational
7
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
7-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
7-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
7-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
7-4
1251
Date Time Period
X 1
AN
1/35
Not Used
7-5
782
Monetary Amount
O 1
R
1/18
Not Used
7-6
380
Quantity
O 1
R
1/15
Not Used
7-7
799
Version Identifier
O 1
AN
1/30
Not Used
7-8
1271
Industry Code
X 1
AN
1/30
Not Used
7-9
1271
Industry Code
X 1
AN
1/30
Situational
8
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
8-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
8-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
8-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
8-4
1251
Date Time Period
X 1
AN
1/35
Not Used
8-5
782
Monetary Amount
O 1
R
1/18
Not Used
8-6
380
Quantity
O 1
R
1/15
Not Used
8-7
799
Version Identifier
O 1
AN
1/30
Not Used
8-8
1271
Industry Code
X 1
AN
1/30
Not Used
8-9
1271
Industry Code
X 1
AN
1/30
Situational
9
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
9-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
9-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
9-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
9-4
1251
Date Time Period
X 1
AN
1/35
Not Used
9-5
782
Monetary Amount
O 1
R
1/18
Not Used
9-6
380
Quantity
O 1
R
1/15
Not Used
9-7
799
Version Identifier
O 1
AN
1/30
Not Used
9-8
1271
Industry Code
X 1
AN
1/30
Not Used
9-9
1271
Industry Code
X 1
AN
1/30
Situational
10
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
10-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
10-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
10-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
10-4
1251
Date Time Period
X 1
AN
1/35
Not Used
10-5
782
Monetary Amount
O 1
R
1/18
Not Used
10-6
380
Quantity
O 1
R
1/15
Not Used
10-7
799
Version Identifier
O 1
AN
1/30
Not Used
10-8
1271
Industry Code
X 1
AN
1/30
Not Used
10-9
1271
Industry Code
X 1
AN
1/30
Situational
11
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
11-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
11-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
11-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
11-4
1251
Date Time Period
X 1
AN
1/35
Not Used
11-5
782
Monetary Amount
O 1
R
1/18
Not Used
11-6
380
Quantity
O 1
R
1/15
Not Used
11-7
799
Version Identifier
O 1
AN
1/30
Not Used
11-8
1271
Industry Code
X 1
AN
1/30
Not Used
11-9
1271
Industry Code
X 1
AN
1/30
Situational
12
C022
Health Care Code Information
O 1
To send health care codes and their associated dates, amounts and quantities
X12 COMPOSITE SYNTAX NOTES:
  1. P0304
    If either C02203 or C02204 is present, then the other is required.
  2. E0809
    Only one of C02208 or C02209 may be present.
X12 COMPOSITE SEMANTIC NOTES:
  1. C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
  2. If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
  3. C022-03 is the date format that will appear in C022-04.
  4. C022-07 qualifies C022-01.
  5. C022-08 represents the ending value in a range of codes.
  6. C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
SITUATIONAL RULE: Required when it is necessary to report additional diagnosis codes.
Required
12-1
1270
Code List Qualifier Code
M 1
ID
1/3
Code identifying a specific industry code list
CODE
DEFINITION
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
TQ
Systemized Nomenclature of Dentistry (SNODENT)
CODE SOURCE: 135: American Dental Association
Required
12-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
Not Used
12-3
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Not Used
12-4
1251
Date Time Period
X 1
AN
1/35
Not Used
12-5
782
Monetary Amount
O 1
R
1/18
Not Used
12-6
380
Quantity
O 1
R
1/15
Not Used
12-7
799
Version Identifier
O 1
AN
1/30
Not Used
12-8
1271
Industry Code
X 1
AN
1/30
Not Used
12-9
1271
Industry Code
X 1
AN
1/30

SVC - SERVICE INFORMATION

X12 Name:
Service Information
X12 Purpose:
To supply payment and control information to a provider for a particular service
Loop:
Loop 2000A - ASSIGNED NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the additional information is about a service line. If not required by this implementation guide, do not send.
TR3 Example:
SVC✱HC:99212:25✱100~
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: Product or Service ID
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.
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: Product or Service ID
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

DTP*472 - SERVICE LINE 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 2100A - SERVICE LINE SERVICE DATE
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when the date of service is not reported at the claim level (1000D). If not required by this implementation guide, do not send.
TR3 Example:
DTP✱472✱D8✱20111030~
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
RD8 is required only when the To and From dates are different.
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 Date

DTP*368 - ADDITIONAL INFORMATION SUBMITTED 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 2100B - ADDITIONAL INFORMATION SUBMITTED DATE
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
DTP✱368✱D8✱20111024~
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
368
Submittal
Date information is submitted.
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: Additional Information Submitted Date

CAT*AE - FORMAT AND VERSION IDENTIFIER

X12 Name:
Category of Patient Information Service
X12 Purpose:
To specify categories of patient information service
X12 Syntax:
  1. C0302
    If CAT03 is present, then CAT02 is required.
  2. P0405
    If either CAT04 or CAT05 is present, then the other is required.
  3. C0605
    If CAT06 is present, then CAT05 is required.
  4. C0704
    If CAT07 is present, then CAT04 is required.
Loop:
Loop 2100B - ADDITIONAL INFORMATION SUBMITTED DATE
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
CAT✱AE✱HL~
CAT
✱
1
755
Report Type
Code
O 1
ID
2
✱
2
756
Report
Transm Code
X 1
ID
1/2
✱
3
799
Version
ID
O 1
AN
1/30
✱
4
1270
Code List
Qual Code
X 1
ID
1/3
✱
5
1271
Industry
Code
X 1
AN
1/30
✱
6
1271
Industry
Code
O 1
AN
1/30
✱
7
799
Version
ID
O 1
AN
1/30
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
755
Report Type Code
O 1
ID
2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY NAME: Attachment Report Type Code
CODE
DEFINITION
AE
Attachment
Required
2
756
Report Transmission Code
X 1
ID
1/2
Code defining timing, transmission method or format by which reports are to be sent
SEGMENT SYNTAX: C0302
INDUSTRY NAME: Attachment Information Format Code
Code specifying the format of the attachment information sent in BDS03. It is up to mutual agreement among trading partners what CAT02 value is used for attachment information not yet adopted or for a business process not addressed under HIPAA.
CODE
DEFINITION
HL
Health Industry Level 7 Interface Standards (HL/7) Format
Format of the content in BDS03 is codified and contains HL7 header and body structure as defined by HL7.
CODE SOURCE: 464: Health Industry Level 7 (HL7)
IA
Electronic Image
Format of the content in BDS03 is an image or scanned image (jpeg, tiff, pdf, etc) and does not contain HL7 components.
MB
Binary Image
Format of the content in BDS03 is not codified but contains the HL7 header and the `body' is an non-XML formatted content, such as an image or scanned image (jpeg, tiff, pdf, etc).
TX
Text
Format of the content in BDS03 is not codified but contains the HL7 header and the `body' is in XML format.
Situational
3
799
Version Identifier
O 1
AN
1/30
Revision level of a particular format, program, technique or algorithm
SEGMENT SYNTAX: C0302
SITUATIONAL RULE: Required when it is necessary to further qualify CAT02 to distinguish between multiple HL7 attachment versions. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
INDUSTRY NAME: Version Identification Code
Not Used
4
1270
Code List Qualifier Code
X 1
ID
1/3
Not Used
5
1271
Industry Code
X 1
AN
1/30
Not Used
6
1271
Industry Code
O 1
AN
1/30
Not Used
7
799
Version Identifier
O 1
AN
1/30

OOI - ASSOCIATED OBJECT TYPE IDENTIFICATION

X12 Name:
Associated Object Type Identification
X12 Purpose:
To identify attributes and status related to the object
Loop:
Loop 2110B - ASSOCIATED OBJECT TYPE IDENTIFICATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
OOI✱1✱47✱ATTACHMENT~
OOI
✱
1
1694
Object ID
Group
M 1
AN
1/2
✱
2
1691
Object Type
Qualifier
M 1
ID
1/3
✱
3
1692
Object Attr
ID
M 1
AN
1/256
✱
4
1693
Controlling
Agency
O 1
ID
1/3
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1694
Object Identification Group
M 1
AN
1/2
To link related object identifications
For this implementation, the value for this data element is "1".
Required
2
1691
Object Type Qualifier
M 1
ID
1/3
Code identifying type of object
SEMANTIC: Object type qualifier (data element 1691) defines the object attribute (either data element 1692 or 1693), instructing the receiving system on how to process and route the object.
CODE
DEFINITION
47
External Standard Requirement
Required
3
1692
Object Attribute Identification
M 1
AN
1/256
Identification of the attribute applying to the object type
The value "ATTACHMENT" is required.
Not Used
4
1693
Controlling Agency
O 1
ID
1/3

BDS - BINARY DATA SEGMENT

X12 Name:
Binary Data Structure
X12 Purpose:
To transfer binary data in a single data segment, convey a critical filter for transmission and allow identification of the end of the data segment through a count; there is no identification of the internal structure of the binary data in this segment
Loop:
Loop 2110B - ASSOCIATED OBJECT TYPE IDENTIFICATION
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
  1. It is recommended that the contents of the BDS not exceed 64 megabytes. When for example, a BDS must be split due to size limitations, the 2000A loop must be repeated.
  2. Please refer to the HL7 standard for an example of the attachment content. The BDS segment is used to hold the additional information. It allows for the use of the HL7 standard using the 275 transaction as the envelope.
TR3 Example:
BDS✱ASC✱3117✱......~The BDS segment in this example does not display the HL7 attachment. Please refer to the HL7 specifications for an example of the attachment. For purposes of this example the attachment is represented by ......
BDS
✱
1
1570
Filter
ID Code
M 1
ID
3
✱
2
784
Length of
Binary Data
M 1
N
1/15
✱
3
785
Binary
Data
M 1
1/(1E+15)-1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1570
Filter ID Code
M 1
ID
3
Code specifying the type of filter used to convert data code values
This represents the encoding format of the data in the BDS.
CODE
DEFINITION
ASC
ASCII Filter
ASC stands for American Standard Code for Information Interchange (ASCII).
B64
Base 64
Required
2
784
Length of Binary Data
M 1
N
1/15
The length in integral octets of the binary data
SEMANTIC: BDS02 is the length of the data in BDS03 after application of the filter indicated by BDS01. For example; a 1000 byte binary file that has been filtered using Base 64 encoding (value 'B64' in BDS01) will have a value of 1336 in the BDS02.
  1. Senders must ensure that the count in BDS02 is equal to the byte count of the contents of the BDS03.
  2. It has been noted that line constraints, transfer protocols, zip programs or conversion processes may insert additional control characters such as line feeds, carriage returns or other specific characters into a transaction. If this occurs in BDS03, the sender's stated count in BDS02 may no longer be equal to the received contents of the data in BDS03 but in no case should it be less than the count indicated in BDS02.
Required
3
785
Binary Data
M 1
1/(1E+15)-1
A string of octets which can assume any binary pattern from hexadecimal 00 to FF. Note: The maximum length is dependent upon the maximum data value that can be entered in DE 784, which value is 999,999,999,999,999.
It is recommended that BDS03 not exceed 64 megabytes. The segment terminator used in the 275 transaction must not be used within the data content of the BDS03.

SE - 275 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✱17✱1234~
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
Each BDS segment, independent of content, counts as one segment only.
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
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275 Additional Information to Support a Health Care Claim or Encounter (006020X314)

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 Additional Information to Support a Health Care Claim or Encounter Implementation Guide describes the use of the ASC X12 Patient Information (275) transaction set for the following business usage:

  • To assist those who send additional supporting information or who receive additional supporting information to 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 to all users of the ASC X12 Patient Information (275) Transaction Set that focuses on the use of the 275 to send additional information about a claim or encounter. 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 use of conveying Additional Information to Support a Health Care Claim or Encounter (275).

This implementation guide describes a solution that includes the encapsulation of a Health Level Seven International (HL7) Standard (www.HL7.org) within the 275 transaction to support the exchange of clinical data. HL7 is an ANSI Accredited Standards Development Organization (SDO) whose domain is clinical and administrative data. See section 1.7.4 for additional details.

This implementation guide is designed to assist those who send additional supporting information or who receive additional supporting information to a claim or encounter using the 275 format.

Entities that use this implementation of the 275 include, but are not limited to, providers, health plans, 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, manages the delivery of health care services, or collects health care data. Other business partners affiliated with the 275 include, but are not limited to, billing services, consulting services, vendors of systems, software and EDI translators, and EDI network intermediaries such as automated clearinghouses (ACHs), value added networks (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 006020X314.

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

  • PI   Patient Information (275)

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. Note: The sender of the original transmission may not always be the entity that picks up the response transaction at a later time (e.g. Provider submitting through a clearinghouse.)

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 other usage limitations.

The 275 transaction structure does not allow submission of additional information in support of more than one request for a health care claim or encounter. A separate Transaction Set Header/Trailer (ST/SE) must be sent for each attachment of additional information. The 275 can support multiple sets of information for a single request for review. See Loop 2110B BDS Segment and the LX Segment at Loop 2000A for additional details.

This implementation guide ONLY addresses using the 275 to support a health care claim or encounter. A separate implementation guide was developed for the 275 Additional Information to Support a Health Care Services Review.

A trading partner agreement may be used to define time parameters for the submission of the solicited 275 and the unsolicited 275. The 275 must be received by the receiver within the specified time frame or the request will proceed through the process without the needed information. The ultimate disposition of the claim or encounter can include, but is not limited to, approval, rejection, or denial.

As a result of the potential impact on transmission and processing times and storage capacity, trading partners may find it necessary to establish size limitations for the BDS Segment. It is recommended that the content of the BDS not exceed 64 megabytes.

1.4 Business Usage

This 275 implementation guide is only used for communication from providers to payers to:

  • Provide solicited response to an ASC X12 Health Care Claim Request for Additional Information (277), a paper request or other method for additional information.
  • Provide unsolicited additional information to support an ASC X12 Health Care Claim or Encounter (837).

This Implementation Guide was written with the intent to send attachment data from provider to payer.

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 Response to a Solicited Health Care Claim Request for Additional Information

A claim that is subjected to Medical or Utilization review during the adjudication process may be pended by the payer. The payer then solicits specific information to supplement or support the provider's request for payment of services. The payer's request for additional information may be service specific or apply to the entire claim. The request is received electronically using the 277, on paper or by other methods. The provider uses the 275 to respond.

The 277 structure allows the payer to request additional information on multiple claims. However, the 275 transaction structure only allows the submitter to send additional information for one claim in each 275. A separate Transaction Set Header/Trailer (ST/SE) must be sent for each claim response. The 275 can accommodate multiple responses for a specific claim. See the LX segment section for additional details.

In the 277, the payer must specify the period of time in which the provider has to respond to the request for additional information. The 275 response must be received by the payer within the specified timeframe, or the claim in question may proceed to the next phase of the payer's adjudication cycle. (The ultimate disposition of the claim or service line can include payment, rejection, or denial.)

1.4.3 Unsolicited Additional Information to Support an 837

When it is known at the time of billing that the additional information is required by the payer to adjudicate the claim, the provider may, in compliance with applicable regulations and trading partner agreements, submit an unsolicited 275. If done at the same time as the 837, the 275 may be sent in a separate interchange (ISA/IEA) or within the same interchange as the initial 837.

A Trading Partner agreement may be used to define the time parameters for submission of the unsolicited 275 in a separate transaction. For example, a payer may specify that the claim will be adjudicated without the information if it is not received within a specific time frame.

1.4.4 Information Flows

Figure 1.1 - Solicited 275 Transaction Flow illustrates the flow of information related to the solicited business flow for the 275 Transaction.

Figure 1.1 - Solicited 275 Transaction Flow

Solicited 275 Transaction Flow

Arrow 1
This represents the submission of the 837 Health Care Claim or Encounter or the 837 Health Care Data reporting from the provider to the payer. In this business model, the 275 attachment with the appropriate imbedded HL7 attachment content containing the additional information is not sent at the same time as the claim.

Arrow 2
After the claim is received, the payer may require additional information in support of the health care claim or encounter before adjudication can be completed. The payer then solicits this information by sending the 277 identifying the information needed.

Arrow 3
The provider will respond to the request for additional information by sending the 275 Additional Information to Support a Health Care Claim or Encounter to the payer with the appropriate imbedded HL7. The provider will respond to the request for additional information by sending the 275 to the payer with the appropriate imbedded HL7 attachment content containing the additional information.

Figure 1.2 - Unsolicited 275 EDI Transaction Flow - 837 and 275 in Same Interchange illustrates the flow of information related to the unsolicited business flow for the 275 Transaction when the 837 and the 275 are sent in the same interchange.

Figure 1.2 - Unsolicited 275 EDI Transaction Flow - 837 and 275 in Same Interchange

Unsolicited 275 EDI Transaction Flow - 837 and 275 in Same Interchange

Arrow 1
This represents the submission of the 837 Health Care Claim or Encounter or the 837 Health Care Data Reporting from the provider to the payer. In this business model, the 275 attachment with the appropriate imbedded HL7 attachment content is sent at the same time as the claim within the same data interchange (ISA/IEA) as the associated 837. Each transaction set is contained within its own Functional Group (GS/GE) within the interchange.

Figure 1.3 - Unsolicited 275 EDI Transaction Flow - 837 and 275 in Different Interchanges illustrates the flow of information related to the unsolicited business flow for the 275 transaction when the 837 and the 275 are sent in two different interchanges.

Figure 1.3 - Unsolicited 275 EDI Transaction Flow - 837 and 275 in Different Interchanges

Unsolicited 275 EDI Transaction Flow - 837 and 275 in Different Interchanges

Arrow 1
This represents the submission of the 837 Health Care Claim or Encounter or 837 Health Care Data Reporting from the provider to the payer.

Arrow 2
In this business model, the 275 with the appropriate imbedded HL7 attachment content is sent in a separate data interchange (ISA/IEA) than the associated 837.

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.

For convenience, the Wordbook definitions for the following business terms, which are used in this implementation guide, are listed below.

Logical Observation Identifier Names and Codes (LOINC®) Code List
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.

The dash "-" character displayed in the LOINC® code (e.g., 18657-7) is part of the code.

Note: Therefore the dash "-" character must not be used as a delimiter.

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.

837 Health Care Claim (Institutional, Professional and Dental)
837 Health Care Services Data Reporting
277 Health Care Claim Request for Additional Information

In addition to the ASC X12 transactions listed above, the HL7 format standard is related to the 275.

1.7.1 The Health Care Claim (837)

Submitting a claim by using the 837 is the first step in the adjudication process. All data elements found on the original bill have their source from the provider's billing system. When it is determined that a claim needs additional information to complete the adjudication process, this information can be sent unsolicited in the 275 transaction.

1.7.2 The Health Care Claim Service: Data Reporting (837)

Reporting medical and cost data to state agencies, federal agencies, commercial carriers and those carriers doing business on behalf of state or federal agencies by using the 837 provides relevant health data for statistical analysis. When the 837 does not support all of the data that is necessary for data reporting purposes, the additional information can be sent in the 275 transaction.

1.7.3 The Health Care Claim Request for Additional Information (277)

Submitting a claim, by using the 837 or another format, is the first step in the claim adjudication process. All data elements found on the original bill have their source from the provider's billing system. When a claim requires supporting 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 with locating the claim or the supporting information.

1.7.4 Health Level Seven (HL7)

The ANSI approved HL7 standard is used to convey the attachment content and is embedded in the 275. Relevant information can be found on the HL7 website (www.hl7.org).

1.7.5 Application Advice (824)

The 824 informs the submitter of the results of the receiving application system's data content edits of transaction sets.

The Application Advice (824) transaction is not required as a response to receipt of a batch transaction compliant with this implementation guide.

The Application Advice (824) transaction is not required as a response to receipt of a real-time transaction compliant with this implementation guide.

The "Application Reporting for Insurance" Implementation Guide is available for insurance industry use. It is recommended that the 824 transaction be used to acknowledge the 275 with the embedded HL7 attachment information. The 824 transaction provides the ability to acknowledge multiple standards.

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.

1.8.1 Time Parameters

A Trading Partner agreement may be used to define the time parameters for submission of the unsolicited 275 in a separate transaction. For example, a payer may specify that the claim will be adjudicated without the information if it is not received within a specific time frame.

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 structure of the 275 and describes the positioning of the business data within that structure. Familiarity with ASC X12 nomenclature, segments, data elements, hierarchical levels, and looping structures is recommended. For a review, see X12.6 and Appendix C, EDI Control Directory.

This implementation guide assumes the use of the ASCII format. If a format other than ASCII is used, then the appropriate conversions must be applied wherever ASCII is explicitly required. The contents of the BDS segment must be encoded as text.

1.10.1 Data Needs For Business Purpose

When a request for additional information is made, the payer supplies the parameters that assist the provider in locating the claim. These parameters are frequently the Provider's Assigned Claim Identifier, type of bill, medical record number, procedure code or revenue code, and the date of service. The provider is the source of this information. If the information is found on the original billed claim, the payer returns these data elements in the 277 transaction.

If at the time of billing, the provider determines that additional information is needed for the payer to adjudicate the claim, an unsolicited 275 may be sent. In this usage, the provider supplies the parameters to enable the payer to identify the claim and/or the service(s) that the information supports.

When the additional information is submitted in the 275, it will either be related to the entire claim or for a specific revenue line or service line. The segments used to submit the requested information are more clearly identified by specifying whether the information is related to the Claim Level or Service Line Level.

The TRN segment is required and will either contain the payer's control number, if sent in response to a 277 or the provider's attachment control number, if sent with the 837. See Section 2 for detail segment usage.

The 275 is divided into two tables. Table 1 contains transaction control information. Table 2 contains the detail information for the business function of the transaction.

The following figure presents segments that may be used for Claim Level information

Figure 1

 

Loop ID

Segment

ID

 

Segment Name

 

Business Purpose

1000D Patient Name

NM1

Patient Name

Name of Patient

 

REF

Provider's Assigned Claim Identifier

Provider's Assigned Claim Identifier

 

REF

Institutional Type of Bill

Institutional Type of Bill

 

REF

Medical Record Number

Medical Record number from the original claim

 

REF

Claim Identification Number for clearinghouses and Other Transmission Intermediaries

A claim identification number for clearinghouses and Other Transmission Intermediaries.

 

REF

Property and Casualty Claim Number

Report the payer assigned Property and Casualty Claim Number.

 

DTP

Claim Service Date

Claim Service Date

2000A Assigned Number

LX

Assigned Number

A sequence number that starts at 1 and is incremented by 1 when the loop is repeated.

 

TRN

Payer's Control Number/ Provider Attachment Control Number

Control Number assigned by either the Payer or Provider.

 

STC

Status Information

Echo the STC segment when in response to a 277. (Not used in unsolicited 275)

2100B Date Additional Information Submitted

DTP

Date Additional Information Was Submitted

The 275 Submittal Date.

 

CAT

Category of Patient Information Service

Used to identify the type of information that will be in the BDS

2110B Electronic Format Identification

OOI

Associated Object Type Identification

Security Level of Data needed in order to use BDS Segment

 

BDS

Binary Data Segment

Attachment information

The following figure presents segments that may be used for line level information

Figure 2

 

Loop ID

Segment

ID

 

Segment Name

 

Business Purpose

1000D Patient Name

NM1

Patient Name

Name of Patient

 

REF

Provider's Assigned Claim Identifier

Provider's Assigned Claim Identifier

 

REF

Institutional Type of Bill

Institutional Type of Bill

 

REF

Medical Record Number

Medical Record number from the original claim

 

REF

Claim Identification Number for clearinghouses and Other Transmission Intermediaries

A claim identification number for clearinghouses and Other Transmission Intermediaries.

 

REF

Property and Casualty Claim Number

Report the payer assigned Property and Casualty Claim Number.

 

DTP

Claim Service Date

Claim Service Date

2000A Assigned Number

LX

Assigned Number

A sequence number that starts at 1 and is incremented by 1 when the loop is repeated.

 

TRN

Payer's Control Number/ Provider Attachment Control Number

Control Number assigned by either the Payer or Provider.

 

STC

Status Information

Echo the STC segment when in response to a 277 (not used in the Unsolicited 275).

 

SVC

Service Information

Specific Revenue Code or Procedure Code which the additional information supports.

 

REF

Procedure Code Modifier

Procedure Code Modifier

2100A Service Line Date of Service

DTP

Service Line Date of Service

Service Line Date of Service

2100B Date Additional Information Submitted

DTP

Date Additional Information Was Submitted

The 275 Submittal Date.

 

CAT

Category of Patient Information Service

Used to identify the type of information that will be in the BDS

 

BDS

Binary Data Segment

Attachment information

1.10.2 Transaction Identification and Purpose

The Transaction Set Header Segment (ST) identifies the transaction set by using 275 as the data value for the transaction set identifier code data element, ST01. The originator of the transaction set assigns the unique control number ST02 which is shown here as 0001. In this example, the originator is the provider. ST03 carries the same value that is populated in GS08 which is the Implementation Version Identifier. For the 275 transaction this is 006020X314.

The 275 transaction structure only allows the submitter to send additional information for one claim in each 275. A separate Transaction Set Header/Trailer (ST/SE) must be sent for each claim response.

The Beginning Segment (BGN) indicates the transaction use. The Transaction Set Purpose Code value of "11" in the BGN01 indicates that this 275 is a response to a 277 Health Care Claim Request for Additional Information. A value of "02" indicates the unsolicited 275 is additional information sent to support an 837 claim or encounter. The originator of the transaction set assigns the unique reference number in BGN02 and the date of creation in BGN03. The Functional Group Header Segment (GS) provides additional identification of the business purpose of multi-functional transaction sets. See Appendix C, EDI Control Directory, for a detailed description of the elements in the GS segment.

The following is an example of the transaction header segments.

ST*275*0001*006020X314~
BGN*11*1*20110131~

1.10.3 NM1 Loop Participants Identification Structure

For the solicited 275, the participants identified in the 275 are generally the payer, submitter (e.g., service bureau, clearinghouse, provider groups), provider, and patient. The Loop ID 1000 is repeated to define the participants involved in the transaction. The implementation guide specifies the participants in the subsequent loops within the transaction set and refers to these participants, respectively. The transaction participants must be in the following order:

  • Payer - This entity is the decision maker in the business transaction. For this business use, this entity is the payer, even when the transaction is sent to a clearinghouse for forwarding to a payer.
  • Submitter - This entity is the sender of the transaction. For this business use, this entity can be a provider, a provider group, a clearinghouse, a service bureau, an employer, etc.
  • Provider - This entity provided the health care service or encounter.
  • Patient - This is the person who received the health care service or encounter.

The segments and data elements found in the 1000 Loop and the 2000 Loop describe the participants and their relationships.

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 (006020X314) defines the X12 requirements for the Additional Information to Support a Health Care Claim or Encounter. It is based on version/release/subrelease 006020 of the ASC X12 standards.