837 Post-adjudicated Claims Data Reporting: Dental (008020X300)

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

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

CODE

DEFINITION

Health Care Claim (837)

Required

142

Application Sender's Code

M 1

2/15

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

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

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

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

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

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

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

SEMANTIC: GS05 is the group time.

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

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

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

Required

455

Responsible Agency Code

M 1

1/2

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

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

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

INDUSTRY NAME: Version, Release, or Industry Identifier Code

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

CODE SOURCE 881: Version / Release / Industry Identifier Code

CODE

DEFINITION

008020X300

Post-adjudicated Claims Data Reporting: Dental

ST*837 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱837✱987654✱008010X300~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code identifying a Transaction Set

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

CODE

DEFINITION

837

Health Care Claim

Required

329

Transaction Set Control Number

M 1

4/9

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

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

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

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

INDUSTRY NAME: Implementation Guide Version Name

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

CODE

DEFINITION

008020X300

Post-adjudicated Claims Data Reporting: Dental

BHT*0019 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0019✱00✱44445✱20120213✱0345✱RP~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 1000A - SUBMITTER NAME

Required

1005

Hierarchical Structure Code

M 1

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

CODE

DEFINITION

0019

Information Source, Subscriber, Dependent

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.

CODE

DEFINITION

Original

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

Reissue

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

Required

127

Reference Identification

O 1

1/80

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

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

INDUSTRY NAME: Originator Application Transaction Identifier

The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

INDUSTRY NAME: Claim or Encounter Identifier

CODE

DEFINITION

Reporting

NM1*41 - SUBMITTER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

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

NM1

✱

✱

Loop 1000A - SUBMITTER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Submitter Last or Organization Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Submitter Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*IC - SUBMITTER EDI CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

Loop 1000B - RECEIVER NAME

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

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

INDUSTRY NAME: Submitter Contact Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*40 - RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Receiver

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Receiver Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Receiver Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

HL - BILLING PROVIDER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

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

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

PRV*BI - BILLING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

PRV✱BI✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Billing

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying 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

CUR*85 - FOREIGN CURRENCY INFORMATION

X12 Name:

Currency

X12 Purpose:

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

X12 Syntax:

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

X12 Comments:

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

Loop:

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

CUR✱85✱CAD~

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

100

Currency Code

M 1

Code specifying the Standard ISO code for country in whose currency the charges are specified

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

280

Exchange Rate

O 1

4/10

Not Used

Entity Identifier Code

O 1

2/3

Not Used

100

Currency Code

O 1

Not Used

669

Currency Market/Exchange Code

O 1

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

337

Time

X 1

4/8

NM1*85 - BILLING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider address, insurer, primary administrator, contract holder, pay-to plan, pay-to factoring agent, or claimant.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Billing Provider Last or Organizational Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Billing Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Billing Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Billing Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Billing Provider Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - BILLING PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Billing Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Billing Provider Address Line

N4 - BILLING PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Billing Provider City Name

Situational

156

State or Province Code

X 1

Code specifying the 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: Billing Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

COMMENT: N403 contains the postal code in an unstructured format. N408 contains the postal code in a structured format. When a postal code data field is used, the parties shall agree as to which data element (N403 or N408) shall be used in the transaction set.

SEGMENT SYNTAX: E0308

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

INDUSTRY NAME: Billing Provider Postal Zone or ZIP Code

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

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

REF - BILLING PROVIDER TAX IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

REF✱EI✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

Social Security Number

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Tax Identification Number

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*0B - BILLING PROVIDER LICENSE INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱0B✱654321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License 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: Billing Provider License Information

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 - BILLING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Commercial Number

Location 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: Billing Provider Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

HL - SUBSCRIBER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

HL✱2✱1✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

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

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

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 1

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

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

The claim (Loop ID-2300) can be used when HL04 has no subordinate levels (HL04 = 0) or when HL04 has subordinate levels indicated (HL04 = 1).
In the first case (HL04 = 0), the subscriber is the patient and there are no dependent claims.
The second case (HL04 = 1) happens when claims for one or more dependents of the subscriber are being sent under the same billing provider HL (for example, a spouse and son are both treated by the same provider). In that case, the subscriber HL04 = 1 because there is at least one dependent to this subscriber. The dependent HL (spouse) would then be sent followed by the Loop ID-2300 for the spouse. The next HL would be the dependent HL for the son followed by the Loop ID-2300 for the son.
In order to send claims for the subscriber and one or more dependents, the Subscriber HL, with Relationship Code SBR02=18 (Self), would be followed by the Subscriber's Loop ID-2300 for the Subscriber's claims. Then the Subscriber HL would be repeated, followed by one or more Patient HL loops for the dependents, with the proper Relationship Code in PAT01, each followed by their respective Loop ID-2300 for each dependent's claims.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SBR*N - SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

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

Loop:

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SBR✱N✱18~

SBR

✱

✱

✱

✱

✱

✱

✱

✱

584

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

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

CODE

DEFINITION

Unconfirmed

Situational

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

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

CODE

DEFINITION

Self

Not Used

127

Reference Identification

O 1

1/80

Not Used

Name

O 1

1/60

Not Used

1336

Insurance Type Code

O 1

1/3

Not Used

1143

Coordination of Benefits Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

Not Used

1732

Source of Payment Typology Code

O 1

2/6

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Subscriber Name Suffix

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

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

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

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Subscriber Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Subscriber Address Line

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Subscriber City Name

Situational

156

State or Province Code

X 1

Code specifying the 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

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Subscriber Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Not Provided

Use when the gender cannot be sent due to reporting restrictions.

Female

Nonbinary

Male

Self-reported as Transgender

Unknown

Use when the gender is unknown.

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 25

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

REF*SY - SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when:

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

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

TR3 Notes:

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

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security Number

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

Required

127

Reference Identification

X 1

1/80

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

REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

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: Property Casualty Claim Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - SUBSCRIBER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2010BB - DATA RECEIVER

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement
AND
The data is available in the payer's system.
If not required by this implementation guide, then do not send.

TR3 Example:

REF✱1W✱ABC123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

CHAMPUS Identification Number

Use to report Tricare identifier

Member Identification Number

ABB

Personal ID Number

Health Insurance Claim (HIC) Number

Medicaid Recipient Identification 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 Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*ZD - DATA RECEIVER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱ZD✱2✱Medicaid Agency~

NM1

✱

✱

Loop 2000C - PATIENT HIERARCHICAL LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Party to Receive Reports

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Data Receiver Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

HL - PATIENT HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

HL✱3✱2✱23✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

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

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

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

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

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

PAT - PATIENT INFORMATION

X12 Name:

Patient Information

X12 Purpose:

To supply patient information

X12 Syntax:

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

Loop:

Loop 2000C - PATIENT HIERARCHICAL LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

PAT✱01~

PAT

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

Specifies the patient's relationship to the person insured.

CODE

DEFINITION

Spouse

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Not Used

1384

Patient Location Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

Weight

X 1

1/10

Not Used

1073

Yes/No Condition or Response Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

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

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Address Line

N4 - PATIENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Patient City Name

Situational

156

State or Province Code

X 1

Code specifying the 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 State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Patient Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DMG*D8 - PATIENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Patient Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Patient Gender Code

CODE

DEFINITION

Not Provided

Use when the gender cannot be sent due to reporting restrictions.

Female

Nonbinary

Male

Self-reported as Transgender

Unknown

Use when the gender is unknown.

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 25

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

REF*SY - PATIENT SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

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

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security Number

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Social Security Number

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*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

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: Property Casualty Claim Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - PATIENT SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement
AND
The data is available in the payer's system.
If not required by this implementation guide, then do not send.

TR3 Example:

REF✱1W✱ABC123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

CHAMPUS Identification Number

Use to report Tricare identifier

Member Identification Number

ABB

Personal ID Number

Health Insurance Claim (HIC) Number

Medicaid Recipient Identification 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: Patient Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

CLM - CLAIM INFORMATION

X12 Name:

Health Claim

X12 Purpose:

To specify basic data about the claim

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the patient hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the patient. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent.

TR3 Example:

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

CLM

✱

1028

Claim Submt
Identifier

✱

✱

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

Patient Sig
Source Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

1383

Claim Submt
Reason Code

✱

✱

Claim Auth
Except Code

1/2

Required

1028

Claim Submitter's Identifier

M 1

1/38

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

INDUSTRY NAME: Patient Control Number

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

Required

782

Monetary Amount

O 1

1/18

Monetary amount

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

INDUSTRY NAME: Total Claim Charge Amount

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

1032

Claim Filing Indicator Code

O 1

1/2

Not Used

1343

Non-Institutional Claim Type Code

O 1

1/2

Required

C023

Health Care Service Location Information

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

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

Required

5-1

1331

Facility Code Value

M 1

1/3

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: Place of Service Code

Required

5-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Place of Service Codes for Professional or Dental Services

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

Required

5-3

1325

Claim Frequency Type Code

O 1

Code specifying the Type of Bill Frequency Code. It is the last digit of Type of Bill in the UB manual, as defined by the National Uniform Billing Committee

INDUSTRY NAME: Claim Frequency Code

This is the Claim Frequency Code as received on the most recently submitted claim from the provider.

CODE SOURCE 235: Claim Frequency Type Code

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

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

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

INDUSTRY NAME: Provider or Supplier Signature Indicator

CODE

DEFINITION

Yes

Situational

1359

Provider Accept Assignment Code

O 1

Code indicating whether the provider accepts assignment

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

INDUSTRY NAME: Assignment or Plan Participation Code

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

CODE

DEFINITION

Assigned

Not Assigned

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

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

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

INDUSTRY NAME: Benefits Assignment Certification Indicator

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

CODE

DEFINITION

Not Applicable

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

Yes

Situational

1363

Release of Information Code

O 1

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

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

CODE

DEFINITION

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

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

Not Used

1351

Patient Signature Source Code

O 1

Situational

C024

Related Causes Information

O 1

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

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

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

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

Required

11-1

1362

Related-Causes Code

M 1

2/3

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

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Situational

11-2

1362

Related-Causes Code

O 1

2/3

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

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

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Not Used

11-3

1362

Related-Causes Code

O 1

2/3

Situational

11-4

156

State or Province Code

O 1

Code specifying the Standard State/Province as defined by appropriate government agency

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

INDUSTRY NAME: Auto Accident State or Province Code

CODE SOURCE 22: States and Provinces

Situational

11-5

Country Code

O 1

2/3

Code identifying the country

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

CODE SOURCE 5: Countries, Currencies and Funds

Situational

1366

Special Program Code

O 1

2/3

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

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

INDUSTRY NAME: Special Program Indicator

CODE

DEFINITION

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

Physically Handicapped Children's Program

Special Federal Funding

Disability

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1029

Claim Status Code

O 1

1/2

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1383

Claim Submission Reason Code

O 1

Situational

1514

Delay Reason Code

O 1

1/2

Code indicating the reason why a request was delayed

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

CODE

DEFINITION

Proof of Eligibility Unknown or Unavailable

Litigation

Authorization Delays

Delay in Certifying Provider

Delay in Supplying Billing Forms

Delay in Delivery of Custom-made Appliances

Third Party Processing Delay

Delay in Eligibility Determination

Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

Administration Delay in the Prior Approval Process

Other

Natural Disaster

Not Used

1774

Claim Authorization Exception Code

O 1

1/2

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱439✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Accident Date

DTP*452 - APPLIANCE PLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱452✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

452

Appliance Placement

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Orthodontic Banding Date

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

DTP✱472✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

DN1 - ORTHODONTIC TOTAL MONTHS OF TREATMENT

X12 Name:

Orthodontic Information

X12 Purpose:

To supply orthodontic information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DN1✱36✱27~
DN1✱✱✱✱Y~

DN1

✱

✱

✱

✱

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DN101 is the estimated number of treatment months.

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

INDUSTRY NAME: Orthodontic Treatment Months Count

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DN102 is the number of treatment months remaining.

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

INDUSTRY NAME: Orthodontic Treatment Months Remaining Count

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

352

Description

O 1

1/80

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

SEMANTIC: DN104 is the appliance description.

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

INDUSTRY NAME: Orthodontic Treatment Indicator

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

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DN2✱8✱E✱✱✱✱JP~

DN2

✱

✱

✱

✱

✱

✱

Required

127

Reference Identification

M 1

1/80

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

Missing

Not Used

380

Quantity

O 1

1/15

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Required

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is necessary to satisfy contract requirements.

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

TR3 Example:

CN1✱02✱550~

CN1

✱

✱

✱

✱

✱

✱

Required

1166

Contract Type Code

M 1

Code identifying a contract type

CODE

DEFINITION

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

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

INDUSTRY NAME: Contract Amount

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

332

Percent, Decimal Format

O 1

1/6

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

SEMANTIC: CN103 is the allowance or charge percent.

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

INDUSTRY NAME: Contract Percentage

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: CN104 is the contract code.

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

INDUSTRY NAME: Contract Code

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

338

Terms Discount Percent

O 1

1/6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

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

INDUSTRY NAME: Terms Discount Percentage

Situational

799

Version Identifier

O 1

1/30

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

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

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

INDUSTRY NAME: Contract Version Identifier

AMT*F5 - PATIENT AMOUNT PAID

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

AMT✱F5✱152.45~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Patient Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Patient Amount Paid

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

478

Credit/Debit Flag Code

O 1

REF*9F - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Referral 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: Referral 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*G1 - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

REF✱G1✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Prior 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: Prior 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*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

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

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

Number assigned by clearinghouse, van, etc.

CODE

DEFINITION

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: Claim Identifier for Transmission Intermediaries

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

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

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

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

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

TR3 Example:

K3✱STATE DATA REQUIREMENT~

✱

449

Fixed Form
Information

✱

✱

Composite
Unit of Mea

Required

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

HI - HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

HI✱BK:52403✱BF:52404~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2310A - REFERRING PROVIDER NAME

Required

C022

Health Care Code Information

M 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
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.
C022-10 is the attribute of the code in C022-02 from the same code list.

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.

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

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

ABK

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

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

Systemized Nomenclature of Dentistry (SNODENT)

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

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

CODE SOURCE: 135: American Dental Association

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Principal Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1-4

1251

Date Time Period

X 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1271

Industry Code

X 1

1/30

Not Used

1-10

1271

Industry Code

O 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, C022-08 and C022-10.
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.
C022-10 is the attribute of the code in C022-02 from the same code list.

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

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

ABF

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

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

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE: 135: American Dental Association

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

2-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

2-4

1251

Date Time Period

X 1

1/35

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

X 1

1/30

Not Used

2-9

1271

Industry Code

X 1

1/30

Not Used

2-10

1271

Industry Code

O 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, C022-08 and C022-10.
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.
C022-10 is the attribute of the code in C022-02 from the same code list.

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

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

ABF

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

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

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE: 135: American Dental Association

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

3-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

3-4

1251

Date Time Period

X 1

1/35

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

X 1

1/30

Not Used

3-9

1271

Industry Code

X 1

1/30

Not Used

3-10

1271

Industry Code

O 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, C022-08 and C022-10.
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.
C022-10 is the attribute of the code in C022-02 from the same code list.

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

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

ABF

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

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

Systemized Nomenclature of Dentistry (SNODENT)

CODE SOURCE: 135: American Dental Association

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

4-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

4-4

1251

Date Time Period

X 1

1/35

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

X 1

1/30

Not Used

4-9

1271

Industry Code

X 1

1/30

Not Used

4-10

1271

Industry Code

O 1

1/30

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

NM1 - REFERRING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2310 contains information about the claim level providers including, but not limited to: rendering, referring, and attending.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

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

NM1

✱

✱

Loop 2310A - REFERRING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

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

Primary Care Provider

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

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Referring Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Referring Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Referring Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Referring Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Referring Provider Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PRV*RF - REFERRING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

PRV✱RF✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying 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

REF - REFERRING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310A - REFERRING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Referring Provider Secondary Identifier

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

NM1*82 - RENDERING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2310 contains information about the claim level providers including, but not limited to: rendering, referring, and attending.

Loop:

Loop 2310B - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

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

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~

NM1

✱

✱

Loop 2310B - RENDERING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Rendering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Rendering Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Rendering Provider Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PRV*PE - RENDERING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying 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

REF - RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310B - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Rendering Provider Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*77 - SERVICE FACILITY LOCATION NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2310 contains information about the claim level providers including, but not limited to: rendering, referring, and attending.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Service Location

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Laboratory or Facility Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Laboratory or Facility Primary Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - SERVICE FACILITY LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Laboratory or Facility Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Laboratory or Facility Address Line

N4 - SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Laboratory or Facility City Name

Situational

156

State or Province Code

X 1

Code specifying the 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: Laboratory or Facility State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Laboratory or Facility Postal Zone or ZIP Code

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

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

REF - SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310D - ASSISTANT SURGEON NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Laboratory or Facility Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DD - ASSISTANT SURGEON NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2310 contains information about the claim level providers including, but not limited to: rendering, referring, and attending.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

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

NM1

✱

✱

Loop 2310D - ASSISTANT SURGEON NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Assistant Surgeon

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Assistant Surgeon Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Assistant Surgeon First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Assistant Surgeon Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Assistant Surgeon Name Suffix

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

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Assistant Surgeon Primary Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PRV*AS - ASSISTANT SURGEON SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

PRV✱AS✱PXC✱1223S0112X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying 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

REF - ASSISTANT SURGEON SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2310D - ASSISTANT SURGEON NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱0B✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Assistant Surgeon Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DQ - SUPERVISING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2310 contains information about the claim level providers including, but not limited to: rendering, referring, and attending.

Loop:

Loop 2310E - SUPERVISING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

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

NM1

✱

✱

Loop 2310E - SUPERVISING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Use this code for the supervising dentist or physician.

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Supervising Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Supervising Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Supervising Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Supervising Provider Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Supervising Provider Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

SBR*R - SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

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

X12 Set Notes:

NOTE: Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

All information contained in Loop ID-2320A applies only to the submitting payer. It is specific only to that payer. If information for an additional payer is necessary, use Loop ID-2320B with its respective 2330 Loops.

Loop ID-2320A and its subordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by the submitting payer.

TR3 Example:

SBR✱P✱18✱G00786✱✱✱6✱✱✱CI✱512~

SBR

✱

✱

✱

✱

✱

✱

✱

✱

584

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

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

INDUSTRY NAME: Payer Responsibility Sequence Code

CODE

DEFINITION

Non-specified

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

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

CODE

DEFINITION

Spouse

Self

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: SBR03 is policy or group number.

SITUATIONAL RULE: Required when the submitting payer has assigned a group identifier to this benefit plan. If not required by this implementation guide, do not send.

INDUSTRY NAME: Insured Group or Policy 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.
This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA.

Situational

Name

O 1

1/60

Free-form name

SEMANTIC: SBR04 is plan name.

SITUATIONAL RULE: Required when the submitting payer has assigned a group name to this benefit plan and SBR03 is not used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Group, Insurance Policy or Plan Network Name

Not Used

1336

Insurance Type Code

O 1

1/3

Required

1143

Coordination of Benefits Code

O 1

Code identifying whether there is a coordination of benefits

CODE

DEFINITION

No Coordination of Benefits

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Required

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

CODE

DEFINITION

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Blue Cross/Blue Shield

Champus

Use when submitting Champus or Tricare claims.

Commercial Insurance Co.

Disability

Federal Employees Program

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Medicare Part D

Medicare Advantage Plan

Self-administered Group

Title V

Unknown

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Use when no other code value applies.

Required

1732

Source of Payment Typology Code

O 1

2/6

Code identifying payer types in the most granular way

INDUSTRY NAME: Source of Payment

The Source of Payment Typology provides a standard for reporting the payer and the payer's product. The Source of Payment Typology is determined by the organization that provides the payment and must be reported using the most granular level of detail defining the payer and the payer's product.

CODE SOURCE 944: Source of Payment Typology

CAS - CLAIM LEVEL ADJUSTMENTS

X12 Name:

Claims Adjustment

X12 Purpose:

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

X12 Syntax:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Codes and amounts must be reported the same as if creating the 835 to send to the provider.

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

1785

Claim Adjst
Group Code

1/10

✱

1034

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1785

Claim Adjustment Group Code

M 1

1/10

Code identifying the general category of payment adjustment.

CODE SOURCE 974: Claim Adjustment Group Codes

Required

1034

Claim Adjustment Reason Code

M 15

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

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

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

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

INDUSTRY NAME: Adjustment Quantity

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

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

AMT✱D✱411~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Payor Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Payer Paid 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.
It is acceptable to show "0" as the amount paid.

Not Used

478

Credit/Debit Flag Code

O 1

OI - PAYER CLAIM ADJUSTMENT/VOID INDICATOR

X12 Name:

Other Health Insurance Information

X12 Purpose:

To specify information associated with other health insurance coverage

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

OI09 and OI11 cannot both be 'Y'. Only OI09 or OI11 can be 'Y', or both can be 'N'.

TR3 Example:

OI✱✱✱✱✱✱✱✱✱Y✱✱N~

✱

✱

Claim Submt
Reason Code

✱

✱

1351

Patient Sig
Source Code

✱

✱

✱

✱

✱

✱

✱

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

Not Used

1383

Claim Submission Reason Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1351

Patient Signature Source Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1359

Provider Accept Assignment Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: OI09 is payer to data reporting adjustment code. A "Y" value indicates a payer-to-data reporting entity claim is an adjustment. An "N" value indicates payer-to-data reporting entity claim is not an adjustment.

INDUSTRY NAME: Payer Claim Adjustment Indicator

CODE

DEFINITION

Yes

Not Used

1073

Yes/No Condition or Response Code

O 1

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: OI11 is payer to data reporting void code. A "Y" value indicates a payer-to-data reporting entity claim is a void. An "N" value indicates payer-to-data reporting entity claim is not a void.

INDUSTRY NAME: Payer Claim Void Indicator

CODE

DEFINITION

Yes

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Outpatient Adjudication

X12 Purpose:

To provide claim level data related to the adjudication of outpatient claims

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

TR3 Example:

MOA✱✱✱A4~

MOA

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

954

Percentage as Decimal

O 1

1/10

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

SEMANTIC: MOA01 is the reimbursement rate.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Reimbursement Rate

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA02 is the claim Healthcare Common Procedure Coding System (HCPCS) payable amount.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: HCPCS Payable 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

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: MOA03 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark 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.

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: MOA04 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark 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.

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: MOA05 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark 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.

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: MOA06 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark 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.

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: MOA07 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark 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.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA08 is the End Stage Renal Disease (ESRD) payment amount.

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: End Stage Renal Disease Payment 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

782

Monetary Amount

O 1

1/18

Monetary amount

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

SITUATIONAL RULE: Required when the submitting payer would be required to provide this information when generating an 835 for the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Non-Payable Professional Component Billed 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.

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱PR✱2✱ABC Payer✱✱✱✱✱PI✱12345~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Payer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer 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

1/80

DTP*573 - CLAIM CHECK OR REMITTANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱573✱D8✱20200601~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

573

Date Claim Paid

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Adjudication or Payment Date

REF - OTHER PAYER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement
AND
The data is available in the payer's system.
If not required by this implementation guide, then do not send.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Payer Identification Number

Employer's Identification Number

Claim Office Number

National Association of Insurance Commissioners (NAIC) Code

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F8 - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱F8✱R555588~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Original Reference Number

This is the submitting payer's internal Claim Control 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: Payer Claim Control Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BP - PAYER PREVIOUS CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the submitting payer has adjusted this claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BP✱R5555589~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Adjustment Control 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: Payer Previous Claim Control Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*PHC - METHOD OF CLAIM/ENCOUNTER SUBMISSION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱PHC✱E~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

PHC

Process Handling Code

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: Method of Claim Submission

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
The information reported in this element must reflect the method in which this claim was received by the submitting payer. Codes reported in REF02 must be one of the following:
C - Crossover
Use when the claim was automatically crossed over from one payer to another.
D - Direct Data Entry
Use when the claim was manually entered through a DDE terminal or web portal.
E - Electronic Submission
Use when the claim was electronically submitted through a transmission or via upload by web portal.
O - Other
Use when the claim was submitted in a different format other than DDE, web portal, electronic or paper.
P - Paper
Use when the claim was submitted via paper, including paper claims put through an OCR process by the payer.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*CE - IN PLAN NETWORK INDICATOR

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱CE✱✱YES~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Class of Contract Code

Not Used

127

Reference Identification

X 1

1/80

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: In Plan Network Indicator

The allowed values for this data element are 'YES' and 'NO'.

Not Used

C040

Reference Identifier

O 1

SBR - OTHER PAYER SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

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

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the submitting payer has payer and adjudication information from prior payers. If not required by this implementation guide, do not send.

TR3 Notes:

All information contained in Loop ID-2320B applies only to the payer identified in Loop ID-2330BA. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320B with its respective 2330 Loops.
Loop ID-2320B and its subordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by the payers who have previously adjudicated the claim.
This loop is not to be provided for payers who have not adjudicated the claim. For example, the provider submitted claim includes payer information that is subsequent to the payer submitting this transaction.
The payer and adjudication information related to this iteration of Loop ID-2320B and 2430 represents processing performed prior to the adjudication of this claim by the submitting payer and the Other Payer information is to be reported as received from the provider.

TR3 Example:

SBR✱P✱18✱G00786✱✱✱1✱✱✱CI✱512~

SBR

✱

✱

✱

✱

✱

✱

✱

✱

584

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Responsibility Sequence Code) of Loop ID-2430 (Line Adjudication Information) must match this value when used.

CODE

DEFINITION

Payer Responsibility Four

Payer Responsibility Five

Payer Responsibility Six

Payer Responsibility Seven

Payer Responsibility Eight

Payer Responsibility Nine

Payer Responsibility Ten

Payer Responsibility Eleven

Primary

Secondary

Tertiary

Unknown

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

CODE

DEFINITION

Spouse

Self

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: SBR03 is policy or group number.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Insured Group or Policy Number

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

Name

O 1

1/60

Free-form name

SEMANTIC: SBR04 is plan name.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Group, Insurance Policy or Plan Network Name

Not Used

1336

Insurance Type Code

O 1

1/3

Required

1143

Coordination of Benefits Code

O 1

Code identifying whether there is a coordination of benefits

CODE

DEFINITION

Coordination of Benefits

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Required

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

CODE

DEFINITION

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Blue Cross/Blue Shield

Champus

Use when submitting Champus or Tricare claims.

Commercial Insurance Co.

Disability

Federal Employees Program

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Medicare Part D

Medicare Advantage Plan

Self-administered Group

Title V

Unknown

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Use when no other code value applies.

Not Used

1732

Source of Payment Typology Code

O 1

2/6

CAS - CLAIM LEVEL ADJUSTMENTS

X12 Name:

Claims Adjustment

X12 Purpose:

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

X12 Syntax:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
When the CAS information for the prior payer listed in Loop ID-2330BA in this instance of Loop ID-2320B was reported on the claim, the codes and associated amounts must be reported as received.
When the prior payer in Loop ID-2330BA of this instance of Loop ID-2320B is the same as the submitting payer, and the Coordination of Benefits (COB) was performed without submission from the provider, CAS segments are to be populated as remitted to the provider on the 835.

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

1785

Claim Adjst
Group Code

1/10

✱

1034

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1785

Claim Adjustment Group Code

M 1

1/10

Code identifying the general category of payment adjustment.

CODE SOURCE 974: Claim Adjustment Group Codes

Required

1034

Claim Adjustment Reason Code

M 15

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

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

INDUSTRY NAME: Adjustment Quantity

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

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

AMT✱D✱411~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Payor Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Payer Paid Amount

It is acceptable to show "0" as the amount paid.
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

478

Credit/Debit Flag Code

O 1

AMT*EAF - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

AMT✱EAF✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

EAF

Amount Owed

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Remaining Patient Liability

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

478

Credit/Debit Flag Code

O 1

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Outpatient Adjudication

X12 Purpose:

To provide claim level data related to the adjudication of outpatient claims

Loop:

Loop 2330BA - OTHER PAYER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

TR3 Example:

MOA✱✱✱A4~

MOA

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

954

Percentage as Decimal

O 1

1/10

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

SEMANTIC: MOA01 is the reimbursement rate.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Reimbursement Rate

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA02 is the claim Healthcare Common Procedure Coding System (HCPCS) payable amount.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: HCPCS Payable Amount

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

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: MOA03 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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

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: MOA04 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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

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: MOA05 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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

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: MOA06 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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

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: MOA07 is the Remittance Advice Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA08 is the End Stage Renal Disease (ESRD) payment amount.

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: End Stage Renal Disease Payment 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

782

Monetary Amount

O 1

1/18

Monetary amount

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

SITUATIONAL RULE: Required when this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Non-Payable Professional Component Billed Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

NM1*PR - OTHER PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2330BA - OTHER PAYER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Payer Organization Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Payer Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

DTP*573 - CLAIM CHECK OR REMITTANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱573✱D8✱20200601~

DTP

✱

✱

Loop 2330BA - OTHER PAYER NAME

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

573

Date Claim Paid

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Adjudication or Payment Date

REF - OTHER PAYER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement
AND
The data is available in the payer's system.
If not required by this implementation guide, then do not send.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Payer Identification Number

Employer's Identification Number

National Association of Insurance Commissioners (NAIC) Code

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Secondary Identifier

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

NM1*IL - OTHER PAYER SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The information in this segment represents the Subscriber for the payer identified in Loop ID-2330BA.

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 identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Payer Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Other Payer Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Other Payer Subscriber Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Other Payer Subscriber Name Suffix

Required

Identification Code Qualifier

X 1

1/2

Code specifying 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

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Payer Subscriber 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

1/80

N3 - OTHER PAYER SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Payer Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Other Payer Subscriber Address Line

N4 - OTHER PAYER 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.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Other Payer Subscriber City Name

Situational

156

State or Province Code

X 1

Code specifying the 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: Other Payer Subscriber State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Other Payer 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: Other Payer 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: Other Payer Subscriber Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

REF*SY - OTHER PAYER SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when:
The social security number is allowed to be used for this purpose under applicable law or regulation.
AND
The social security number is available in the payer's system.

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

TR3 Notes:

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

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security Number

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Subscriber Social Security 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

NM1*QC - OTHER PAYER PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The information in this segment represents the Patient for the payer identified in Loop ID-2330BA.

TR3 Example:

NM1✱QC✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Payer Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Other Payer Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Other Payer Patient Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Other Payer Patient Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Other Payer Patient 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

1/80

N3 - OTHER PAYER PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Payer Patient Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Other Payer Patient Address Line

N4 - OTHER PAYER PATIENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Other Payer Patient City Name

Situational

156

State or Province Code

X 1

Code specifying the 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: Other Payer Patient State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Other Payer Patient Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Other Payer Patient 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: Other Payer Patient Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

REF*SY - OTHER PAYER PATIENT SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

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

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security Number

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

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Patient Social Security 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

LX - SERVICE LINE NUMBER

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

NOTE: Loop 2400 contains Service Line information.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SV3✱AD:D2150✱80✱✱✱✱1~

SV3

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

Oral Cavity
Designat.

✱

1358

Prosthesis/
Inlay Code

✱

✱

✱

✱

✱

✱

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

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

Situational

1-4

1339

Procedure Modifier

O 1

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

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

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

Situational

1-5

1339

Procedure Modifier

O 1

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

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

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

Situational

1-6

1339

Procedure Modifier

O 1

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

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

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

Situational

1-7

352

Description

O 1

1/80

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

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

INDUSTRY NAME: Procedure Code Description

Not Used

1-8

234

Product/Service ID

O 1

1/80

Not Used

1-9

1339

Procedure Modifier

O 1

Not Used

1-10

1339

Procedure Modifier

O 1

Not Used

1-11

1339

Procedure Modifier

O 1

Not Used

1-12

1339

Procedure Modifier

O 1

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

INDUSTRY NAME: Line Item Charge Amount

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

1331

Facility Code Value

O 1

1/3

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

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

INDUSTRY NAME: Place of Service Code

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

Situational

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

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

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

Required

4-1

1361

Oral Cavity Designation Code

M 1

1/3

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

CODE SOURCE 135: American Dental Association

Situational

4-2

1361

Oral Cavity Designation Code

O 1

1/3

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

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

CODE SOURCE 135: American Dental Association

Situational

4-3

1361

Oral Cavity Designation Code

O 1

1/3

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

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

CODE SOURCE 135: American Dental Association

Situational

4-4

1361

Oral Cavity Designation Code

O 1

1/3

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

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

CODE SOURCE 135: American Dental Association

Situational

4-5

1361

Oral Cavity Designation Code

O 1

1/3

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

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

CODE SOURCE 135: American Dental Association

Situational

1358

Prosthesis, Crown or Inlay Code

O 1

Code specifying the placement status for the dental work

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

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

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

CODE

DEFINITION

Initial Placement

Replacement

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

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

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

INDUSTRY NAME: Procedure Count

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

Not Used

352

Description

O 1

1/80

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1328

Diagnosis Code Pointer

O 12

1/2

TOO*JP - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

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

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

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

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱472✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

DTP - PRIOR PLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱441✱D8✱20120401~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

139

Estimated

Required when the exact Prior Placement Date is not known.

441

Prior Placement

Required when the exact Prior Placement Date is known.

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Prior Placement Date

DTP*452 - APPLIANCE PLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱452✱D8✱20120108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

452

Appliance Placement

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Orthodontic Banding Date

DTP*446 - REPLACEMENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱446✱D8✱20120127~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

446

Replacement

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Replacement Date

DTP*196 - TREATMENT START DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱196✱D8✱20120115~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

196

Start

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Treatment Start Date

DTP*198 - TREATMENT COMPLETION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

DTP✱198✱D8✱20120129~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

198

Completion

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Treatment Completion Date

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is necessary to satisfy contract requirements.

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

TR3 Example:

CN1✱02✱550~

CN1

✱

✱

✱

✱

✱

✱

Required

1166

Contract Type Code

M 1

Code identifying a contract type

CODE

DEFINITION

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

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

INDUSTRY NAME: Contract Amount

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

332

Percent, Decimal Format

O 1

1/6

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

SEMANTIC: CN103 is the allowance or charge percent.

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

INDUSTRY NAME: Contract Percentage

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: CN104 is the contract code.

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

INDUSTRY NAME: Contract Code

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

338

Terms Discount Percent

O 1

1/6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

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

INDUSTRY NAME: Terms Discount Percentage

Situational

799

Version Identifier

O 1

1/30

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

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

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

INDUSTRY NAME: Contract Version Identifier

REF*G1 - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G1✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Prior 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: Prior Authorization or Referral 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*9F - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Referral 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: Referral 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

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

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

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

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

TR3 Example:

K3✱STATE DATA REQUIREMENT~

✱

449

Fixed Form
Information

✱

✱

Composite
Unit of Mea

Loop 2420A - RENDERING PROVIDER NAME

Required

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

NM1*82 - RENDERING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2420 contains information about the service line providers including, but not limited to: rendering, referring and attending. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

OR

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

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

TR3 Notes:

Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
If, for whatever reason, the data is not stored within the payer's system, do not use.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~

NM1

✱

✱

Loop 2420A - RENDERING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Rendering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Rendering Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Rendering Provider Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PRV*PE - RENDERING PROVIDER SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying 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

REF - RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2420A - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Rendering Provider Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DD - ASSISTANT SURGEON NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop 2420B - ASSISTANT SURGEON NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

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

NM1

✱

✱

Loop 2420B - ASSISTANT SURGEON NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Assistant Surgeon

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Assistant Surgeon Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Assistant Surgeon First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Assistant Surgeon Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Assistant Surgeon Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Assistant Surgeon Primary Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PRV*AS - ASSISTANT SURGEON SPECIALTY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

PRV✱AS✱PXC✱1223S0112X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying 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

REF - ASSISTANT SURGEON SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2420B - ASSISTANT SURGEON NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Assistant Surgeon Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DQ - SUPERVISING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop 2420C - SUPERVISING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

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

NM1

✱

✱

Loop 2420C - SUPERVISING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Use this code for the supervising dentist or physician.

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Supervising Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Supervising Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Supervising Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Supervising Provider Identifier

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

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱0B✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location 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: Supervising Provider Secondary Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

SVD*R - LINE ADJUDICATION INFORMATION

X12 Name:

Service Line Adjudication

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

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

TR3 Notes:

When SVD01 matches the SBR01 in Loop ID-2320B, the payer and adjudication information related to this iteration of Loop ID-2320B and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider.

When SVD01 matches the SBR01 in Loop ID-2320A, the payer and adjudication information related to this iteration of Loop ID-2320A and 2430 represents the adjudication results of the submitting payer.

TR3 Example:

SVD✱P✱55✱HC:84550✱✱3~

SVD

✱

✱

✱

Comp. Med.
Proced. ID

✱

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

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

SEMANTIC: SVD01 is the payer identification code.

INDUSTRY NAME: Payer Responsibility Sequence Code

The value reported in this field indicates the payer responsible for the reimbursement described in this iteration of Loop ID-2430. The value indicates the Payer by matching the SBR01 (Payer Responsibility Sequence Code) in Loop ID-2320A, or the Other Payer by matching the SBR01 (Other Payer Responsibility Sequence Code) in Loop ID-2320B.

CODE

DEFINITION

Non-specified

Required

782

Monetary Amount

M 1

1/18

Monetary amount

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

INDUSTRY NAME: Service Line Paid Amount

Zero "0" is an acceptable value for this element.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Required

C003

Composite Medical Procedure Identifier

O 1

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

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

X12 COMPOSITE SEMANTIC NOTES:

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

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

Required

3-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

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

Required

3-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

3-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

This is the first procedure code modifier.

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

Situational

3-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

This is the second procedure code modifier.

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

Situational

3-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

This is the third procedure code modifier.

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

Situational

3-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

This is the fourth procedure code modifier.

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

Not Used

3-7

352

Description

O 1

1/80

Not Used

3-8

234

Product/Service ID

O 1

1/80

Situational

3-9

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 the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

Situational

3-10

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 the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

Situational

3-11

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 the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

Situational

3-12

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 the adjudicated procedure code includes a procedure code modifier reported by the provider. If not required by this implementation guide, do not send.

Not Used

234

Product/Service ID

O 1

1/80

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVD05 is the paid units of service.

INDUSTRY NAME: Paid Service Unit Count

The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
When SVD01 matches the SBR01 in Loop ID-2320A, this is the number of paid units which would have been sent on the remittance advice. When paid units are not present on the remittance advice, the value must be one.

When SVD01 matches the SBR01 in Loop ID-2320B, this is the number of paid units as reported on the submitted claim. When paid units are not present on the submitted claim, the value must be one.

Situational

554

Assigned Number

O 1

1/9

Number assigned for differentiation within a transaction set

COMMENT: SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.

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

INDUSTRY NAME: Bundled Line Number

CAS - LINE ADJUSTMENT

X12 Name:

Claims Adjustment

X12 Purpose:

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

X12 Syntax:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

1785

Claim Adjst
Group Code

1/10

✱

1034

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1785

Claim Adjustment Group Code

M 1

1/10

Code identifying the general category of payment adjustment.

CODE SOURCE 974: Claim Adjustment Group Codes

Required

1034

Claim Adjustment Reason Code

M 15

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

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

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

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

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

X 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

782

Monetary Amount

X 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

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

INDUSTRY NAME: Adjustment Amount

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

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

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

INDUSTRY NAME: Adjustment Quantity

DTP*573 - LINE CHECK OR REMITTANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱573✱D8✱20200601~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

573

Date Claim Paid

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Adjudication or Payment Date

AMT*EAF - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop: