278 Health Care Services Review - Request for Review and Response (006020X315)

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

CODE SOURCE: 121: Health Industry Number

Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)

Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)

Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

CODE SOURCE: 121: Health Industry Number

Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)

Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)

Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

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

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00602

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2009

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

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

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

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

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

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

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

GS*HI - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

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

X12 Comments:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱XX✱SENDER CODE✱RECEIVER CODE✱19991231✱0802✱1✱X✱006020X315~

✱

✱

Application
Send's Code

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

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

CODE

DEFINITION

Health Care Services Review Information (278)

Required

142

Application Sender's Code

M 1

2/15

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

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

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

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

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

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

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

SEMANTIC: GS05 is the group time.

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

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

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

Required

455

Responsible Agency Code

M 1

1/2

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

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

INDUSTRY NAME: Version, Release, or Industry Identifier Code

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

CODE SOURCE 881: Version / Release / Industry Identifier Code

CODE

DEFINITION

006020X315

Health Care Services Review - Request for Review and Response

ST*278 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to indicate the start of a health care services review request transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management request.

TR3 Example:

ST✱278✱0001✱006020X315~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely identifying a Transaction Set

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

CODE

DEFINITION

278

Health Care Services Review Information

Required

329

Transaction Set Control Number

M 1

4/9

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

The Transaction Set Control 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

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

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

INDUSTRY NAME: Implementation Guide Version Name

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

CODE

DEFINITION

006020X315

Health Care Services Review - Request for Review and Response

BHT*0007 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0007✱13✱200300114000001✱20111001✱1400~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 2000A - UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL

Required

1005

Hierarchical Structure Code

M 1

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

Used to specify the sequential order of HL segments. The HL loops in the data stream must comply with this sequential order. An HL parent loop must be followed by any subordinate child loops prior to commencing a new HL parent loop at the same hierarchical level.

CODE

DEFINITION

0007

Information Source, Information Receiver, Subscriber, Dependent, Event, Services

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Cancellation

Use this code to cancel a previously submitted 278 transaction. Only 278 transactions that used a BHT06 code of "RU" can be canceled. The cancellation 278 transaction must contain the same BHT06 code as the previously submitted 278 transaction.

Request

Authority to Deduct (Reply)

Use this code for medical services reservations to reserve or deduct a service with the health plan. BHT06 must be equal to "RU".

Required

127

Reference Identification

O 1

1/80

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

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

INDUSTRY NAME: Submitter Transaction Identifier

Use this element to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier must be returned in the corresponding 278 response transaction's BHT03. This identifier will only be returned by the last entity to handle the 278. This identifier will not be passed through the complete life of the transaction. All recipients of 278 request transactions are required to return the Submitter Transaction Identifier in their 278 response if one is submitted.
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

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Situational

640

Transaction Type Code

O 1

Code specifying the type of transaction

SITUATIONAL RULE: Required when requesting Medical Services Reservation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Medical Services Reservation

HL - UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the information source hierarchical level. For a request transaction, this segment corresponds to the identification of the payer, HMO, or other utilization management organization who will be the source of the decision/response.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

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

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2010A - UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the source of information. In the case of a request transaction, the source of information would normally be the payer or utilization review organization making the decision on the request.

TR3 Example:

NM1✱X3✱2✱ABC PAYER✱✱✱✱✱46✱123450000~

NM1

✱

✱

Loop 2000B - REQUESTER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Third-Party Administrator

Employer

Payer

Use only when the organization receiving the request is a health plan but is not the entity rendering the medical decision, as in plan to plan communication or communication from the health plan to the medical review organization.

Utilization Management Organization

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Use this code only if the reviewing entity is an individual, such as an individual primary care physician.

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed to identify the UMO. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the reviewing entity is an individual (NM102 = 1), such as a primary care provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Name Suffix

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

Use when UMO is a payer and XV is not used.

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

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Utilization Management Organization (UMO) Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - REQUESTER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the health care services review information receiver. For request transactions, this segment corresponds to the identification of the entity initiating the request for review.

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - REQUESTER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the receiver of information. In the case of a request transaction, the receiver would normally be the entity who will ultimately be receiving the decision.

TR3 Example:

NM1✱1P✱1✱WHITE✱CHRIS✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Use when the requester is an individual provider.

Third-Party Administrator

Employer

Facility

Use when the requester is a facility, such as a clinic or hospital.

Payer

Use only when the organization sending the request is a health plan, as in plan to plan communication or communication from the health plan to the medical review organization.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed to identify the requester. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is present and NM102 = 1. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when requesting the services of a specific person, facility, group practice, or clinic and the provider NPI is known by the requester. If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

Required for providers in the United States or its territories when the provider is eligible to receive a National Provider Identifier (NPI).

OR

Required for providers not in the United States or its territories when the provider has received an NPI. If not required by this implementation guide, do not send.

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

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Requester Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - REQUESTER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Provider Site Number

Required when needed to identify the physician, clinic, or group practice associated with the requester identified in this NM1 loop.

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

The social security number must not be used for any Federally administered programs such as Medicare or CHAMPUS.

Carrier Assigned Reference Number

Required when necessary to provide the requester/provider ID as assigned by the UMO identified in Loop 2000A.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Requester Supplemental 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - REQUESTER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when necessary to identify the requester by location. If not required, by this implementation guide, do not send.

TR3 Notes:

Use to identify a specific location when the requester has multiple locations and authority varies based on location.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Requester Address Line

Use this element for the first line of the requester's address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Address Line

N4 - REQUESTER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when necessary to identify the requester by location. If not required, by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Requester City Name

Situational

156

State or Province Code

X 1

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: Requester State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

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

INDUSTRY NAME: Requester Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Requester Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

INDUSTRY NAME: Requester Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - REQUESTER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the UMO must direct requests for additional information to a specific requester contact, electronic mail, facsimile, or telephone number. 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✱JOHN SMITH✱TE✱5555551234✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the response must be directed to a particular contact and the name of the entity to contact is not already defined or is different than the name supplied in the NM1 segment of this loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued, or to transmit a contact communication number. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued, or to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - REQUESTER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop 2000C - SUBSCRIBER LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the requester's role in the care of the patient and the requesting provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Situational

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when necessary to identify the requesting provider's specialty. If not required by this implementation guide, do not send.

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Situational

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when necessary to identify the requesting provider's specialty. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Taxonomy Code

Provider Specialty 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

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.

TR3 Example:

HL✱3✱2✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name and identification number of the subscriber (who may also be the patient).
The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02)
Refer to Section 1.11.2 Identifying the Patient for specific information on how to identify an individual to a UMO.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber and the middle name/initial of the subscriber is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when subscriber's military title or rank is needed by the UMO to further identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the suffix of an individual's name is needed to further identify the subscriber; e.g., Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

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

Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Primary Identifier

Subscriber Member Number

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - SUBSCRIBER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.

TR3 Notes:

The primary identifier is the Member Identification Number in the NM1 segment.
Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is provided in the NM1 segment as a Member Identification Number when it is the primary number by which the UMO knows the member (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless it is different from the Member Identification Number provided in the NM1 segment.
If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

Branch Identifier

Group Number

Department Number

Patient Account Number

The maximum number of characters to be supported in REF02 for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system. Use this code only if the subscriber is the patient.

Health Insurance Claim (HIC) Number

Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there is also a need to pass the subscriber's HIC number. This might occur in a Medicare HMO situation.

Identity Card Number

Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

Social Security Number

Use this code only if the Social Security Number is not the primary identifier for the subscriber. The social security number must not be used for any Federally administered programs such as Medicare or CHAMPUS.

Agency Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Use this element for the first line of the Subscriber address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Address Line

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Subscriber City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Subscriber Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Subscriber Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.

TR3 Notes:

Refer to Section 1.11.2 Identifying the Patient for specific information on how to identify an individual to a UMO.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Subscriber Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when gender (DMG03) was used to determine medical necessity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

Not Used

Country Code

O 1

2/3

INS*Y - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when subscriber's military role is needed by the UMO to further identify the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱AO~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

1/2

✱

584

Employment
Status Code

✱

✱

✱

Loop 2000D - DEPENDENT LEVEL

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

Relationship to Insured Code

CODE

DEFINITION

Self

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Required

584

Employment Status Code

O 1

Code showing the general employment status of an employee/claimant

Use to qualify the patient's relationship to the military.

CODE

DEFINITION

Active Military - Overseas

Active Military - USA

Deceased

Retired Military - USA

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Not Used

1470

Number

O 1

1/9

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is someone other than the subscriber and the patient does not have a unique (different from the subscriber) member ID. If not required by this implementation guide, do not send.

TR3 Notes:

If the patient has a unique member ID, use Loop 2000C to identify the patient.
Required segments in this loop are required only when this loop is used.

TR3 Example:

HL✱4✱3✱23✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*QC - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name of the dependent who is the patient.
The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02)
Refer to Section 1.11.2 Identifying the Patient for specific information on how to identify an individual to a UMO.

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent and the middle name/initial of the dependent is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent and the suffix of an individual's name; e.g. Sr., Jr., or III of the dependent is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Name Suffix

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - DEPENDENT SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.

TR3 Notes:

Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

The maximum number of characters to be supported in REF02 for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or TRICARE.

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Supplemental 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - DEPENDENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Dependent Address Line

Use this element for the first line of the Dependent address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Address Line

N4 - DEPENDENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Dependent City Name

Situational

156

State or Province Code

X 1

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: Dependent State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Dependent Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Dependent Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Dependent Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

DMG*D8 - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.

TR3 Notes:

Refer to Section 1.11.2 Identifying the Patient for specific information on how to identify an individual to a UMO.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Dependent Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when gender (DMG03) was used to determine medical necessity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

Not Used

Country Code

O 1

2/3

INS*N - DEPENDENT RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when patient relationship to insured or birth sequence is needed by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.

TR3 Notes:

This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name and date of birth.

TR3 Example:

INS✱N✱19~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

1/2

✱

584

Employment
Status Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

Relationship to Insured Code

CODE

DEFINITION

Spouse

Child

Other Relationship

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Situational

1470

Number

O 1

1/9

A generic number

SEMANTIC: INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).

SITUATIONAL RULE: Required when the dependent is a child from a multiple birth. If not required by this implementation guide, do not send.

INDUSTRY NAME: Birth Sequence Number

HL - PATIENT EVENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Loop 2000E to provide information on the patient event associated with this health care services review.

TR3 Example:

HL✱5✱4✱EV✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Event

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN*1 - PATIENT EVENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to assign a unique trace number to the patient event request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

This enables the requester to
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional patient information related to this patient event request.
If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.

TR3 Example:

TRN✱1✱2001042801✱9012345678✱CARDIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

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: Patient Event 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.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when a specific division or group of the company identified in the previous data element (TRN03) is needed by the requester to further identify a specific component of the entity. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Trace Assigning Entity Additional 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.

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the type of health care services review request.

TR3 Example:

UM✱SC✱I✱3✱✱✱✱✱✱Y~

✱

✱

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Admission Review

Required if requesting an admission to a facility.

Health Services Review

Required if requesting a review of services related to an episode of care.

Individual

Required when BHT06 is equal to "RU".

Specialty Care Review

Required if requesting a referral to a specialty provider.

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

CODE

DEFINITION

Appeal - Immediate

Use this value to identify appeals of review decisions where the service required was emergency or urgent.

Appeal - Standard

Use this value to identify appeals of review decisions where the service required was not emergency or urgent.

Cancel

Extension

Use this when requesting additional service units and/or the duration of time for a prior approved service.

Initial

Reconsideration

Renewal

Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

Revised

Use if the requester is changing the specifics of a previously submitted request for which services have not been rendered.

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEMANTIC: UM03 is the Service Type (Code Source 958).

SITUATIONAL RULE: Required when Loop 2000F is not valued. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Service Type Code

Situational

C023

Health Care Service Location Information

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
C023-02 qualifies C023-01.

SITUATIONAL RULE: Required when UM04 is not valued at 2000F. If not required by this implementation guide, do not send.

Value at 2000F, Service Level, overrides the patient event for that service only.

Required

4-1

1331

Facility Code Value

M 1

1/3

Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-02.

Required

4-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

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

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Situational

C024

Related Causes Information

O 1

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

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

SITUATIONAL RULE: Required when the patient's condition is accident or employment related. If not required by this implementation guide, do not send.

Required

5-1

1362

Related-Causes Code

M 1

2/3

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

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Situational

5-2

1362

Related-Causes Code

O 1

2/3

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

SITUATIONAL RULE: Required when there is greater than 1 related cause for this certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Employment

Other Accident

Not Used

5-3

1362

Related-Causes Code

O 1

2/3

Situational

5-4

156

State or Province Code

O 1

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

SITUATIONAL RULE: Required when UM05-01 = "AA" and the accident occurred out of the service provider's state. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

CODE SOURCE 22: States and Provinces

Situational

5-5

Country Code

O 1

2/3

Code identifying the country

SITUATIONAL RULE: Required when the automobile accident occurred out of the United States to identify the country in which the accident occurred. If not required by this implementation guide, do not send.

CODE SOURCE 5: Countries, Currencies and Funds

Situational

1338

Level of Service Code

O 1

1/3

Code specifying the level of service rendered

SITUATIONAL RULE: Required when UM02=1 or if the patient event requires a level of service for care other than routine. If not required by this implementation guide, do not send.

CODE

DEFINITION

Emergency

Elective

Urgent

Situational

1213

Current Health Condition Code

O 1

Code indicating current health condition of the individual

SITUATIONAL RULE: Required when the patient's condition, as expressed by the codes in this data element, is a factor in the provider's determination of services to be performed that are not typically requested for the patient's diagnosis and proposed treatment. If not required by this implementation guide, do not send.

CODE

DEFINITION

Acute

Stable

Chronic

Systemic

Localized

Mild Disease

Normal, Healthy

Severe Systemic disease

Severe Systemic Disease that is a Constant Threat to Life

Excellent

Fair

Good

Poor

Situational

923

Prognosis Code

O 1

Code indicating physician's prognosis for the patient

SITUATIONAL RULE: Required when the patient's prognosis, as expressed by the codes in this data element, is a factor in the provider's determination of services to be performed that are not typically requested for the patient's diagnosis and proposed treatment. If not required by this implementation guide, do not send.

CODE

DEFINITION

Poor

Guarded

Fair

Good

Very Good

Excellent

Less than 6 Months to Live

Terminal

Situational

1363

Release of Information Code

O 1

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

SITUATIONAL RULE: Required when applicable legislation requires that a signature be collected and reported on this Health Care Services Review. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

The Release of Information response is limited to the information carried in this service review.

CODE

DEFINITION

The Provider has Limited or Restricted Ability to Release Data Related to a Claim

For professional service, this value is only used when state or federal laws supersede the HIPAA privacy rule by requiring that the provider collect a signature and the patient is either not present or physically unable to sign at the time the provider submits the request.

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

Situational

1514

Delay Reason Code

O 1

1/2

Code indicating the reason why a request was delayed

SITUATIONAL RULE: Required when the request is not submitted within the normal timeframe of the UMO. If not required by this implementation guide, do not send.

CODE

DEFINITION

Proof of Eligibility Unknown or Unavailable

Litigation

Authorization Delays

Delay in Certifying Provider

Third Party Processing Delay

Delay in Eligibility Determination

Administration Delay in the Prior Approval Process

Other

Natural Disaster

Lack of Information

No response to initial request

REF*BB - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when submitting an additional health care services review request associated with a request already processed by the UMO. If not required by this implementation guide, do not send.

TR3 Notes:

This is the authorization number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.

TR3 Example:

REF✱BB✱A123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Authorization Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - PREVIOUS REVIEW ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when submitting a follow-up to a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.

TR3 Example:

REF✱NT✱123Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Administrative Reference 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱439✱D8✱20111030~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Accident Date

DTP*484 - LAST MENSTRUAL PERIOD DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the certification is pregnancy related. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱484✱D8✱20110930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

484

Last Menstrual Period

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Last Menstrual Period Date

DTP*ABC - ESTIMATED BIRTH DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the certification is related to the estimated date of delivery. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱ABC✱D8✱20110930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

ABC

Estimated Date of Birth

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Estimated Birth Date

DTP*431 - ONSET OF CURRENT SYMPTOMS OR ILLNESS DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱431✱D8✱20110108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

431

Onset of Current Symptoms or Illness

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Onset Date

DTP*AAH - EVENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.

TR3 Notes:

If UM01 = AR use Admit Date.

TR3 Example:

DTP✱AAH✱D8✱20110930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

AAH

Event

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Event Date

DTP*435 - ADMISSION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱435✱D8✱20110930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

435

Admission

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use this for the range of dates when admission can occur.

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Admission Date

DTP*096 - DISCHARGE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱096✱D8✱20110930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Discharge Date

HI - PATIENT DIAGNOSIS

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when known by the requester to convey diagnosis information. If not required by this implementation guide, do not send.

TR3 Notes:

Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

TR3 Example:

HI✱ABF:I213:D8:20131209~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

ABF

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

The ICD-10 code set and corresponding qualifier can only be used: On or after the mandated HIPAA implementation date or, when the Secretary grants an exception to use the code set as a pilot project as allowed under the law.

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)

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

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)

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)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

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)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

2-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

2-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

X 1

1/30

Not Used

2-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

3-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

3-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

X 1

1/30

Not Used

3-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

4-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

4-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

X 1

1/30

Not Used

4-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

5-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

5-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

X 1

1/30

Not Used

5-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

6-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

6-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

X 1

1/30

Not Used

6-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

7-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

7-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

X 1

1/30

Not Used

7-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

8-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

8-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

X 1

1/30

Not Used

8-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

9-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

9-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

9-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

9-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

9-5

782

Monetary Amount

O 1

1/18

Not Used

9-6

380

Quantity

O 1

1/15

Not Used

9-7

799

Version Identifier

O 1

1/30

Not Used

9-8

1271

Industry Code

X 1

1/30

Not Used

9-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

10-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

10-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

10-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

10-5

782

Monetary Amount

O 1

1/18

Not Used

10-6

380

Quantity

O 1

1/15

Not Used

10-7

799

Version Identifier

O 1

1/30

Not Used

10-8

1271

Industry Code

X 1

1/30

Not Used

10-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

11-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

11-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

11-5

782

Monetary Amount

O 1

1/18

Not Used

11-6

380

Quantity

O 1

1/15

Not Used

11-7

799

Version Identifier

O 1

1/30

Not Used

11-8

1271

Industry Code

X 1

1/30

Not Used

11-9

1271

Industry Code

X 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is 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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

12-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

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)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

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

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

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

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

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

Required

12-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

12-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

12-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

12-5

782

Monetary Amount

O 1

1/18

Not Used

12-6

380

Quantity

O 1

1/15

Not Used

12-7

799

Version Identifier

O 1

1/30

Not Used

12-8

1271

Industry Code

X 1

1/30

Not Used

12-9

1271

Industry Code

X 1

1/30

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.

TR3 Notes:

An explanation of the uses of this segment follows.

HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days".

Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days".

An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".

TR3 Example:

HSD✱VS✱1✱DA✱1✱7✱10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days".)
HSD✱VS✱1✱DA✱✱✱✱W~ (This indicates "1 visit per day whenever necessary".)

HSD

✱

✱

✱

✱

✱

Time Period
Qualifier

✱

✱

Ship/Del or
Calend Code

✱

Situational

673

Quantity Qualifier

X 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD02 is valued to qualify the type of service count for this patient event. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD01 is valued to indicate the service quantity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

If this is a request for an extension to an existing certification (UM02 = 4), then HSD02 represents the number of visits by which the certification is extended. If this is a request to revise an existing certification (UM02 = S), then HSD02 represents the new total.

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SITUATIONAL RULE: Required when HSD04 is valued to qualify the timeframe in which the quantity of services (HSD02) will be rendered. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Months

Week

Situational

1167

Sample Selection Modulus

O 1

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

SITUATIONAL RULE: Required when needed to indicate sampling frequency for this service. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

X 1

1/2

Code defining periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when patient events must be rendered within a specific timeframe. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Episode

Visit

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when patient events must be rendered within a specific timeframe. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when the patient event must be rendered within a specific calendar delivery pattern. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Sunday, Monday, Thursday, Friday, Saturday

Tuesday through Saturday

Sunday, Wednesday, Thursday, Friday, Saturday

Monday, Wednesday, Thursday, Friday, Saturday

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

1/3 Mon., 1/3 Wed., 1/3 Fri.

Whenever Necessary

1/2 By Wed., Bal. By Fri.

None (Also Used to Cancel or Override a Previous Pattern)

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code which specifies the time for routine shipments or deliveries

SITUATIONAL RULE: Required when a specific time delivery pattern for the services in this patient event must be identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

None (Also Used to Cancel or Override a Previous Pattern)

CRC*07 - AMBULANCE CERTIFICATION INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱07✱Y✱01~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Ambulance Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Treatment is rendered related to the terminal illness

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Treatment is rendered related to the terminal illness

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Treatment is rendered related to the terminal illness

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Treatment is rendered related to the terminal illness

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Treatment is rendered related to the terminal illness

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

CRC*08 - CHIROPRACTIC CERTIFICATION INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱08✱Y✱14~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Chiropractic Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient or a care-giver has been instructed in use of equipment

Without the equipment, the patient would require surgery

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient or a care-giver has been instructed in use of equipment

Without the equipment, the patient would require surgery

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient or a care-giver has been instructed in use of equipment

Without the equipment, the patient would require surgery

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient or a care-giver has been instructed in use of equipment

Without the equipment, the patient would require surgery

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient or a care-giver has been instructed in use of equipment

Without the equipment, the patient would require surgery

CRC*09 - DURABLE MEDICAL EQUIPMENT INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱09✱Y✱29~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Durable Medical Equipment Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is ambulatory

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Patient is Confined to a Room or an Area Without Bathroom Facilities

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

Patient is in a nursing home

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Certification signed by the physician is on file at the supplier's office

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Durable Medical Equipment (DME) Purchased New

Durable Medical Equipment (DME) Is Under Warranty

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Patient Requires Intensive IV Therapy

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Independent at Home

Legally Blind

Speech Limitations

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is ambulatory

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Patient is Confined to a Room or an Area Without Bathroom Facilities

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

Patient is in a nursing home

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Certification signed by the physician is on file at the supplier's office

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Durable Medical Equipment (DME) Purchased New

Durable Medical Equipment (DME) Is Under Warranty

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Patient Requires Intensive IV Therapy

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Independent at Home

Legally Blind

Speech Limitations

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is ambulatory

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Patient is Confined to a Room or an Area Without Bathroom Facilities

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

Patient is in a nursing home

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Certification signed by the physician is on file at the supplier's office

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Durable Medical Equipment (DME) Purchased New

Durable Medical Equipment (DME) Is Under Warranty

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Patient Requires Intensive IV Therapy

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Independent at Home

Legally Blind

Speech Limitations

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is ambulatory

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Patient is Confined to a Room or an Area Without Bathroom Facilities

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

Patient is in a nursing home

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Certification signed by the physician is on file at the supplier's office

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Durable Medical Equipment (DME) Purchased New

Durable Medical Equipment (DME) Is Under Warranty

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Patient Requires Intensive IV Therapy

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Independent at Home

Legally Blind

Speech Limitations

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is ambulatory

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Patient is Confined to a Room or an Area Without Bathroom Facilities

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

Patient is in a nursing home

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Certification signed by the physician is on file at the supplier's office

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Durable Medical Equipment (DME) Purchased New

Durable Medical Equipment (DME) Is Under Warranty

Transportation Was To the Nearest Facility

Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications

Patient Requires Intensive IV Therapy

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Independent at Home

Legally Blind

Speech Limitations

CRC*11 - OXYGEN THERAPY CERTIFICATION INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱11✱Y✱25~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Oxygen Therapy Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Patient was transported in an emergency situation

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is in a nursing home

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Treatment is rendered related to the terminal illness

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Dyspnea with Minimal Exertion

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was transported in an emergency situation

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is in a nursing home

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Treatment is rendered related to the terminal illness

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Dyspnea with Minimal Exertion

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was transported in an emergency situation

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is in a nursing home

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Treatment is rendered related to the terminal illness

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Dyspnea with Minimal Exertion

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was transported in an emergency situation

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is in a nursing home

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Treatment is rendered related to the terminal illness

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Dyspnea with Minimal Exertion

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was transported in an emergency situation

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is in a nursing home

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Treatment is rendered related to the terminal illness

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Dyspnea with Minimal Exertion

CRC*75 - FUNCTIONAL LIMITATIONS INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱75✱Y✱02~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Functional Limitations

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

Patient has poor diabetic control

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Intensive IV Therapy

Amputation

Ambulation Limitations

Bowel Limitations, Bladder Limitations, or both (Incontinence)

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Cane Required

Complete Bedrest

CNJ

Cumulative Injury

Contracture

Dyspnea with Minimal Exertion

Endurance Limitations

Exercises Prescribed

Hearing Limitations

Legally Blind

Lethargic

Other Limitation

Paralysis

Partial Weight Bearing

Speech Limitations

TNJ

Traumatic Injury

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

Patient has poor diabetic control

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Intensive IV Therapy

Amputation

Ambulation Limitations

Bowel Limitations, Bladder Limitations, or both (Incontinence)

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Cane Required

Complete Bedrest

CNJ

Cumulative Injury

Contracture

Dyspnea with Minimal Exertion

Endurance Limitations

Exercises Prescribed

Hearing Limitations

Legally Blind

Lethargic

Other Limitation

Paralysis

Partial Weight Bearing

Speech Limitations

TNJ

Traumatic Injury

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

Patient has poor diabetic control

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Intensive IV Therapy

Amputation

Ambulation Limitations

Bowel Limitations, Bladder Limitations, or both (Incontinence)

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Cane Required

Complete Bedrest

CNJ

Cumulative Injury

Contracture

Dyspnea with Minimal Exertion

Endurance Limitations

Exercises Prescribed

Hearing Limitations

Legally Blind

Lethargic

Other Limitation

Paralysis

Partial Weight Bearing

Speech Limitations

TNJ

Traumatic Injury

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

Patient has poor diabetic control

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Intensive IV Therapy

Amputation

Ambulation Limitations

Bowel Limitations, Bladder Limitations, or both (Incontinence)

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Cane Required

Complete Bedrest

CNJ

Cumulative Injury

Contracture

Dyspnea with Minimal Exertion

Endurance Limitations

Exercises Prescribed

Hearing Limitations

Legally Blind

Lethargic

Other Limitation

Paralysis

Partial Weight Bearing

Speech Limitations

TNJ

Traumatic Injury

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was bed confined before the ambulance service

Patient was bed confined after the ambulance service

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility

Patient is confined to a bed or chair

Ambulation is Impaired and Walking Aid is Used for Mobility

Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed

Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons

Patient's Ability to Breathe is Severely Impaired

Patient condition requires frequent and/or immediate changes in body positions

Patient can operate controls

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use

Item has been prescribed as part of a planned regimen of treatment in patient home

Patient is highly susceptible to decubitus ulcers

Patient or a care-giver has been instructed in use of equipment

Patient has poor diabetic control

Without the equipment, the patient would require surgery

Patient has had a total knee replacement

Patient has intractable lymphedema of the extremities

This Feeding is the Only Form of Nutritional Intake for This Patient

Oxygen delivery equipment is stationary

Patient Has Mobilizing Respiratory Tract Secretions

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair

Patient Requires Leg Elevation for Edema or Body Alignment

Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair

Patient Requires Reclining Function of a Wheelchair

Patient is Unable to Operate a Wheelchair Manually

Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Intensive IV Therapy

Amputation

Ambulation Limitations

Bowel Limitations, Bladder Limitations, or both (Incontinence)

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Cane Required

Complete Bedrest

CNJ

Cumulative Injury

Contracture

Dyspnea with Minimal Exertion

Endurance Limitations

Exercises Prescribed

Hearing Limitations

Legally Blind

Lethargic

Other Limitation

Paralysis

Partial Weight Bearing

Speech Limitations

TNJ

Traumatic Injury

Walker Required

Wheelchair Required

CRC*76 - ACTIVITIES PERMITTED INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱76✱Y✱10~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Activities Permitted

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Patient is ambulatory

Patient is Confined to a Room or an Area Without Bathroom Facilities

Patient can operate controls

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient or a care-giver has been instructed in use of equipment

Patient has had a total knee replacement

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Bedrest BRP (Bathroom Privileges)

Cane Required

Complete Bedrest

Crutches Required

Endurance Limitations

Exercises Prescribed

Independent at Home

No Restrictions

Paralysis

Partial Weight Bearing

Transfer to Bed, or Chair, or Both

Up as Tolerated

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient is ambulatory

Patient is Confined to a Room or an Area Without Bathroom Facilities

Patient can operate controls

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient or a care-giver has been instructed in use of equipment

Patient has had a total knee replacement

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Bedrest BRP (Bathroom Privileges)

Cane Required

Complete Bedrest

Crutches Required

Endurance Limitations

Exercises Prescribed

Independent at Home

No Restrictions

Paralysis

Partial Weight Bearing

Transfer to Bed, or Chair, or Both

Up as Tolerated

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient is ambulatory

Patient is Confined to a Room or an Area Without Bathroom Facilities

Patient can operate controls

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient or a care-giver has been instructed in use of equipment

Patient has had a total knee replacement

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Bedrest BRP (Bathroom Privileges)

Cane Required

Complete Bedrest

Crutches Required

Endurance Limitations

Exercises Prescribed

Independent at Home

No Restrictions

Paralysis

Partial Weight Bearing

Transfer to Bed, or Chair, or Both

Up as Tolerated

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient is ambulatory

Patient is Confined to a Room or an Area Without Bathroom Facilities

Patient can operate controls

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient or a care-giver has been instructed in use of equipment

Patient has had a total knee replacement

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Bedrest BRP (Bathroom Privileges)

Cane Required

Complete Bedrest

Crutches Required

Endurance Limitations

Exercises Prescribed

Independent at Home

No Restrictions

Paralysis

Partial Weight Bearing

Transfer to Bed, or Chair, or Both

Up as Tolerated

Walker Required

Wheelchair Required

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient is ambulatory

Patient is Confined to a Room or an Area Without Bathroom Facilities

Patient can operate controls

Patient owns equipment

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient or a care-giver has been instructed in use of equipment

Patient has had a total knee replacement

Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision

Bedrest BRP (Bathroom Privileges)

Cane Required

Complete Bedrest

Crutches Required

Endurance Limitations

Exercises Prescribed

Independent at Home

No Restrictions

Paralysis

Partial Weight Bearing

Transfer to Bed, or Chair, or Both

Up as Tolerated

Walker Required

Wheelchair Required

CRC*77 - MENTAL STATUS INFORMATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is requesting certification and to justify the reason for the request. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱77✱Y✱07~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

Condition Code Category

CODE

DEFINITION

Mental Status

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

Patient was admitted to a hospital

Patient was unconscious or in shock

Patient had to be physically restrained

Patient is Confined to a Room or an Area Without Bathroom Facilities

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient is highly susceptible to decubitus ulcers

Patient is in a nursing home

Patient is conscious

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Agitated

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Complete Bedrest

Comatose

Disoriented

Depressed

Forgetful

Hostile

Lethargic

Other Mental Condition

Oriented

Uncooperative

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was unconscious or in shock

Patient had to be physically restrained

Patient is Confined to a Room or an Area Without Bathroom Facilities

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient is highly susceptible to decubitus ulcers

Patient is in a nursing home

Patient is conscious

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Agitated

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Complete Bedrest

Comatose

Disoriented

Depressed

Forgetful

Hostile

Lethargic

Other Mental Condition

Oriented

Uncooperative

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was unconscious or in shock

Patient had to be physically restrained

Patient is Confined to a Room or an Area Without Bathroom Facilities

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient is highly susceptible to decubitus ulcers

Patient is in a nursing home

Patient is conscious

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Agitated

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Complete Bedrest

Comatose

Disoriented

Depressed

Forgetful

Hostile

Lethargic

Other Mental Condition

Oriented

Uncooperative

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was unconscious or in shock

Patient had to be physically restrained

Patient is Confined to a Room or an Area Without Bathroom Facilities

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient is highly susceptible to decubitus ulcers

Patient is in a nursing home

Patient is conscious

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Agitated

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Complete Bedrest

Comatose

Disoriented

Depressed

Forgetful

Hostile

Lethargic

Other Mental Condition

Oriented

Uncooperative

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when multiple conditions apply to the certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was unconscious or in shock

Patient had to be physically restrained

Patient is Confined to a Room or an Area Without Bathroom Facilities

Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary

Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary

Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair

Patient is highly susceptible to decubitus ulcers

Patient is in a nursing home

Patient is conscious

Treatment is rendered related to the terminal illness

Severe

Moderate

Sudden Onset of Disorientation

Sudden Onset of Severe, Incapacitating Pain

Patient Requires Protective Isolation

Patient Requires Frequent Monitoring

Agitated

BPD

Beneficiary is Partially Dependent

BTD

Beneficiary is Totally Dependent

Complete Bedrest

Comatose

Disoriented

Depressed

Forgetful

Hostile

Lethargic

Other Mental Condition

Oriented

Uncooperative

CL1 - NURSING HOME RESIDENTIAL STATUS

X12 Name:

Claim Codes

X12 Purpose:

To supply information specific to hospital claims

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when certification involves a nursing home resident and Loop 2000F is not used. If not required by this implementation guide, do not send.

TR3 Example:

CL1✱3✱✱01~

CL1

✱

✱

Admission
Source Code

✱

✱

Nurse Home
Status Code

Not Used

1315

Admission Type Code

O 1

Not Used

1314

Admission Source Code

O 1

Not Used

1352

Patient Status Code

O 1

1/2

Situational

1345

Nursing Home Residential Status Code

O 1

Code specifying the status of a nursing home resident at the time of service

SITUATIONAL RULE: Required when certification involves a nursing home resident. If not required by this implementation guide, do not send.

CODE

DEFINITION

Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)

Newly Admitted

Newly Eligible

No Longer Eligible

Still a Resident

Temporary Absence - Hospital

Temporary Absence - Other

Transferred to Intermediate Care Facility - Level II (ICF II)

Other

CR1 - AMBULANCE TRANSPORT INFORMATION

X12 Name:

Ambulance Certification

X12 Purpose:

To supply information related to the ambulance service rendered to a patient

X12 Syntax:

P0102
If either CR101 or CR102 is present, then the other is required.
P0506
If either CR105 or CR106 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.

TR3 Notes:

When the CR1 segment is used, then Loop 2010EB is required.

TR3 Example:

CR1✱LB✱155✱T✱A~

CR1

✱

✱

✱

✱

Ambulance
Reason Code

✱

✱

✱

✱

✱

✱

Situational

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when CR102 is present. If not required by this implementation guide, do not send.

CODE

DEFINITION

Kilogram

Pound

Situational

Weight

X 1

1/10

Numeric value of weight

SEMANTIC: CR102 is the weight of the patient at time of transport.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when patient weight information is needed to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Weight

Required

1316

Ambulance Transport Code

O 1

Code indicating the type of ambulance transport

CODE

DEFINITION

Initial Trip

Return Trip

Transfer Trip

Round Trip

Situational

1317

Ambulance Transport Reason Code

O 1

Code indicating the reason for ambulance transport

SITUATIONAL RULE: Required when ambulance transport reason is required to determine medical necessity. If not required by this implementation guide, do not send.

CODE

DEFINITION

Patient was transported to nearest facility for care of symptoms, complaints, or both

Patient was transported for the benefit of a preferred physician

Patient was transported for the nearness of family members

Patient was transported for the care of a specialist or for availability of specialized equipment

Patient Transferred to Rehabilitation Facility

Patient Transferred to Residential Facility

Situational

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when distance of transportation is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Miles

Kilometers

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CR106 is the distance traveled during transport.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when distance of transportation is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transport Distance

Not Used

166

Address Information

O 1

1/55

Not Used

166

Address Information

O 1

1/55

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR109 is the purpose for the round trip ambulance service.

SITUATIONAL RULE: Required when CR103 (Ambulance Transport Code) = "X Round Trip". If not required by this implementation guide, do not send.

INDUSTRY NAME: Round Trip Purpose Description

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR110 is the purpose for the usage of a stretcher during ambulance service.

SITUATIONAL RULE: Required when needed to justify usage of a stretcher. If not required by this implementation guide, do not send.

INDUSTRY NAME: Stretcher Purpose Description

CR2 - SPINAL MANIPULATION SERVICE INFORMATION

X12 Name:

Chiropractic Certification

X12 Purpose:

To supply information related to the chiropractic service rendered to a patient

X12 Syntax:

P0102
If either CR201 or CR202 is present, then the other is required.
C0403
If CR204 is present, then CR203 is required.
P0506
If either CR205 or CR206 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.

TR3 Example:

CR2✱1✱5✱✱✱✱✱✱C✱Y✱✱✱Y~

CR2

✱

✱

✱

Subluxation
Level Code

X 1

✱

1367

Subluxation
Level Code

✱

✱

✱

✱

✱

✱

✱

✱

Situational

609

Count

X 1

1/9

Occurrence counter

SEMANTIC: CR201 is the number this treatment is in the series.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when requesting certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.

INDUSTRY NAME: Treatment Series Number

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CR202 is the total number of treatments in the series.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when requesting certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.

INDUSTRY NAME: Treatment Count

Situational

1367

Subluxation Level Code

X 1

2/3

Code identifying the specific level of subluxation

COMMENT: When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.

SEGMENT SYNTAX: C0403

SITUATIONAL RULE: Required when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Cervical 1

Cervical 2

Cervical 3

Cervical 4

Cervical 5

Cervical 6

Cervical 7

Coccyx

Ilium

Lumbar 1

Lumbar 2

Lumbar 3

Lumbar 4

Lumbar 5

Occiput

Sacrum

Thoracic 1

T10

Thoracic 10

T11

Thoracic 11

T12

Thoracic 12

Thoracic 2

Thoracic 3

Thoracic 4

Thoracic 5

Thoracic 6

Thoracic 7

Thoracic 8

Thoracic 9

Situational

1367

Subluxation Level Code

O 1

2/3

Code identifying the specific level of subluxation

SEGMENT SYNTAX: C0403

SITUATIONAL RULE: Required when the patient's condition or treatment involves subluxation to express the ending level of subluxation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Cervical 1

Cervical 2

Cervical 3

Cervical 4

Cervical 5

Cervical 6

Cervical 7

Coccyx

Ilium

Lumbar 1

Lumbar 2

Lumbar 3

Lumbar 4

Lumbar 5

Occiput

Sacrum

Thoracic 1

T10

Thoracic 10

T11

Thoracic 11

T12

Thoracic 12

Thoracic 2

Thoracic 3

Thoracic 4

Thoracic 5

Thoracic 6

Thoracic 7

Thoracic 8

Thoracic 9

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

380

Quantity

X 1

1/15

Not Used

380

Quantity

O 1

1/15

Required

1342

Nature of Condition Code

O 1

Code indicating the nature of a patient's condition

INDUSTRY NAME: Patient Condition Code

CODE

DEFINITION

Acute Condition

Chronic Condition

Non-acute

Non-Life Threatening

Routine

Symptomatic

Acute Manifestation of a Chronic Condition

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an uncomplicated condition.

INDUSTRY NAME: Complication Indicator

CODE

DEFINITION

Yes

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR210 is a description of the patient's condition.

SITUATIONAL RULE: Required when necessary to clarify patient condition. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Condition Description

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR211 is an additional description of the patient's condition.

SITUATIONAL RULE: Required when necessary to clarify patient condition. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Condition Description

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier review; an "N" value indicates X-rays are not maintained and available for carrier review.

SITUATIONAL RULE: Required when X-rays are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: X-ray Availability Indicator

CODE

DEFINITION

Yes

CR5 - HOME OXYGEN THERAPY INFORMATION

X12 Name:

Oxygen Therapy Certification

X12 Purpose:

To supply information regarding certification of medical necessity for home oxygen therapy

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting initial, extended, or revised certification of home oxygen therapy. If not required by this implementation guide, do not send.

TR3 Notes:

Use the UM segment data element UM02 instead of CR501 to specify the Certification Type Code.
Use the HSD segment instead of CR502 to specify the treatment period.

TR3 Example:

CR5✱✱✱D✱✱✱1✱✱✱✱✱87✱N✱✱✱✱✱A~

CR5

✱

1322

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Oxygen Test
Cond Code

✱

1350

Oxygen Test
Find Code

✱

1350

Oxygen Test
Find Code

✱

1350

Oxygen Test
Find Code

✱

✱

✱

Not Used

1322

Certification Type Code

O 1

Not Used

380

Quantity

O 1

1/15

Required

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

Situational

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

SITUATIONAL RULE: Required when CR503 is present and more than one type of equipment is required to administer the oxygen therapy. If not required by this implementation guide, do not send.

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR505 is the reason for equipment.

SITUATIONAL RULE: Required when needed to provide additional information that could impact the medical decision. If not required by this implementation guide, do not send.

INDUSTRY NAME: Equipment Reason Description

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR506 is the oxygen flow rate in liters per minute.

INDUSTRY NAME: Oxygen Flow Rate

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR507 is the number of times per day the patient must use oxygen.

SITUATIONAL RULE: Required when daily oxygen use count is relevant to the type of home oxygen therapy identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Daily Oxygen Use Count

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR508 is the number of hours per period of oxygen use.

SITUATIONAL RULE: Required when daily oxygen use count is relevant to the type of home oxygen therapy identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Oxygen Use Period Hour Count

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR509 is the special orders for the respiratory therapist.

SITUATIONAL RULE: Required when necessary to convey special orders for the respiratory therapist. If not required by this implementation guide, do not send.

INDUSTRY NAME: Respiratory Therapist Order Text

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR510 is the arterial blood gas.

SITUATIONAL RULE: Required when arterial blood gas quantity is relevant to the type of home oxygen therapy requested. If not required by this implementation guide, do not send.

INDUSTRY NAME: Arterial Blood Gas Quantity

Either CR510 or CR511 is required.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR511 is the oxygen saturation.

SITUATIONAL RULE: Required when arterial blood gas quantity is relevant to the type of home oxygen therapy requested. If not required by this implementation guide, do not send.

INDUSTRY NAME: Oxygen Saturation Quantity

Either CR510 or CR511 is required.

Situational

1349

Oxygen Test Condition Code

O 1

Code indicating the conditions under which a patient was tested

SITUATIONAL RULE: Required when reporting oxygen test results. If not required by this implementation guide, do not send.

CODE

DEFINITION

Exercising

No special conditions for test

On oxygen

At rest on room air

Sleeping

Walking

Other

Situational

1350

Oxygen Test Findings Code

O 1

Code indicating the findings of oxygen tests performed on a patient

SITUATIONAL RULE: Required when patient's arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or oxygen saturation is greater than 88%. If not required by this implementation guide, do not send.

CODE

DEFINITION

Dependent edema suggesting congestive heart failure

"P" Pulmonale on Electrocardiogram (EKG)

Erythrocythemia with a hematocrit greater than 56 percent

Situational

1350

Oxygen Test Findings Code

O 1

Code indicating the findings of oxygen tests performed on a patient

SITUATIONAL RULE: Required when patient's arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or oxygen saturation is greater than 88%, and more than one finding is applicable. If not required by this implementation guide, do not send.

CODE

DEFINITION

Dependent edema suggesting congestive heart failure

"P" Pulmonale on Electrocardiogram (EKG)

Erythrocythemia with a hematocrit greater than 56 percent

Situational

1350

Oxygen Test Findings Code

O 1

Code indicating the findings of oxygen tests performed on a patient

SITUATIONAL RULE: Required when patient's arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or oxygen saturation is greater than 88%, and more than two findings are applicable. If not required by this implementation guide, do not send.

CODE

DEFINITION

Dependent edema suggesting congestive heart failure

"P" Pulmonale on Electrocardiogram (EKG)

Erythrocythemia with a hematocrit greater than 56 percent

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.

SITUATIONAL RULE: Required when either CR503, CR504 or CR518 = "D" (Liquid Portable) or "E" (Gaseous Portable). If not required by this implementation guide, do not send.

INDUSTRY NAME: Portable Oxygen System Flow Rate

Required

1382

Oxygen Delivery System Code

O 1

Code to indicate if a particular form of delivery was prescribed

CODE

DEFINITION

Nasal Cannula

Oxygen Conserving Device

Oxygen Conserving Device with Oxygen Pulse System

Oxygen Conserving Device with Reservoir System

Transtracheal Catheter

Situational

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

SITUATIONAL RULE: Required when CR503 and CR504 are present and more than two types of equipment are required to administer the oxygen therapy. If not required by this implementation guide, do not send.

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

CR6 - HOME HEALTH CARE INFORMATION

X12 Name:

Home Health Care Certification

X12 Purpose:

To supply information related to the certification of a home health care patient

X12 Syntax:

P0304
If either CR603 or CR604 is present, then the other is required.
P091011
If either CR609, CR610 or CR611 are present, then the others are required.
P151617
If either CR615, CR616 or CR617 are present, then the others are required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting for certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.

TR3 Notes:

Requests for home health care must include a principal diagnosis (HI01 = BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.

TR3 Example:

CR6✱7✱20111004✱✱✱✱✱N✱I~

Required

923

Prognosis Code

M 1

Code indicating physician's prognosis for the patient

CODE

DEFINITION

Poor

Guarded

Fair

Good

Very Good

Excellent

Less than 6 Months to Live

Terminal

Required

373

Date

M 1

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

SEMANTIC: CR602 is the date covered home health services began.

INDUSTRY NAME: Home Health Start Date

Situational

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the event date has not been identified in DTP, Event Date in this loop and the duration of this plan of treatment is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1251

Date Time Period

X 1

1/35

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

SEMANTIC: CR604 is the certification period covered by this plan of treatment.

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Home Health Certification Period

Not Used

373

Date

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.

INDUSTRY NAME: Medicare Coverage Indicator

CODE

DEFINITION

Not Applicable

Required

1322

Certification Type Code

M 1

Code indicating the type of certification

This element must have the same value as UM02.

CODE

DEFINITION

Appeal - Immediate

Appeal - Standard

Cancel

Extension

Initial

Reconsideration

Renewal

Revised

Situational

373

Date

X 1

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

SEMANTIC: CR609 is the date that the surgery identified in CR611 was performed.

SEGMENT SYNTAX: P091011

SITUATIONAL RULE: Required when home health care is related to a specific surgical procedure, the surgery date is known, and the surgical procedure code is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Surgery Date

Situational

235

Product/Service ID Qualifier

X 1

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

SEMANTIC: CR610 qualifies CR611.

SEGMENT SYNTAX: P091011

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

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

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

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

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

CODE SOURCE: 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

Situational

1137

Medical Code Value

X 1

1/15

Code value for describing a medical condition or procedure

SEMANTIC: CR611 is the surgical procedure most relevant to the care being rendered.

SEGMENT SYNTAX: P091011

INDUSTRY NAME: Surgical Procedure Code

Situational

373

Date

O 1

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

SEMANTIC: CR612 is the date the agency received the verbal orders from the physician for start of care.

SITUATIONAL RULE: Required when the requester received verbal orders from the physician for the start of home health care and the date when the order was received is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Physician Order Date

Situational

373

Date

O 1

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

SEMANTIC: CR613 is the date that the patient was last seen by the physician.

SITUATIONAL RULE: Required when the date the patient was last seen by the physician is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Last Visit Date

Situational

373

Date

O 1

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

SEMANTIC: CR614 is the date of the home health agency's most recent contact with the physician.

SITUATIONAL RULE: Required when the physician has been contacted by the home health service provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Physician Contact Date

Situational

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P151617

SITUATIONAL RULE: Required when home health care is associated with a recent inpatient stay, the admission stay date is known, and the facility type is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1251

Date Time Period

X 1

1/35

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

SEMANTIC: CR616 is the date range of the most recent inpatient stay.

SEGMENT SYNTAX: P151617

INDUSTRY NAME: Last Admission Period

Situational

1384

Patient Location Code

X 1

Code identifying the location where patient is receiving medical treatment

SEMANTIC: CR617 indicates the type of facility from which the patient was most recently discharged.

SEGMENT SYNTAX: P151617

CODE

DEFINITION

Acute Care Facility

Boarding Home

Hospice

Intermediate Care Facility

Long-term or Extended Care Facility

Not Specified

Nursing Home

Sub-acute Care Facility

Other Location

Rehabilitation Facility

Outpatient Facility

Private Home

Residential Treatment Facility

Skilled Nursing Home

Rest Home

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

PWK - ADDITIONAL PATIENT INFORMATION

X12 Name:

Paperwork

X12 Purpose:

To identify the type or transmission or both of paperwork or supporting information

X12 Syntax:

P0506
If either PWK05 or PWK06 is present, then the other is required.
P1011
If either PWK10 or PWK11 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop, and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.

TR3 Notes:

This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

Refer to Section 1.11.5.1 for more information on using this PWK segment.

TR3 Example:

PWK✱OB✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

Code indicating the title or contents of a document, report or supporting item

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Expected outcomes of rehabilitative services.

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use for medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Information to support necessity of ambulance trip.

Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

Purchase Order Attachment

Use for purchase of medical or dental equipment.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Required when using the PWK segment to provide missing teeth information.

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Quality Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Death Notification

Photographs

Required

756

Report Transmission Code

O 1

1/2

Code defining timing, transmission method or format by which reports are to be sent

CODE

DEFINITION

Available on Request at Provider Site

Required when using the PWK segment to provide missing teeth information.

Use when the paperwork is not being sent with the request at this time. It will be made available to the UMO (or approving entity) on request.

By Mail

Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

E-Mail

File Transfer

By Fax

Voice

Use this for voicemail or phone communication.

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Situational

Identification Code Qualifier

X 1

1/2

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

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a code number.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM, FT or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Attachment Control Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM, FT or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Attachment Control Number

The requester can use it when PWK02 equals "AA" if the requester wants to send a document control number for an attachment remaining at the Provider's office.

Situational

352

Description

O 1

1/80

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

COMMENT: PWK07 may be used to indicate special information to be shown on the specified report.

SITUATIONAL RULE: Required when needed to add any additional information about the attachment described in this segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Description

To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to transmit a text message to the UMO about the patient event. If not required by this implementation guide, do not send.

TR3 Notes:

Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.

TR3 Example:

MSG✱This is a free-form text message~

MSG

✱

933

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

X 1

Not Used

1470

Number

O 1

1/9

NM1 - PATIENT EVENT PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.

TR3 Notes:

If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Attending Physician

Operating Physician

Other Physician

Service Location

AAJ

Admitting Services

Use this value to identify the admitting provider.

Assistant Surgeon

Ordering Physician

Referring Provider

Do not use if the entity identified in 2010B is the referring provider.

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when identifying a specific person, facility, group practice, or clinic and NM108/NM109 are not present. Not used if identifying a specialty entity utilizing the PRV segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when military title or rank further identifies the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when requesting the services of a specific person, facility, group practice, or clinic and the provider ID is known by the requester. If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Event Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - PATIENT EVENT PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:

Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

The social security number must not be used for any Federally administered programs such as Medicare or CHAMPUS.

Carrier Assigned Reference Number

Use when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010AA or 2010AB has assigned its own identifier for this provider.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Event Provider Supplemental 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.

Situational

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

Not Used

C040

Reference Identifier

O 1

N3 - PATIENT EVENT PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the provider has multiple locations and a specific location for this patient event needs to be identified. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Address Line

Use this element for the first line of the provider's address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Address Line

N4 - PATIENT EVENT PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the provider has multiple locations and a specific location for this patient event needs to be identified. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Patient Event Provider City Name

Situational

156

State or Province Code

X 1

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: Patient Event Provider State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Patient Event Provider Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Patient Event Provider Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Patient Event Provider Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - PATIENT EVENT PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a contact name and/or communication number for the provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the requester needs to indicate a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Name

Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required, do not send.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued, or to transmit a contact communication number. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued, or to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - PATIENT EVENT PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop 2010EB - PATIENT EVENT TRANSPORT INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Example:

PRV✱PE✱PXC✱208D00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Use only when NM101 = AAJ.

Assistant Surgeon

Use only when NM101 = DD.

Attending

Use only when NM101 = 71.

Operating

Use only when NM101 = 72.

Ordering

Use only when NM101 = DK.

Other Physician

Use only when NM101 = 73.

Primary Care Physician

Use only when NM101 = P3.

Performing

Use only when NM101 = SJ.

Referring

Use only when NM101 = DN.

Required

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

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

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

NM1 - PATIENT EVENT TRANSPORT INFORMATION

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when requesting transport of the patient. If not required by this implementation guide, do not send.

TR3 Notes:

At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop

TR3 Example:

NM1✱PW✱2✱PATIENT DIALYSIS CENT~
NM1✱FS✱2~

NM1

✱

✱

Loop 2010EB - PATIENT EVENT TRANSPORT INFORMATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Drop-off Location

Final Scheduled Destination

Next Destination

Pickup Address

Next Scheduled Destination

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the name of the location for which the patient is being transported is known. If not required by this implementation, do not send.

INDUSTRY NAME: Patient Event Transport Location Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - PATIENT EVENT TRANSPORT LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Transport Location Address Line

Use this element for the first line of the transport location address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Transport Location Address Line

N4 - PATIENT EVENT TRANSPORT LOCATION CITY/STATE/ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop 2010EB - PATIENT EVENT TRANSPORT INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Situational

City Name

O 1

2/30

Free-form text for city name

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

SITUATIONAL RULE: Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

SITUATIONAL RULE: Required when N401 and N402 are not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location Postal Zone or ZIP Code

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

Not Used

Country Code

X 1

2/3

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Not Used

1715

Country Subdivision Code

X 1

1/3

NM1 - PATIENT EVENT OTHER UMO NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2010EC - PATIENT EVENT OTHER UMO NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱CA✱2~

NM1

✱

✱

Loop 2010EC - PATIENT EVENT OTHER UMO NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Alternate Insurer

Use this code to indicate that the other UMO is commercial insurance.

Carrier

Use this code to indicate that the other UMO is Medicare Part B.

Intermediary

Use this code to indicate that the other UMO is Medicare Part A.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when NM101 is equal to "00" to indicate the name of the other UMO. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other UMO Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF*ZZ - OTHER UMO DENIAL REASON

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱ZZ✱0M~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other UMO Denial Reason

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

352

Description

X 1

1/80

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other UMO Denial Reason

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Situational

4-3

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the other UMO denied the request for more than two reasons. If not required by this implementation guide, do not send.

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Situational

4-4

127

Reference Identification

X 1

1/80

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the other UMO denied the request for more than two reasons. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other UMO Denial Reason

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Situational

4-5

128

Reference Identification Qualifier

X 1

2/3

Code qualifying the Reference Identification

COMPOSITE SYNTAX: P0506

SITUATIONAL RULE: Required when the other UMO denied the request for more than three reasons. If not required by this implementation guide, do not send.

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Situational

4-6

127

Reference Identification

X 1

1/80

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

COMPOSITE SYNTAX: P0506

SITUATIONAL RULE: Required when the other UMO denied the request for more than three reasons. If not required by this implementation guide, do not send.

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

DTP*598 - OTHER UMO DENIAL 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 2010EC - PATIENT EVENT OTHER UMO NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱598✱D8✱20110930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

598

Rejected

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Other UMO Denial Date

HL - SERVICE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when specific services are associated with this patient event. If not required by this implementation guide, do not send.

TR3 Example:

HL✱6✱5✱SS✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Services

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

TRN*1 - SERVICE TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This enables the requester to
• uniquely identify this service line request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional service information related to this service line request.
If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.

TR3 Example:

TRN✱1✱111099✱9012345678✱RADIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

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: Service 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.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: TRN04 identifies a further subdivision within the organization.

INDUSTRY NAME: Trace Assigning Entity Additional 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.

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Health Services Review

Required if requesting a review of services related to an episode of care.

Specialty Care Review

Required if requesting a referral to a specialty provider.

Situational

1322

Certification Type Code

O 1

Code indicating the type of certification

SITUATIONAL RULE: Required when different from the UM02 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use this value to identify appeals of review decisions where the service required was emergency or urgent.

Appeal - Standard

Use this value to identify appeals of review decisions where the service required was not emergency or urgent.

Cancel

Extension

Use this when requesting additional service units and/or the duration of time for a prior approved service.

Initial

Reconsideration

Renewal

Revised

Use if the requester is changing the specifics of a previously submitted request for which services have not been rendered.

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEMANTIC: UM03 is the Service Type (Code Source 958).

SITUATIONAL RULE: Required when different from the UM03 value at the Patient Event level (Loop 2000E) or when SV1, SV2, or SV3 is not valued in this Service loop. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.Values at the Service Level override the values entered at the Patient Event Level for this service.

INDUSTRY NAME: Service Type Code

Situational

C023

Health Care Service Location Information

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
C023-02 qualifies C023-01.

SITUATIONAL RULE: Required when different from the UM04 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

For this service, values at the Service Level override values at the Patient Event Level.

Required

4-1

1331

Facility Code Value

M 1

1/3

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-02.

Required

4-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

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

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

REF*BB - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.

TR3 Example:

REF✱BB✱A123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Authorization Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - PREVIOUS REVIEW ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

This is the administrative number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.

TR3 Example:

REF✱NT✱123Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Administrative Reference 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱D8✱20111030~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Service Date

SV1 - PROFESSIONAL SERVICE

X12 Name:

Professional Service

X12 Purpose:

To specify the service line item detail for a health care professional

X12 Syntax:

P0304
If either SV103 or SV104 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting a specific Professional Service. If not required by this implementation guide, do not send.

TR3 Example:

SV1✱HC:99211:25✱12.25✱UN✱1✱✱✱1:2:3✱✱✱✱N~

SV1

✱

C003

✱

✱

✱

✱

✱

✱

Diagnosis
Code Pointr

✱

✱

✱

✱

✱

✱

✱

✱

✱

Healthcare
Short Code

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

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

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Advanced Billing Concepts (ABC) 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 Complimentary, Alternative, or Holistic Procedure 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 service reviews which are not covered under HIPAA.

CODE SOURCE: 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the first procedure code modifier.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the second procedure code modifier.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the third procedure code modifier.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the fourth procedure code modifier.

Situational

1-7

352

Description

O 1

1/80

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

SITUATIONAL RULE: Required when the provider needs to convey additional clarification to miscellaneous, unspecified, or non descriptive procedures or modifiers. If not required by this implementation guide, may be provider at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Procedure Code Description

Situational

1-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when the requester cannot determine the intensity or complexity of the service to be performed and therefore requires authorization for a range of procedures. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code

Use SV101-02 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

Situational

1-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the fifth procedure code modifier.

Situational

1-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the sixth procedure code modifier.

Situational

1-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the seventh procedure code modifier.

Situational

1-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the eighth procedure code modifier.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV102 is the submitted service line item amount.

SITUATIONAL RULE: Required when the procedure charge amount is necessary to approve a monetary limitation for the health care services requests. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when service units were not provided in the HSD segment and a specific number of services are being requested for this procedure. If not required by this implementation guide, do not send.

CODE

DEFINITION

International Unit

International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Minutes

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Service Unit Count

Not Used

1331

Facility Code Value

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

Situational

1328

Diagnosis Code Pointer

O 12

1/2

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

SEMANTIC: The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.

SITUATIONAL RULE: Required when this procedure relates to a specific diagnosis reported in the Loop 2000E HI - Patient Diagnosis segment to point to the specific diagnosis. If not required by this implementation guide, do not send.

This element is a repeating data element that may be repeated up to 12 times. The first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line.

Acceptable values are 1 through 12, and correspond to the HI01 through HI12 element number that holds the diagnosis values in the Event Loop (2000E).

If no diagnosis pointer is provided, then this procedure applies to all diagnosis.

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1340

Multiple Procedure Code

O 1

1/2

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.

SITUATIONAL RULE: Required when the requested service is based on EPSDT. If not required by this implementation guide, do not send.

INDUSTRY NAME: EPSDT Indicator

CODE

DEFINITION

Yes

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1364

Review Code

O 1

1/2

Not Used

1341

National or Local Assigned Review Value

O 1

1/2

Not Used

1327

Copay Status Code

O 1

Not Used

1334

Health Care Professional Shortage Area Code

O 1

Not Used

127

Reference Identification

O 1

1/80

Not Used

116

Postal Code

O 1

3/15

Not Used

782

Monetary Amount

O 1

1/18

Situational

1337

Level of Care Code

O 1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when needed to further clarify the level of care in which a patient resides. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

Not Used

1360

Provider Agreement Code

O 1

SV2 - INSTITUTIONAL SERVICE

X12 Name:

Institutional Service

X12 Purpose:

To specify the service line item detail for a health care institution

X12 Syntax:

R0102
At least one of SV201 or SV202 is required.
P0405
If either SV204 or SV205 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

TR3 Example:

SV2✱120✱✱1500✱DA✱5✱300~
SV2✱300✱HC:80019✱73.42✱UN✱1~

SV2

✱

✱

✱

✱

✱

✱

✱

✱

✱

1345

Nurse Home
Status Code

✱

Situational

234

Product/Service ID

X 1

1/80

Identifying number for a product or service

SEMANTIC: SV201 is the revenue code.

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required when requesting approval on a revenue code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Revenue Code

See Code Source 132: National Uniform Billing Committee (NUBC) Codes.

Situational

C003

Composite Medical Procedure Identifier

X 1

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

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when requesting approval for a specific procedure code. If not required by this implementation guide, do not send.

Required

2-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

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

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

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

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

CODE SOURCE: 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Advanced Billing Concepts (ABC) Codes

CODE SOURCE: 843: Advanced Billing Concepts (ABC) Codes

Required

2-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

2-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this data element for the first procedure code modifier.

Situational

2-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this data element for the second procedure code modifier.

Situational

2-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this data element for the third procedure code modifier.

Situational

2-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this data element for the fourth procedure code modifier.

Situational

2-7

352

Description

O 1

1/80

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

INDUSTRY NAME: Procedure Code Description

Situational

2-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Use SV202-02 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Situational

2-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the fifth procedure code modifier.

Situational

2-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the sixth procedure code modifier.

Situational

2-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the seventh procedure code modifier.

Situational

2-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

Use this modifier for the eighth procedure code modifier.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV203 is the submitted service line item amount.

INDUSTRY NAME: Service Line Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

CODE

DEFINITION

Days

International Unit

Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g. blood factors).

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

INDUSTRY NAME: Service Unit Count

Situational

1371

Unit Rate

O 1

1/10

The rate per unit of associate revenue for hospital accommodation

SITUATIONAL RULE: Required when SV201 is valued and accommodation rate is necessary to approve a monetary limitation for the health care services requests. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Rate

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1345

Nursing Home Residential Status Code

O 1

Code specifying the status of a nursing home resident at the time of service

SITUATIONAL RULE: Required when the Health Care Services Review Request is for Long Term Care. If not required by this implementation guide, do not send.

CODE

DEFINITION

Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)

Newly Admitted

Newly Eligible

No Longer Eligible

Still a Resident

Temporary Absence - Hospital

Temporary Absence - Other

Transferred to Intermediate Care Facility - Level II (ICF II)

Other

Situational

1337

Level of Care Code

O 1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when needed to further clarify the level of care being requested for admission to a nursing facility, or when the request is for non-nursing facility and the level of care in which the patient resides is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.

TR3 Example:

SV3✱AD:D2150✱80~

SV3

✱

C003

✱

✱

✱

Oral Cavity
Designat.

✱

1358

Prosthesis/
Inlay Code

✱

✱

✱

✱

✱

✱

1328

Diagnosis
Code Pointr

O 12

1/2

Required

C003

Composite Medical Procedure Identifier

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CDT = Current Dental Terminology

CODE SOURCE: 135: American Dental Association

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
Use this data element for the first procedure code modifier.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
Use this data element for the second procedure code modifier.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
Use this data element for the third procedure code modifier.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
Use this data element for the fourth procedure code modifier.

Situational

1-7

352

Description

O 1

1/80

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

SITUATIONAL RULE: Required when the service request is for a "Not Otherwise Classified" (NOC) or "By Report" procedure code or to report the following information on this service line: Date of Initial Impression, Date of Initial Preparation Crown, Initial Preparation Crown Tooth Number, or Initial Endodontic Treatment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Situational

1-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Use SV301-02 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Situational

1-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

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

Use this modifier for the fifth procedure code modifier.

Situational

1-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

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

Use this modifier for the sixth procedure code modifier.

Situational

1-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

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

Use this modifier for the seventh procedure code modifier.

Situational

1-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when additional clarification to the associated procedure code for which authorization is being requested. If not required by this implementation guide, do not send.

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

Use this modifier for the eighth procedure code modifier.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

SITUATIONAL RULE: Required when the usual and customary cost is necessary to approve a monetary limitation for the health care services requests. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

1331

Facility Code Value

O 1

1/3

Situational

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when necessary to report areas of the mouth that are being treated. If not required by this implementation guide, do not send.

Required

4-1

1361

Oral Cavity Designation Code

M 1

1/3

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

Code source 135: American Dental Association Codes

CODE SOURCE 135: American Dental Association

Situational

4-2

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Code source 135: American Dental Association Codes

CODE SOURCE 135: American Dental Association

Situational

4-3

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Code source 135: American Dental Association Codes

CODE SOURCE 135: American Dental Association

Situational

4-4

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Code source 135: American Dental Association Codes

CODE SOURCE 135: American Dental Association

Situational

4-5

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Code source 135: American Dental Association Codes

CODE SOURCE 135: American Dental Association

Situational

1358

Prosthesis, Crown or Inlay Code

O 1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when needed to indicate the placement status of the prosthetic for this service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when the procedure reported in SV301-02 was performed more than once and it is not required to identify areas of the oral cavity or individual teeth. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Number of procedures

Situational

352

Description

O 1

1/80

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

SEMANTIC: SV307 is the reason for replacement.

SITUATIONAL RULE: Required when necessary to describe the reason for replacement. If not required by this implementation guide, do not send.

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1328

Diagnosis Code Pointer

O 12

1/2

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

SEMANTIC: The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.

TOO*JP - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

Code source 135: American Dental Association Codes

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when reporting tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a second tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a third tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a fourth tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a fifth tooth surface. If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SV3 is valued and requesting a services review for which a missing tooth, extracted tooth, tooth to be extracted, or an impacted tooth is needed to determine authorization. If not required by this implementation guide, do not send.

TR3 Example:

DN2✱5✱E✱✱✱✱JP~

DN2

✱

✱

✱

✱

✱

✱

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: DN201 is the tooth number.

INDUSTRY NAME: Tooth Number

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

1368

Tooth Status Code

O 1

1/2

Code specifying the status of the tooth

CODE

DEFINITION

To Be Extracted

Impacted

Missing

Extracted

Not Used

380

Quantity

O 1

1/15

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Required

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

DRA - DRUG AUTHORIZATION

X12 Name:

Drug Authorization

X12 Purpose:

To specify a drug for which authorization is being requested

X12 Syntax:

P0405
If either DRA04 or DRA05 is present, then the other is required.
P080910
If either DRA08, DRA09 or DRA10 are present, then the others are required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when more information is needed than what could be provided in the SV1 or SV2 for specific drug requests. If not required by this implementation guide do not send.

TR3 Notes:

If the request is for a compound drug, repeat the segment for each ingredient in the compound.

DRA

✱

✱

✱

C003

✱

✱

✱

1/264

✱

✱

✱

✱

✱

✱

✱

✱

✱

O 999

1/264

Required

352

Description

M 2

1/80

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

SEMANTIC: DRA01 is the drug name. Position of data in the repeating data element conveys no significance.

INDUSTRY NAME: Drug Name

Required

1322

Certification Type Code

M 1

Code indicating the type of certification

SEMANTIC: DRA02 is the drug therapy type.

INDUSTRY NAME: Drug Therapy Type

CODE

DEFINITION

Extension

Use this code if it is the first use of this drug or therapeutic equivalent as a supplemental therapy for treatment of this condition.

Initial

Use this code if it is the first use of this drug or its therapeutic equivalent for treatment of this condition.

Renewal

Use this code for continuation of the use of this drug or its therapeutic equivalent for treatment of this condition.

Revised

Use this code if it the first use of this drug or its therapeutic equivalent to replace a previous unsuccessful or non-optimal therapy for treatment of this condition.

Situational

C003

Composite Medical Procedure Identifier

O 2

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

SEMANTIC: DRA03 Position of data in the repeating data element conveys no significance.

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when a specific packaging of a drug is being requested or when using a representative NDC. If not required by this implementation guide, do not send.

Required

3-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Required

3-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: National Drug Code or Device Identifier of the Unique Device Identifier

Not Used

3-3

1339

Procedure Modifier

O 1

Not Used

3-4

1339

Procedure Modifier

O 1

Not Used

3-5

1339

Procedure Modifier

O 1

Not Used

3-6

1339

Procedure Modifier

O 1

Not Used

3-7

352

Description

O 1

1/80

Not Used

3-8

234

Product/Service ID

O 1

1/80

Not Used

3-9

1339

Procedure Modifier

O 1

Not Used

3-10

1339

Procedure Modifier

O 1

Not Used

3-11

1339

Procedure Modifier

O 1

Not Used

3-12

1339

Procedure Modifier

O 1

Required

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

CODE

DEFINITION

International Unit

Gram

Milligram

Milliliter

Unit

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: DRA05 is the quantity being requested.

SEGMENT SYNTAX: P0405

INDUSTRY NAME: National Drug Unit Count

Required

933

Free-form Message Text

O 1

1/264

Free-form message text

SEMANTIC: DRA06 is the Sig (The Sig is a Latin term used in the pharmacy industry that represents the instructions/directions that are printed on the drug label.)

INDUSTRY NAME: Sig

If the Sig is not known at the the time of the request, send unknown in this data element.

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: DRA07 is the self administer indicator. A "Y" value indicates that the drug can be administered by the patient. An "N" value indicates that the drug can not be administered by the patient.

SITUATIONAL RULE: Required when the drug can not be self administered by the patient. If not required by this implementation guide, do not send.

INDUSTRY NAME: Self Administered Drug Indicator

CODE

DEFINITION

Situational

1073

Yes/No Condition or Response Code

X 1

Code indicating a Yes or No condition or response

SEMANTIC: DRA08 is the end stage renal disease (ESRD) indicator. A "Y" value indicates that the patient has ESRD. An "N" value indicates that the patient does not have ESRD.

SEGMENT SYNTAX: P080910

SITUATIONAL RULE: Required when the patient has ESRD certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: ESRD Indicator

CODE

DEFINITION

Yes

Situational

374

Date/Time Qualifier

X 1

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

SEGMENT SYNTAX: P080910

SITUATIONAL RULE: Required when the patient has ESRD certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

458

Certification

Situational

373

Date

X 1

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

SEMANTIC: DRA10 is the ESRD certification date.

SEGMENT SYNTAX: P080910

SITUATIONAL RULE: Required when the patient has ESRD certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: ESRD Certification Date

Situational

933

Free-form Message Text

O 999

1/264

Free-form message text

SEMANTIC: DRA11 is for questions that are related to the authorization of the drug. Position of data in the repeating data element conveys no significance.

SITUATIONAL RULE: Required when UMO policy has defined additional information necessary for the completion of the authorization. If not required by this implementation guide, do not send.

INDUSTRY NAME: Drug Authorization Question/Answer

Use this data element to convey the UMO question and the answer.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DRA12 is the number of refills requested.

SITUATIONAL RULE: Required when refills are ordered. If not required by this implementation guide, do not send.

Situational

C060

Question and Answer

O 999

Used to supply the answers to pre-defined questions

SEMANTIC: DRA13 Position of data in the repeating data element conveys no significance.

X12 COMPOSITE SEMANTIC NOTES:

C060-01 is the question number from a pre-defined questionnaire.
C060-02 is the answer to the pre-defined question. A "Y" value indicates the answer to the question is yes. A "N" value indicates the answer to the question is no.

SITUATIONAL RULE: Required when the UMO has a pre-defined set of a yes/no answer questions that must be answered. If not required by this implementation guide, do not send.

Required

13-1

350

Assigned Identification

M 1

1/20

Alphanumeric characters assigned for differentiation within a transaction set

INDUSTRY NAME: Pre-Defined Question Indicator

Required

13-2

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Pre-Defined Question Response

CODE

DEFINITION

Unknown

Not Applicable

Yes

Required

1330

Dosage Form Code

O 1

Code indicating the form in which the drug is dispensed

CODE

DEFINITION

Tablet

Capsule

Lozenge or Troche

Internal Powder

Injectable Lyophilized Powder

Elixir

Suspension

Syrup

Solution

Emulsion

Liquid

Rectal Cream or Ointment

Rectal Suppository

Vaginal Suppository

Vaginal Cream

Urethral Suppository

Enema

Vaginal Ointment

External Ointment

External Cream

External Powder

Not Used

933

Free-form Message Text

O 999

1/264

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

HSD✱VS✱1✱DA✱1✱7✱10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days".)
HSD✱VS✱1✱DA✱✱✱✱W~ (This indicates "1 visit per day whenever necessary".)

HSD

✱

✱

✱

✱

✱

Time Period
Qualifier

✱

✱

Ship/Del or
Calend Code

✱

Situational

673

Quantity Qualifier

X 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when needed to indicate the type of service count quantified in HSD02. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD01 is valued to indicate the service quantity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Service Quantity
If this is a request for an extension to an existing certification (UM02 = 4), then HSD02 represents the number of visits by which the certification is extended. If this is a request to revise an existing certification (UM02 = S), then HSD02 represents the new total.

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SITUATIONAL RULE: Required when needed to indicate the timeframe in which the quantity of services in HSD02 will be rendered. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Months

Week

Situational

1167

Sample Selection Modulus

O 1

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

SITUATIONAL RULE: Required when needed to indicate sampling frequency for this service. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

X 1

1/2

Code defining periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to indicate the time period for which the services will be continued. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Episode

Visit

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to indicate the number of time periods in HSD05 that are requested. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when the service must be rendered within a specific calendar delivery pattern. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Sunday, Monday, Thursday, Friday, Saturday

Tuesday through Saturday

Sunday, Wednesday, Thursday, Friday, Saturday

Monday, Wednesday, Thursday, Friday, Saturday

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

1/3 Mon., 1/3 Wed., 1/3 Fri.

Whenever Necessary

1/2 By Wed., Bal. By Fri.

None (Also Used to Cancel or Override a Previous Pattern)

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code which specifies the time for routine shipments or deliveries

SITUATIONAL RULE: Required when needed to indicate the time delivery pattern for the services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

None (Also Used to Cancel or Override a Previous Pattern)

PWK - ADDITIONAL SERVICE INFORMATION

X12 Name:

Paperwork

X12 Purpose:

To identify the type or transmission or both of paperwork or supporting information

X12 Syntax:

P0506
If either PWK05 or PWK06 is present, then the other is required.
P1011
If either PWK10 or PWK11 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.
This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

Refer to Section 1.11.5.1 for more information on using this PWK segment.

TR3 Example:

PWK✱OB✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

Code indicating the title or contents of a document, report or supporting item

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Expected outcomes of rehabilitative services.

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use for medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Information to support necessity of ambulance trip.

Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

Purchase Order Attachment

Use for purchase of medical or dental equipment.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Quality Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Death Notification

Photographs

Required

756

Report Transmission Code

O 1

1/2

Code defining timing, transmission method or format by which reports are to be sent

CODE

DEFINITION

Available on Request at Provider Site

Use when the paperwork is not being sent with the request at this time. It will be made available to the UMO (or approving entity) on request.

By Mail

Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

E-Mail

File Transfer

By Fax

Voice

Use this for voicemail or phone communication.

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Situational

Identification Code Qualifier

X 1

1/2

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

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a code number.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM, FT or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Attachment Control Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM, FT or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Attachment Control Number

The requester can use it when PWK02 equals "AA" if the requester wants to send a document control number for an attachment remaining at the Provider's office.

Situational

352

Description

O 1

1/80

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

COMMENT: PWK07 may be used to indicate special information to be shown on the specified report.

SITUATIONAL RULE: Required when needed to add any additional information about the attachment described in this segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Description

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to transmit a message to the UMO about the service. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

MSG✱This is a free-form text message~

MSG

✱

933

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

X 1

Not Used

1470

Number

O 1

1/9

NM1 - SERVICE PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when requesting a service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
If this loop is not valued, loop 2010EA is required to identify the service provider, specialist, or speciality entity to provide services.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Physician, Clinic or Group Practice

Operating Physician

Other Physician

Service Location

Assistant Surgeon

Ordering Physician

Supervising Physician

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Service Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Middle Name or Initial

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when military title or rank further identifies the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Service Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - SERVICE PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM1 of this loop is used and the NM109 is not valued and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

The social security number must not be used for any Federally administered programs such as Medicare or CHAMPUS.

Carrier Assigned Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Provider Supplemental 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.

Situational

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

See Code Source 22: State and Outlying Areas of the US.

Not Used

C040

Reference Identifier

O 1

N3 - SERVICE PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the provider has multiple locations and a specific location for this patient event needs to be identified. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Service Provider Address Line

Use this element for the first line of the provider's address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Address Line

N4 - SERVICE PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the provider has multiple locations and a specific location for this patient event needs to be identified. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Service Provider City Name

Situational

156

State or Province Code

X 1

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: Service Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Service Provider Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Service Provider Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Service Provider Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - SERVICE PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the Information Source needs to indicate a particular contact and the name of the entity to contact is not already defined or is different than the name within the prior name segment (NM1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued, or to transmit a contact communication number. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued, or to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - SERVICE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop: