837 Health Care Claim: Dental (008020X325)

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

008020X325

Health Care Claim: 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✱0002✱008020X325~

✱

✱

✱

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 Numbers in ST02 and SE02 must be identical and must be a numeric value. The number (i.e. numeric value) is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the numeric value 0001 and increment from there. The Transaction Set Control Number also aids in error resolution research.

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

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

INDUSTRY NAME: Implementation Guide Version Name

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

CODE

DEFINITION

008020X325

Health Care Claim: 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 Notes:

The second example denotes the case where the entire transaction set contains ENCOUNTERS.

TR3 Example:

BHT✱0019✱00✱0123✱20220618✱0932✱CH~
BHT✱0019✱00✱44445✱20220213✱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

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

CODE

DEFINITION

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

Use when the transmission has never been sent to the receiver.

Reissue

Use when the sender needs 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

Subrogation Demand

Use when willing trading partners agree to perform post payment claim recovery through the submission of subrogation claims.
NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction.

Chargeable

Use when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.

Reporting

Use when the entire ST-SE envelope contains only capitated encounters and the transaction is being sent to an entity for purposes other than adjudication of a claim.

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

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: Submitter Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the Middle Name or Initial is known to the sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter Middle Name or Initial

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: 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 communication numbers including extensions.

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 1000B - RECEIVER NAME

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

The maximum number of characters to be supported for this field is 256.

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.

The maximum number of characters to be supported for this field is 256.

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.

The maximum number of characters to be supported for this field is 256.

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 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 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 LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Billing Provider is also the Rendering Provider for at least one of the claims in this transaction.
If not required by this implementation guide, do not send.

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 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:

When the entity is not a Health Care provider (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.
When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.

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 the person has a first name. 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 NM102 = 1 (person) and the Middle Name or Initial is known to the sender. 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 NM102 = 1 (person) and the Suffix is known to the sender. 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 NM109 is used. 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 for providers in the United States or its territories when the provider is eligible to receive a National Provider Identifier (NPI).ORRequired for providers not in the United States or its territories when the provider has received an NPI. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

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:

Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
The Billing Provider Address must be a street address. If billing provider location is in an area where there are no street addresses, enter a description of the location (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80").

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 a second address line is needed. 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 Example:

N4✱KANSAS CITY✱MO✱641051909~

✱

✱

✱

✱

✱

✱

✱

✱

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.

INDUSTRY NAME: Billing Provider Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

INDUSTRY NAME: Billing Provider 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 - 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 Billing Provider in 2010AA.

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

Use when reporting the Employer's Identification Number (EIN).

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

Use when reporting a 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

PER*IC - BILLING PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is different than that contained in the Loop ID-1000A (Submitter) PER segment
AND
Loop ID-2010AC (Pay-to Plan) or Loop ID-2010AD (Pay-to Factoring Agent) is present. If not required by implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2010AB - PAY-TO ADDRESS

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 in the first iteration of the Billing Provider Contact Information segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider 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

The maximum number of characters to be supported for this field is 256.

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.

The maximum number of characters to be supported for this field is 256.

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.

The maximum number of characters to be supported for this field is 256.

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*87 - PAY-TO ADDRESS

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:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.

TR3 Notes:

Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.

TR3 Example:

NM1✱87✱2~

NM1

✱

✱

Loop 2010AB - PAY-TO ADDRESS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Pay-to Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

N3 - PAY-TO ADDRESS - ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱1234 MAIN STREET✱FLOOR 5~
N3✱PO BOX 123~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Pay-To Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Pay-To Address Line

N4 - PAY-TO ADDRESS 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 2010AB - PAY-TO ADDRESS

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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: Pay-to Address 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: Pay-To Address 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: Pay-to Address 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: Pay-to Address 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: Pay-to Address 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

NM1*PTP - PAY-TO PLAN 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:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when BHT06 = 31 (Subrogation Demand). If not required by this implementation guide, do not send.

TR3 Example:

NM1✱PTP✱2✱ABC PAY TO PLAN✱✱✱✱✱XV✱12345~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

PTP

Pay-to Plan Name

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: Pay-To Plan Organizational 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 NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Plan Identifier (HPID)

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when reporting the Health Plan ID (HPID) or Other Entity Identifier (OEID). If not required by this implementation guide, do not send.

INDUSTRY NAME: Pay-To Plan 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 - PAY-TO PLAN ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Pay-To Plan Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Pay-To Plan Address Line

N4 - PAY-TO PLAN 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:

Required

Segment Repeat:

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: Pay-To Plan 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: Pay-To Plan 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: Pay-To Plan 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: Pay-to Plan 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: Pay-to Plan 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*2U - PAY-TO PLAN 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 NM109 of this loop is not used.
OR
Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer 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: Pay-to Plan 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*EI - PAY-TO PLAN TAX IDENTIFICATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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

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: Pay-To Plan 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

NM1*O4 - PAY-TO FACTORING AGENT 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:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when willing trading partners agree to use this implementation, and a Factoring Agent owns the rights to the financial obligation for this claim, and payment is intended to be made to this entity. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is not a HIPAA requirement as of this writing.
This loop must not be used if the 2010AC Pay-to Plan loop is used.

TR3 Example:

NM1✱O4✱2✱XYZ AGENT✱✱✱✱✱XV✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Factor

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: Pay-to Factoring Agent Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Pay-to Factoring Agent First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Pay-to Factoring Agent 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 NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Pay-to Factoring Agent 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 Plan Identifier (HPID)

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when reporting the Health Plan ID (HPID) or Other Entity Identifier (OEID). If not required by this implementation guide, do not send.

INDUSTRY NAME: Pay-to Factoring Agent 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 - PAY-TO FACTORING AGENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Pay-to Factoring Agent Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Pay-to Factoring Agent Address Line

N4 - PAY-TO FACTORING AGENT 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:

Required

Segment Repeat:

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: Pay-to Factoring Agent 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: Pay-to Factoring Agent 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: Pay-to Factoring Agent 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: Pay-to Factoring Agent 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: Pay-to Factoring Agent 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*2U - PAY-TO FACTORING AGENT SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

REF✱2U✱251338~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer 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: Pay-to Factoring Agent 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 - PAY-TO FACTORING AGENT TAX IDENTIFICATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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

Social Security 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: Pay-to Factoring Agent 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

PER*IC - PAY-TO FACTORING AGENT CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2000B - SUBSCRIBER LEVEL

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

INDUSTRY NAME: Pay-to Factoring Agent 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

The maximum number of characters to be supported for this field is 256.

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.

The maximum number of characters to be supported for this field is 256.

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.

The maximum number of characters to be supported for this field is 256.

Not Used

443

Contact Inquiry Reference

O 1

1/20

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is reported in the subscriber loop, and the patient HL in Loop ID-2000C is not used.
If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID-2000C are required.

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.

Refer to Section 1.4.4.2.2.2 Subscriber / Patient Hierarchical Level (HL) Segments for instructions on submitting subscriber and dependent claims in the same batch.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Use when the patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

Use when the patient is not the subscriber and cannot be identified to the destination payer in Loop ID 2010BB by a unique Member Identification Number.

SBR - SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

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

Loop:

Loop 2000B - SUBSCRIBER LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SBR✱P✱✱GRP01020102✱✱✱✱✱✱CI~

SBR

✱

1138

Payer Resp
Seq No Code

✱

1069

Individual
Relat Code

✱

✱

✱

✱

✱

✱

584

Employment
Status Code

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

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

INDUSTRY NAME: 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.
This code value identifies, in the opinion of the submitter, the relative adjudication order of the destination payer among all of the payers identified in this claim.

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

Use when sending payer to payer COB claims and the original payer determined the presence of this coverage from eligibility files received from this payer

OR

Use when the original claim did not provide the responsibility sequence for this payer.

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 or is considered to be the subscriber. If not required by this implementation guide, do not send.

CODE

DEFINITION

Self

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 subscriber's identification card shows a group number.ORRequired when the subscriber's group number is otherwise gathered (e.g. eligibility inquiry).If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Group or Policy Number

This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
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 the subscriber's identification card shows a group name.ORRequired when the subscriber's group name is otherwise gathered (e.g. eligibility inquiry). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Subscriber Group Name

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

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

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

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 Workers' Compensation or other Property & Casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.

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 or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the Middle Name or Initial is known to the sender. 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 NM102 = 1 (person) and the Suffix is known to the sender. 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 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

Use when indicating the subscriber's identification number as assigned by the payer.

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM102 = 1 (person). 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:

Situational

Segment Repeat:

Situational Rule:

Required when Loop-ID 2000C Patient Level is not used

OR

Required when the Claim Filing Indicator Code in Loop ID-2000B SBR09 = WC (Workers' Compensation). If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Subscriber Address Line

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
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:

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 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: Subscriber Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Subscriber Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Subscriber Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

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:

Situational

Segment Repeat:

Situational Rule:

Required when Loop-ID 2000C Patient Level is not used. If not required by this implementation guide, do not send.

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

Female

Male

Unknown

Use when the patient's gender cannot be explicitly identified as Male or Female and there are no reporting restrictions.

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 an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EJ✱660415~REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security 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 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 & 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 the services included in this claim are part of a Property & Casualty claim that is not related to Workers' Compensation.

OR

Required when the services included in this claim are considered Workers' Compensation and the claim number has been established by the payer at the time of service. If not required by this implementation guide, do not send.

TR3 Notes:

This is a Property & Casualty payer-assigned claim number. Providers receive this number from the Property & Casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.3, Property & Casualty, for additional information about Property & Casualty claims.
This segment is not a HIPAA requirement as of this writing.
In the case where the patient is the same person as the subscriber, the Property & Casualty Claim Number is sent in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is sent in Loop ID-2010CA. If Loop ID-2010CA is sent, then the Property & Casualty Claim Number must not be sent in Loop ID-2010BA.

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

PER*IC - PROPERTY & CASUALTY SUBSCRIBER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for Property & Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
For Property & Casualty, the Property & Casualty Subscriber Contact may be used to report the name and telephone number of the policyholder. The policyholder for automobile accident claims is typically the individual or company listed on the proof of insurance card. The policyholder for workers' compensation claims is typically the patient's employer. When the policyholder or "subscriber" is a non-person entity, it is recommended that the health care provider use the name of a responsible individual within that organization.

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 Subscriber contact is a person other than the person identified in the Subscriber Name NM1 (Loop ID-2010BA). If not required by this implementation guide, do not send.

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

The maximum number of characters to be supported for this field is 256.

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

Telephone Extension

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.

The maximum number of characters to be supported for this field is 256.

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

443

Contact Inquiry Reference

O 1

1/20

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:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the destination payer.
For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code 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

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 Plan Identifier (HPID)

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when reporting the Health Plan ID (HPID) or Other Entity Identifier (OEID). If not required by this implementation guide, do not send.

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

N3 - PAYER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer address is available. 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: Payer Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Payer Address Line

N4 - PAYER 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 the payer address is available. 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: Payer 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: Payer 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: Payer 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: Payer Country

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: Payer Country Subdivision

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*2U - PAYER 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:

TR3 Example:

REF✱2U✱435261708~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer 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: 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 - 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 2000C - PATIENT LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Use when reporting a proprietary provider number assigned by the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is true regardless of whether that payer is a government, private, commercial, or any other payer.

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 - PATIENT 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 Loop ID-2000B HL04 = 1. If not required by this implementation guide, do not send.

TR3 Notes:

If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is reported in the subscriber loop, and the patient HL in Loop ID-2000C is not used.

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

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

Dependent

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

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 LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

PAT✱01~

PAT

✱

1069

Individual
Relat Code

✱

✱

Employment
Status Code

✱

✱

✱

✱

✱

✱

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

Specifies the patient's relationship to the person insured.

CODE

DEFINITION

Spouse

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Not Used

1384

Patient Location Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

Weight

X 1

1/10

Not Used

1073

Yes/No Condition or Response Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 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 the person has a first name. 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 the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

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 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 a second address line is needed. 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 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 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: 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: 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: 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

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 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

Female

Male

Unknown

Use when the patient's gender cannot be explicitly identified as Male or Female and there are no reporting restrictions.

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*Y4 - PROPERTY & CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

This is a Property & Casualty payer-assigned claim number. Providers receive this number from the Property & Casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.3, Property & Casualty, for additional information about Property & Casualty claims.
This segment is not a HIPAA requirement as of this writing.

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 - PROPERTY & CASUALTY PATIENT 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 an identification number is needed by the receiver to identify the patient for Property & Casualty claims. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EJ✱660415~REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Member Identification Number

Use when reporting a patient identification number for the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim.

Social Security 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 Patient 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

PER*IC - PROPERTY & CASUALTY PATIENT CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for Property & Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID-2010BA and this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 Patient contact is a person other than the person identified in the Patient Name NM1 (Loop ID-2010CA). If not required by this implementation guide, do not send.

INDUSTRY NAME: Property & Casualty Patient Contact Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

The maximum number of characters to be supported for this field is 256.

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

Telephone Extension

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.

The maximum number of characters to be supported for this field is 256.

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

443

Contact Inquiry Reference

O 1

1/20

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:

The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
For purposes of this documentation, the claim detail information is presented only in the patient 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 or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.4.2.2.2 for details.

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: Provider's Assigned Claim Identifier

The maximum number of characters to be supported for this field is '35'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
When Loop ID-2010AC is not present, this identifier is generated by the provider for the purpose of reassociation to their claim accounts receivable, and must not be modified. This identifier, as submitted in the 837, is returned in the 835 and/or other transactions. This identifier is not to be validated beyond standard TR3 syntax and semantic rules.
When Loop ID-2010AC is present, CLM01 represents the Pay-To Plan's claim number (ICN/DCN) assigned during their processing of the claim. See Section 1.4.2.4 Coordination of Benefits - Subrogation for information on subrogation claim reporting.
The developers of this implementation guide strongly recommend that submitters use unique identifiers for this data element for each individual claim.

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.
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 overridden 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

CODE SOURCE 235: Claim Frequency Type Code

Required

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.

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 the subscriber's health plan for the destination payer is Medicare, including Medicare Fee For Service (FFS) or a Medicare Advantage Plan (Medicare Part C).If not required by this implementation guide, do not send.

INDUSTRY NAME: Assignment or Plan Participation Code

This element is NOT for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
This element indicates the provider's assignment with the Medicare Fee For Service (FFS) program and by extension the Medicare Advantage Plan (Medicare Part C).
The value in this element does not supersede an agreement between the provider and payer regarding assignment or participation status unless that agreement allows claim by claim exceptions.
On COB claims where Medicare is not the destination payer, assignment or participation designation with Medicare is not reported in this CLM07 element; rather, it is reported in the Loop 2320 Other Insurance Coverage Information (OI Segment) corresponding to Medicare as the other payer.

CODE

DEFINITION

Assigned

Use when the provider has a participation agreement with Medicare.
OR
Use when the provider does not have a participation agreement with Medicare but has elected to accept assignment for this claim.

Not Assigned

Use when the provider does not have a participation agreement with Medicare and has elected not to accept assignment for this claim.

Required

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.

INDUSTRY NAME: Benefits Assignment Certification Indicator

This element is for reporting whether the patient has or has not assigned benefits to the provider.

CODE

DEFINITION

Yes

Required

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

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

CODE

DEFINITION

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

Use when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

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

Use when Provider has a signed statement permitting release of dental 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 the services provided are employment related or the result of an accident. 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

Use when reporting an employment related illness.

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 the services are related to an employment related accident and the CLM11-01 value is "AA" or "OA". If not required by this implementation guide, do not send.

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Employment

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 CLM11-01 has a value of "AA" and the automobile accident occurred in the US, including its territories, or Canada. 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 CLM11-01 has a value of "AA" and the accident occurred in a country other than US, including its territories, or Canada. 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

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 the services were rendered under one of the following circumstances, programs, or projects for Medicaid. 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

Situational

1360

Provider Agreement Code

O 1

Code indicating the type of agreement under which the provider is submitting this claim

SITUATIONAL RULE: Required when a non-participating (non-par) provider is submitting a participating (par) claim and the destination payer is not Medicare, including Medicare Fee For Service (FFS) or a Medicare Advantage Plan (Medicare Part C). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

CODE

DEFINITION

Participation Agreement

Use when a non-par provider is sending a par claim as allowed under certain plans.

Not Used

1029

Claim Status Code

O 1

1/2

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

SITUATIONAL RULE: Required when the entire claim is being submitted as a predetermination request. If not required by this implementation guide, do not send.

INDUSTRY NAME: Predetermination of Benefits Code

The Predetermination of Benefits Code, when sent, indicates that the entire claim is being sent for predetermination. When the code is not sent, the entire claim is being submitted for payment.

CODE

DEFINITION

Predetermination of Dental Benefits

Situational

1514

Delay Reason Code

O 1

1/2

Code indicating the reason why a request was delayed

SITUATIONAL RULE: Required when the claim is submitted late (past contracted date of filing limitations). 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

Situational

1774

Claim Authorization Exception Code

O 1

1/2

Code identifying the reason for requesting an exception to standard processing of the claim

SITUATIONAL RULE: Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed, the service was performed without obtaining an authorization. If not required by this implementation guide, do not send.

CODE

DEFINITION

Immediate/Urgent Care

Services Rendered in a Retroactive Period

Emergency Care

Subscriber has Temporary Medicaid

Use when reporting the subscriber has Temporary Medicaid.

Request from County for Second Opinion to Determine if Recipient Can Work

Request for Override Pending

Special Handling

DTP*523 - ORIGINAL CLAIM CREATION 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 Notes:

This is the date that the provider created this iteration of the claim from their business application system for transmission to the payer. This date must not be changed by subsequent entities who may handle the claim. Subsequent entities must use the BHT04 (Transaction Set Creation Date) for this purpose.

TR3 Example:

DTP✱523✱D8✱20220517~

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

523

Date of Claim

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

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the services provided are the result of an accident (Loop 2300 CLM11-01 has a value of "AA" or "OA"). If not required by this implementation guide, do not send.

TR3 Example:

DTP✱439✱D8✱20221030~

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 - ORTHODONTIC BANDING 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 reporting the date orthodontic appliances were placed. If not required by this implementation guide, do not send.

TR3 Notes:

This date applies 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.

TR3 Example:

DTP✱452✱D8✱20221030~

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 all the service lines for this claim were performed and the claim is not a predetermination request (Loop ID 2300 CLM19 (Predetermination of Benefits Code) is not used). If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

DTP✱472✱D8✱20221030~

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

DTP*050 - REPRICER RECEIVED 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 a repricer is passing the claim on to the payer. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

DTP✱050✱D8✱20221030~

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

050

Received

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: Repricer Received Date

DN1 - ORTHODONTIC TREATMENT INFORMATION

X12 Name:

Orthodontic Information

X12 Purpose:

To supply orthodontic information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.

TR3 Notes:

When reporting this segment, at least one of DN101, DN102, or DN103 must be present.

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 reporting the total months of orthodontic treatment. 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 reporting the number of months of orthodontic treatment remaining for a transfer patient. If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Months Remaining Count

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: DN103 is the orthodontic indicator. A "Y" value indicates that the claim contains services related to treatment for orthodontic purposes. An "N" value indicates that the services for this claim are not for orthodontic purposes.

SITUATIONAL RULE: Required when the services reported on this claim are for orthodontic purposes and both DN101 and DN102 are not used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Orthodontic Treatment Indicator

Not Used

352

Description

O 1

1/80

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 the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.

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

PWK - CLAIM SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

To identify the type or transmission or both of paperwork or supporting information

X12 Syntax:

P0506
If either PWK05 or PWK06 is present, then the other is required.
P1011
If either PWK10 or PWK11 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is an attachment available for this claim. If not required by this implementation guide, do not send.

TR3 Example:

PWK✱OZ✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

Code indicating the title or contents of a document, report or supporting item

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Referral Form

Dental Models

Diagnostic Report

Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

Support Data for Claim

Periodontal Charts

Radiology Films

Radiology Reports

Required

756

Report Transmission Code

O 1

1/2

Code specifing timing, transmission method or format by which reports are to be sent

INDUSTRY NAME: Attachment Transmission Code

CODE

DEFINITION

Available on Request at Provider Site

Use when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity).

By Mail

Use when paper attachments are sent by mail.

Electronically Only

Use when attachments are sent electronically and transmitted in another functional group (for example, X12N 275 - Additional Information to Support a Health Care Claim or Encounter).

E-Mail

Use when attachments are sent by e-mail.

File Transfer

Use when attachments are sent by File Transfer to payer or maintained by an attachment warehouse or similar vendor.

By Fax

Use when paper attachments are sent by fax.

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Situational

Identification Code Qualifier

X 1

1/2

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

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a code number.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 = "BM", "EL", "EM", "FX" or "FT". If not required by this implementation guide, do not send.

CODE

DEFINITION

Attachment Control Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 = "BM", "EL", "EM", "FX" or "FT". If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Control Number

PWK06 is a unique identifier assigned by the provider to be used to identify the supplemental documentation for this claim. When using the X12N 275 - Additional Information to Support a Health Care Claim or Encounter, the number in PWK06 is carried in the TRN Segment.
For the purpose of this implementation, the maximum field length is 50.

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

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 patient has made payment specifically toward this claim. 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).

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*G3 - PREDETERMINATION 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 sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.

TR3 Notes:

Reference numbers at this position apply to the entire claim.

TR3 Example:

REF✱G3✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Predetermination of Benefits 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: Predetermination of Benefits 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*82 - DENTAL READINESS CLASSIFICATION CODE

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when submitting a claim for the TRICARE - Active Duty Dental Program
AND
when not submitting a predetermination.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱82✱DRC1~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Data Item Description (DID) Reference

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: Dental Readiness Code

DRC1 - (Class 1) Active duty service members with current dental examinations who do not require dental treatment or reevaluation.
DRC2 - (Class 2) Active duty service members with current dental examinations whose oral conditions are unlikely to result in dental emergencies within 12 months.
DRC3 - (Class 3) Active duty service members who require urgent or emergent dental treatment.
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:

Situational

Segment Repeat:

Situational Rule:

Required when CLM05-03 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.

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

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*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 a referral number is assigned by the payer or Utilization Management Organization (UMO) and the referral applies to the entire claim. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must not be used to report the Predetermination of Benefits Identification Number.
Information in this Loop ID-2300 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2400 with the same value in REF01.

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 a prior authorization number is assigned by the payer or Utilization Management Organization (UMO) and the prior authorization applies to the entire claim. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must not be used to report the Predetermination of Benefits Identification Number.
Generally, prior authorization numbers are assigned by the payer or UMO to authorize a service prior to it being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or is the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330B REF which holds that payer's information.

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*9A - REPRICED 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 this information is deemed necessary by the repricer. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

REF✱9A✱RJ55555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Repriced Claim Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Repriced Claim Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9C - ADJUSTED REPRICED 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 this information is deemed necessary by the repricer. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

REF✱9C✱RP44444444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Adjusted Repriced Claim Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Adjusted Repriced Claim Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

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 (clearinghouses and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.

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

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*SOJ - PROPERTY & CASUALTY STATE OF CLAIM JURISDICTION

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 services are considered part of a Property & Casualty claim where either Loop ID 2010BA or Loop ID 2010CA REF segment (Property & Casualty Claim Number) is used and the claim is being submitted under state jurisdictionally defined statutes, rules, or regulations for electronic exchange of health information. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is not a HIPAA requirement as of this writing.
This is not the state of jurisdiction for determination of benefits but is the state whose rules under which the electronic claim has been submitted.

TR3 Example:

REF✱SOJ✱IL~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

SOJ

State of Claim Jurisdiction

CODE SOURCE: 22: States and Provinces

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: State of Claim Jurisdiction

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 X12N has reviewed and approved the data requirements of a regulatory/legislative authority for use of the K3 Segment and has concluded that there is no current method to meet the requirement. (See Section 1.4.6.1 for obtaining X12N approval). If not required by this implementation guide, do not send.

TR3 Notes:

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

- X12N must conclude there is no other available option in the implementation guide to meet the emergency regulatory/legislative requirement.

- The requester must submit a change request accompanied by the relevant business documentation 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 applicable X12N work group 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.

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

INDUSTRY NAME: Temporary Solution for a Statutory/Regulatory Requirement

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

NTE*ADD - CLAIM NOTE

X12 Name:

Note/Special Instruction

X12 Purpose:

To transmit information in a free-form format, if necessary, for comment or special instruction

X12 Comments:

The NTE segment permits free-form information/data which, under ANSI X12 standard implementations, is not machine processible. The use of the NTE segment should therefore be avoided, if at all possible, in an automated environment.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send.

TR3 Notes:

The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.

TR3 Example:

NTE✱ADD✱PATIENT IS EXTREMELY SENSITIVE TO PAIN AND REQUIRES ADDITIONAL SEDATION~

NTE

✱

✱

Required

363

Note Reference Code

O 1

Code identifying the functional area or purpose for which the note applies

CODE

DEFINITION

ADD

Additional Information

Required

352

Description

M 1

1/80

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

INDUSTRY NAME: Claim Note Text

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 the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.

TR3 Notes:

Do not transmit the decimal point for ICD codes.

TR3 Example:

HI✱ABF:K029✱ABF:M2602✱ABF:M2604~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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.

Required

1-1

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)

Use when reporting SNODENT Codes. This code set is not allowed for use under HIPAA at the time of this writing and can only be used:

If a new rule names the SNODENT codes as an allowable code set under HIPAA,
OR
Use when 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: 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 it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. 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.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

See element HI02-01 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.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

See element HI02-01 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

HI - CONDITION INFORMATION

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 it is necessary to report Condition Codes for Workers' Compensation claims. If not required by this implementation guide, do not send.

TR3 Example:

HI✱BG:W3~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

The allowed Condition Codes are for Workers' Compensation claims only and have been defined by the National Uniform Claim Committee on their website:
http://www.nucc.org

CODE SOURCE: 641: Condition Code List

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition 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 it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. 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

Condition

The allowed Condition Codes are for Workers' Compensation claims only and have been defined by the National Uniform Claim Committee on their website:
http://www.nucc.org

CODE SOURCE: 641: Condition Code List

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition 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.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

The allowed Condition Codes are for Workers' Compensation claims only and have been defined by the National Uniform Claim Committee on their website:
http://www.nucc.org

CODE SOURCE: 641: Condition Code List

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition 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.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

The allowed Condition Codes are for Workers' Compensation claims only and have been defined by the National Uniform Claim Committee on their website:
http://www.nucc.org

CODE SOURCE: 641: Condition Code List

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition 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

HCP - CLAIM PRICING/REPRICING INFORMATION

X12 Name:

Health Care Pricing

X12 Purpose:

To specify pricing or repricing information about a health care claim or line item

X12 Syntax:

R0113
At least one of HCP01 or HCP13 is required.
P0910
If either HCP09 or HCP10 is present, then the other is required.
P1112
If either HCP11 or HCP12 is present, then the other is required.

Loop:

Loop 2310A - REFERRING PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by the repricer. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

HCP✱03✱100✱10✱RPO12345~

HCP

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1473

Pricing Methodology Code

X 1

Code specifying pricing methodology at which the claim or line item has been priced or repriced

SEGMENT SYNTAX: R0113

INDUSTRY NAME: Pricing Methodology

Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.

CODE

DEFINITION

Zero Pricing (Not Covered Under Contract)

Priced as Billed at 100%

Priced at the Standard Fee Schedule

Priced at a Contractual Percentage

Bundled Pricing

Peer Review Pricing

Flat Rate Pricing

Combination Pricing

Maternity Pricing

Other Pricing

Lower of Cost

Ratio of Cost

Cost Reimbursed

Adjustment Pricing

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP02 is the allowed amount.

INDUSTRY NAME: Repriced Allowed 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: HCP03 is the savings amount.

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

INDUSTRY NAME: Repriced Savings 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: HCP04 is the repricing organization identification number.

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

INDUSTRY NAME: Repricing Organization Identifier

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

Situational

118

Rate

O 1

1/9

Rate expressed in the standard monetary denomination for the currency specified

SEMANTIC: HCP05 is the pricing rate associated with per diem or flat rate repricing.

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

INDUSTRY NAME: Repricing Per Diem or Flat Rate Amount

Not Used

127

Reference Identification

O 1

1/80

Not Used

782

Monetary Amount

O 1

1/18

Not Used

234

Product/Service ID

O 1

1/80

Not Used

235

Product/Service ID Qualifier

X 1

Not Used

234

Product/Service ID

X 1

1/80

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

380

Quantity

X 1

1/15

Situational

901

Reject Reason Code

X 1

Code identifying reason for rejection as assigned by issuer

SEMANTIC: HCP13 is the rejection message returned from the third party organization.

SEGMENT SYNTAX: R0113

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

CODE

DEFINITION

Cannot Identify Provider as TPO (Third Party Organization) Participant

Claim does not contain enough information for re-pricing

Situational

1526

Policy Compliance Code

O 1

1/2

Code specifying policy compliance

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

CODE

DEFINITION

Procedure Followed (Compliance)

Not Followed - Call Not Made (Non-Compliance Call Not Made)

Not Medically Necessary (Non-Compliance Non-Medically Necessary)

Not Followed Other (Non-Compliance Other)

Emergency Admit to Non-Network Hospital

Situational

1527

Exception Code

O 1

1/2

Code specifying the exception reason for consideration of out-of-network health care services

SEMANTIC: HCP15 is the exception reason generated by a third party organization.

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

CODE

DEFINITION

Non-Network Professional Provider in Network Hospital

Emergency Care

Services or Specialist not in Network

Out-of-Service Area

State Mandates

Other

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 this claim involves a referral. 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 to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" 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 submitted in this transaction.
See the NUCC website www.nucc.org for the definitions of professional providers.

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

Primary Care Provider

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 the person has a first name. 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 the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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 the provider has received an NPI and the NPI is available to the submitter. If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF*A6 - 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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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 NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. If not required by this implementation guide, do not send.

TR3 Notes:

Information in this 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.
See the NUCC website www.nucc.org for the definitions of professional providers.

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

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 Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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: Rendering Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

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:

Required

Segment Repeat:

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.

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

TR3 Notes:

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.

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Location Number

Use when reporting the provider's location when different than the billing or service location.

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 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:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the name and/or the address of Service Location is different than that carried in Loop ID-2010AA (Billing Provider)
AND
the Service Location is not a subpart of the Billing Provider with its own NPI that is different than the NPI reported in Loop ID-2010AA NM109. If not required by this implementation guide, do not send.

TR3 Notes:

Information in this 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.
When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
The purpose of this loop is to identify specifically where the service was rendered.

TR3 Example:

NM1✱77✱2✱ABC CLINIC✱✱✱✱✱XX✱1234567891~

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

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the Service Location is an organization health care provider who is external to the entity identified as the Billing Provider in Loop ID-2010AA. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Location Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

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 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 the service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity.If not required by this implementation guide, do not send.

INDUSTRY NAME: Laboratory or Facility 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 - SERVICE LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

If service location is in an area where there are no street addresses, enter a description of the location (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80").

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Service Location Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Service Location Address Line

N4 - SERVICE 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:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱641051909~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Service Location 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: Service Location 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: Service Location 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.

INDUSTRY NAME: Service Location Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Service Location 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 - SERVICE 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:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used,
AND
the Billing Provider Loop ID-2010AA NM109 is not used,
AND
an identifier is necessary for the receiver to identify the provider.

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

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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: Service Location 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 the Rendering Provider provided these services in the role of the Assisting Surgeon.
If not required by this implementation guide, do not send.

TR3 Notes:

Information in this 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.

TR3 Example:

NM1✱DD✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567890~

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 the person has a first name. 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 the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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: Assistant Surgeon 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

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:

Required

Segment Repeat:

TR3 Notes:

Information in this 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.

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

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Location Number

Use when reporting the provider's location when different than the billing or service location.

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 the rendering provider is supervised by a physician or dentist. If not required by this implementation guide, do not send.

TR3 Notes:

Information in this 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.
See the NUCC website www.nucc.org for the definitions of professional providers.

TR3 Example:

NM1✱DQ✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567890~

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

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 the person has a first name. 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 the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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: Supervising Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF*A6 - 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.

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:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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.

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Use when reporting a proprietary provider number by the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is a government, private, commercial, or any other payer.

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

SBR - OTHER SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.

TR3 Notes:

All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.
See Section 1.4.2 for more information on Coordination of Benefits.

TR3 Example:

SBR✱S✱01✱GR00786✱✱✱✱✱✱13~

SBR

✱

1138

Payer Resp
Seq No Code

✱

1069

Individual
Relat Code

✱

✱

✱

✱

✱

✱

584

Employment
Status Code

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

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

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 (Other Payer Responsibility Sequence Code) of Loop ID-2430 (Line Adjudication Information) must match this value when used.
This code value identifies, in the opinion of the submitter, the relative adjudication order of the non-destination payer in this iteration of Loop ID-2320 among all of the payers identified in this claim.

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.

INDUSTRY NAME: Insured Group or Policy Number

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

INDUSTRY NAME: Other Insured Group Name

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

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

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

RAS - CLAIM ADJUSTMENT INFORMATION

X12 Name:

Reason Adjustment

X12 Purpose:

To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts must 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 Other Payer Name (Loop ID-2330B) made claim level adjustments to the dollar amount charged. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.5, Balancing, for additional information.

TR3 Example:

RAS✱125.32✱PR✱1~RAS✱25✱PR✱3~RAS✱200✱CO✱6^7~RAS✱500✱CO✱45:HE:MA01~RAS✱1225✱CO✱16:HE:M24^15:HE:N517~RAS✱2225✱CO✱16:HE:M44:M45:M49^146:HE:MA63:MA65~RAS✱2100✱OA✱18:HE:N522:N702~

RAS

✱

✱

Claim Adjst
Group Code

✱

✱

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: RAS01 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

This monetary amount is the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment. This amount must not be zero (0).
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

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

C058

Adjustment Reason

M 15

To provide a reason and related explanation for a Health Care Claim or Service change in payment versus the original submitted charges

SEMANTIC: Position of data in the repeating composite data element conveys no significance.

X12 COMPOSITE SYNTAX NOTES:

P0203
If either C05802 or C05803 is present, then the other is required.
C0403
If C05804 is present, then C05803 is required.
C0504
If C05805 is present, then C05804 is required.
C0605
If C05806 is present, then C05805 is required.
C0706
If C05807 is present, then C05806 is required.

X12 COMPOSITE SEMANTIC NOTES: C05802 qualifies C05803, C05804, C05805, C05806 and C05807.

More than one iteration of this composite may only be provided when the entire claim submitted charge is being adjusted by this RAS segment and there are multiple adjustment reasons that are each applicable for the adjustment of that full amount in RAS01.
This composite identifies the reason for the adjustment of the dollar amount identified in RAS01.

Required

3-1

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

3-2

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when the payer identified in Other Payer Name Loop ID-2330B reported a remark code associated with this claim adjustment reason code in the remittance advice. If not required by this implementation guide, do not send.

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

Situational

3-3

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203, C0403

INDUSTRY NAME: Remark Code

Situational

3-4

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0403, C0504

INDUSTRY NAME: Remark Code

Situational

3-5

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0504, C0605

INDUSTRY NAME: Remark Code

Situational

3-6

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0605, C0706

INDUSTRY NAME: Remark Code

Situational

3-7

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0706

INDUSTRY NAME: Remark Code

Not Used

380

Quantity

O 1

1/15

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:

Situational

Segment Repeat:

Situational Rule:

Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.

OR

Required when Loop ID-2010AC is present.

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

TR3 Notes:

When Loop 2010AC is a Medicaid Agency, this amount represents the maximum amount of liability the Medicaid agency is requesting to recover by submitting the subrogation claim.

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*B6 - CLAIM ALLOWED AMOUNT

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 submitting a Coordination of Benefits (COB) claim, and the Other Payer identified in Loop ID- 2330B of this iteration of Loop ID-2320 has adjudicated this claim and provided the 835 with only claim level allowed amount information.

OR

Required when submitting a Coordination of Benefits (COB) claim, and the Other Payer identified in Loop ID-2330B of this iteration of Loop ID- 2320 has adjudicated this claim and the payer issued a paper, virtual, or other alternate format of remittance advice with the allowed amount reported and the submitter does not have the ability to report line item information.

OR

Required when submitting a Coordination of Benefits (COB) claim, and the Other Payer identified in Loop ID-2330B of this iteration of Loop ID- 2320 is the same as the submitter reported in Loop ID-1000A. If not required by this implementation guide, do not send.

TR3 Notes:

This is Loop ID-2100 Claim Allowed Amount (AMT02) when reported on an 835.
This is the total claim allowed amount when remittance information is reported using other formats.
In situations other than payer to payer COB, this amount is not sent if it is not explicitly available on an 835 or other remittance. If the allowed amount is not available, do not calculate the amount.
When the Claim Allowed Amount is zero dollars, report zero (0).

TR3 Example:

AMT✱B6✱425~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Allowed - Actual

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Claim Allowed Amount

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

Not Used

478

Credit/Debit Flag Code

O 1

AMT*EAF - REMAINING PATIENT LIABILITY AMOUNT

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 the claim is submitted by the provider and the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320 has adjudicated this claim, and provided claim level information only,

AND

In the provider's opinion, the amount billable to the patient, is different than the sum of the amounts (RAS01) associated with Patient Responsibility (PR) Claim Adjustment Group Code (RAS02) in this 2320 loop. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. The amount reported here may, or may not, equal the sum of the amounts reported as Patient Responsibility (PR) in the RAS segments.
This segment is not used in Payer-to-Payer Coordination of Benefits (COB).
This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.

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

AMT*A8 - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT

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 the destination payer's cost avoidance policy allows providers to bypass claim submission to the payer identified in the Other Payer Loop ID-2330B of this iteration of Loop ID-2320. If not required by this implementation guide, do not send.

TR3 Notes:

When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any RAS segments are used as this claim has not been adjudicated by this payer.

TR3 Example:

AMT✱A8✱273~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Noncovered Charges - Actual

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Non-Covered Charge Amount

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

Not Used

478

Credit/Debit Flag Code

O 1

OI - OTHER INSURANCE COVERAGE INFORMATION

X12 Name:

Other Health Insurance Information

X12 Purpose:

To specify information associated with other health insurance coverage

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

All information contained in the OI segment applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320.

TR3 Example:

OI✱✱✱✱✱✱✱A✱N✱✱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

Situational

1359

Provider Accept Assignment Code

O 1

Code indicating whether the provider accepts assignment

SITUATIONAL RULE: Required when the other payer reported in this 2320 loop is Medicare, including Medicare Fee For Service (FFS) or a Medicare Advantage Plan (Medicare Part C). If not required by this implementation guide, do not send.

INDUSTRY NAME: Medicare Assignment Code

For payer to payer COB claims, this code indicates how the claim was adjudicated by the previous payer, which may be different than the assignment/participation indicator submitted on the original claim.

CODE

DEFINITION

Assigned

Use when the claim was processed as assigned.

Assignment Accepted on Clinical Lab Services Only

Use when the claim was processed as assigned.

Not Assigned

Use when the claim was processed as non-assigned.

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: OI08 is payer-to-payer adjustment code. A "Y" value indicates a payer-to-payer COB claim is an adjustment. An "N" value indicates payer-to-payer COB claim is not an adjustment.

SITUATIONAL RULE: Required when the claim is for payer to payer COB. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Payer Claim Adjustment Indicator

CODE

DEFINITION

Yes

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: OI10 is payer-to-payer void code. A "Y" value indicates a payer-to-payer COB claim is a void. An "N" value indicates payer-to-payer COB claim is not a void.

SITUATIONAL RULE: Required when the claim is for payer to payer COB. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Payer Voided Claim Indicator

CODE

DEFINITION

Yes

Not Used

1073

Yes/No Condition or Response 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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when outpatient adjudication information is reported in the remittance advice. If not required by this implementation guide, do not send.

TR3 Example:

MOA✱50✱100~

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 returned in the remittance advice. 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 returned in the remittance advice. 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.

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

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

SITUATIONAL RULE: Required when returned in the remittance advice. 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.

LQ - HEALTH CARE REMARK CODES

X12 Name:

Industry Code Identification

X12 Purpose:

To identify standard industry codes

X12 Syntax:

C0102
If LQ01 is present, then LQ02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when it is necessary to report claim level remark codes that are not associated with a claim adjustment reason code in a RAS Segment in this Loop ID 2320. If not required by this implementation guide, do not send.

TR3 Notes:

Remark codes from paper remittance advice that are not associated with a claim adjustment reason code in the RAS Segment are reported in this segment.

TR3 Example:

LQ✱HE✱MA15~

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: C0102

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

National Council for Prescription Drug Programs Reject Codes

CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: C0102

INDUSTRY NAME: Remark Code

NM1*IL - OTHER SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

If a patient can be uniquely identified by the Other Payer reported in Loop ID-2330B by a unique Member Identification Number, then the patient is reported in the subscriber loop.
See Section 1.4.2 for more information on Coordination of Benefits.

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 Subscriber Last Name or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the Middle Name or Initial is known to the sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other 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 NM102 = 1 (person) and the Suffix is known to the sender. If not required by this implementation guide do not send.

INDUSTRY NAME: Other 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

Use when indicating the subscriber's identification number as assigned by the payer.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other 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 SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information is available. 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 Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Other Subscriber Address Line

N4 - OTHER SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
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 the information is available and Loop ID-2330A N3 Segment is sent in this iteration of Loop ID-2320. 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 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 Subscriber 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: Other 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 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 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 SUBSCRIBER SOCIAL SECURITY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

REF✱EJ✱660415~REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security 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: Other 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*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 Notes:

See Section 1.4.2 for more information on Coordination of Benefits.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code 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

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 Plan Identifier (HPID)

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when reporting the Health Plan ID (HPID) or Other Entity Identifier (OEID). If not required by this implementation guide, do not send.

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

N3 - OTHER PAYER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer address is available. 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 Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Other Payer Address Line

N4 - OTHER PAYER 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 the payer address is available. 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 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 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: Other Payer 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 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 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

DTP*573 - PAYMENT EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Payment Effective Date, is not used. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱573✱D8✱20221030~

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: Payment Effective Date

REF*2U - 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:

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer 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: 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

REF*G1 - OTHER PAYER PRIOR AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer identified in this loop has assigned a prior authorization number and the prior authorization applies to the entire claim. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must not be used to report the Predetermination of Benefits Identification Number.
When prior authorization is submitted at this level (Loop ID-2330B) it applies to all the service lines that do not have an overriding REF - Prior Authorization (Loop ID-2400).

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: Other Payer 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*9F - OTHER PAYER 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 the payer identified in this loop has assigned a referral number to this claim.
If not required by this implementation guide, do not send.

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: Other Payer 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*G3 - OTHER PAYER PREDETERMINATION 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 the payer identified in this loop has assigned a predetermination identification number to this claim.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱G3✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Predetermination of Benefits 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: Other Payer Predetermination of Benefits 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 - OTHER PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a payer-to-payer COB claim.

OR

Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send.

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

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's 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*1K - OTHER 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 2330C - OTHER PAYER REFERRING PROVIDER

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim has been adjusted by the other payer in a payer-to-payer COB situation.

AND

Loop ID-2330 REF F8 is used.

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

TR3 Notes:

This is the ICN/DCN of the adjusted claim. When the original claim has been adjusted multiple times, this is the Payer Claim Control Number that represents the adjudication this claim is replacing.

TR3 Example:

REF✱1K✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payor's 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: Other 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

NM1 - OTHER PAYER REFERRING PROVIDER

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 corresponding Loop ID-2310 NM109 is not used and one or more additional payer-specific provider identifiers are required by this non-destination payer (Loop ID-2330B). 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 to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" 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 submitted in this transaction.
See the NUCC website www.nucc.org for the definitions of professional providers.

TR3 Example:

NM1✱DN✱1~

NM1

✱

✱

Loop 2330C - OTHER PAYER REFERRING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

Primary Care Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

REF*A6 - OTHER PAYER 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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 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 - OTHER PAYER RENDERING PROVIDER

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 2330D - OTHER PAYER RENDERING PROVIDER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

See the NUCC website www.nucc.org for the definitions of professional providers.

TR3 Example:

NM1✱82✱1~

NM1

✱

✱

Loop 2330D - OTHER PAYER RENDERING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

REF - OTHER PAYER 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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: Other Payer 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*85 - OTHER PAYER BILLING PROVIDER

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 2330E - OTHER PAYER BILLING PROVIDER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the provider sent in the corresponding Loop ID-2010AA is not a Health Care Provider and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱85✱2~

NM1

✱

✱

Loop 2330E - OTHER PAYER BILLING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

REF - OTHER PAYER 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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: Other Payer Billing Provider 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 - OTHER PAYER SERVICE LOCATION

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 2330F - OTHER PAYER SERVICE LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Example:

NM1✱77✱2~

NM1

✱

✱

Loop 2330F - OTHER PAYER SERVICE LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

REF - OTHER PAYER SERVICE 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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: Other Payer Service Location 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 - OTHER PAYER ASSISTANT SURGEON

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 2330G - OTHER PAYER ASSISTANT SURGEON

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Example:

NM1✱DD✱1~

NM1

✱

✱

Loop 2330G - OTHER PAYER ASSISTANT SURGEON

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

REF - OTHER PAYER ASSISTANT SURGEON 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:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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: Other Payer 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 - OTHER PAYER SUPERVISING PROVIDER

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 2330H - OTHER PAYER SUPERVISING PROVIDER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Example:

NM1✱DQ✱1~

NM1

✱

✱

Loop 2330H - OTHER PAYER SUPERVISING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 when reporting 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

Not Used

1035

Name Last or Organization Name

X 1

1/80

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

REF*A6 - OTHER PAYER 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:

Required

Segment Repeat:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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

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 1.4.2.3 for more information on bundling and 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~

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

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

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 a second modifier clarifies or improves the reporting accuracy of the associated procedure code. 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 a third modifier clarifies or improves the reporting accuracy of the associated procedure code. 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 a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. 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, in the judgment of the submitter, the procedure code does not definitively describe the service/product/supply and loop 2410 is not used.ORRequired when SV301-02 is a non-specific procedure code as defined by the payer. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Non-specific codes may include in their descriptors terms such as: Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other, Miscellaneous; Prescription Drug; Generic; or Prescription Drug, Brand Name.

Some procedures (such as anesthesia and laboratory) have code descriptors that include "Not Otherwise Specified"; however, these are not considered "non-specific" procedure codes.

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

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.
This is the total charge amount for this service line.

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 value is different than value carried in CLM05-01 in Loop ID-2300. 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 the nomenclature associated with the procedure reported in SV301-02 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments.

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.

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 reporting a second area of the oral cavity. 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 reporting a third area of the oral cavity. 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 reporting a fourth area of the oral cavity. 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 reporting a fifth area of the oral cavity. 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 to indicate the placement status of the prosthetic on this line. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when the procedure reported in SV301-02 was performed more than once and it is not required to identify areas of the oral cavity or individual teeth.If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Count

Number of procedures

Not Used

352

Description

O 1

1/80

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1328

Diagnosis Code Pointer

O 12

1/2

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

SEMANTIC: The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.

SITUATIONAL RULE: Required when this service relates to a specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send.

The first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 4, and correspond to Composite Data Elements 01 through 04 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300.

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 reporting tooth information related to this service line. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

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 the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

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 it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.

Additional tooth surface codes can be carried in TOO03-02 through TOO03-05. The code values are the same as in TOO03-01.

CODE

DEFINITION

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 it is necessary to report an additional tooth surface. 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 it is necessary to report an additional tooth surface. 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 it is necessary to report an additional tooth surface. 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 the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.

TR3 Notes:

Do not use this DTP segment when submitting a Predetermination of Dental Benefits.

TR3 Example:

DTP✱472✱D8✱20221030~

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 the value of SV305 for this iteration of the Loop ID-2400 loop is "R". If not required by this implementation guide, do not send.

TR3 Example:

DTP✱441✱D8✱20220401~

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

Use when the exact Prior Placement Date is not known.

441

Prior Placement

Use 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 - ORTHODONTIC BANDING DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱452✱D8✱20221030~

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 reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱446✱D8✱20221030~

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

REF*G3 - SERVICE PREDETERMINATION 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 sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined that is now being submitted for payment and is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

TR3 Notes:

Reference numbers at this position apply to the current line item only.

TR3 Example:

REF✱G3✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Predetermination of Benefits 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: Predetermination of Benefits 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

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

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 the service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300)

OR

Required when a prior authorization only applies to this service line (Loop ID-2400) and no claim level (Loop ID-2300) prior authorization was reported. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must not be used to report the Predetermination of Benefits Identification Number.

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

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

REF*6R - LINE ITEM 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 Notes:

If the provider does not use a unique line item control number or the originating claim did not have a line item control number (i.e., Payer to Payer COB, paper to electronic), then use the LX01 value.
Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
The line item control number needs to be unique within a Provider's Assigned Claim Identifier (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider 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: Line Item Control Number

The maximum number of characters to be supported for this field is 30. A submitter may submit fewer characters depending upon their needs. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
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*9B - REPRICED LINE ITEM REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by the repricer. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

REF✱9B✱444444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Repriced Line Item Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Repriced Line Item Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9D - ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by the repricer. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

REF✱9D✱444444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Adjusted Repriced Line Item Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Adjusted Repriced Line Item Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

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 this service line involved a referral number AND it is different than the number reported at the claim level (Loop-ID 2300).

OR

Required when this service line involved a referral number AND a claim level referral (Loop ID 2300) was not reported. If not required by this implementation guide, do not send.

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

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

AMT*SCT - STATE CARE TAX

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 State Care Tax applies to the service line and the submitter is required to report this information to the receiver. If not required by this implementation guide, do not send.

TR3 Notes:

Sales Tax is not reported in this Segment.
The State Care Tax Amount must be included in the Line Item Charge Amount (SV302) of the related Service Line.

TR3 Example:

AMT✱SCT✱20~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

SCT

State Care Tax

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: State Care Tax

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

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:

TR3 Notes:

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

- X12N must conclude there is no other available option in the implementation guide to meet the emergency regulatory/legislative requirement.

- The requester must submit a change request accompanied by the relevant business documentation 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 applicable X12N work group 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.

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

INDUSTRY NAME: Temporary Solution for a Statutory/Regulatory Requirement

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

HCP - LINE PRICING/REPRICING INFORMATION

X12 Name:

Health Care Pricing

X12 Purpose:

To specify pricing or repricing information about a health care claim or line item

X12 Syntax:

R0113
At least one of HCP01 or HCP13 is required.
P0910
If either HCP09 or HCP10 is present, then the other is required.
P1112
If either HCP11 or HCP12 is present, then the other is required.

Loop:

Loop 2420A - RENDERING PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by the repricer. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
This segment is not completed by providers. The information is completed by repricers only.

TR3 Example:

HCP✱03✱100✱10✱RPO12345~

HCP

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1473

Pricing Methodology Code

X 1

Code specifying pricing methodology at which the claim or line item has been priced or repriced

SEGMENT SYNTAX: R0113

INDUSTRY NAME: Pricing Methodology

Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.

CODE

DEFINITION

Zero Pricing (Not Covered Under Contract)

Priced as Billed at 100%

Priced at the Standard Fee Schedule

Priced at a Contractual Percentage

Bundled Pricing

Peer Review Pricing

Flat Rate Pricing

Combination Pricing

Maternity Pricing

Other Pricing

Lower of Cost

Ratio of Cost

Cost Reimbursed

Adjustment Pricing

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP02 is the allowed amount.

INDUSTRY NAME: Repriced Allowed 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: HCP03 is the savings amount.

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

INDUSTRY NAME: Repriced Savings 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: HCP04 is the repricing organization identification number.

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

INDUSTRY NAME: Repricing Organization Identifier

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

Situational

118

Rate

O 1

1/9

Rate expressed in the standard monetary denomination for the currency specified

SEMANTIC: HCP05 is the pricing rate associated with per diem or flat rate repricing.

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

INDUSTRY NAME: Repricing Per Diem or Flat Rate Amount

Not Used

127

Reference Identification

O 1

1/80

Not Used

782

Monetary Amount

O 1

1/18

Not Used

234

Product/Service ID

O 1

1/80

Situational

235

Product/Service ID Qualifier

X 1

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

SEGMENT SYNTAX: P0910

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Situational

234

Product/Service ID

X 1

1/80

Identifying number for a product or service

SEMANTIC: HCP10 is the approved procedure code.

SEGMENT SYNTAX: P0910

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

INDUSTRY NAME: Repriced Approved HCPCS Code

Situational

355

Unit or Basis for Measurement Code

X 1

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

SEGMENT SYNTAX: P1112

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

CODE

DEFINITION

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: HCP12 is the approved service units or inpatient days.

SEGMENT SYNTAX: P1112

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

INDUSTRY NAME: Repriced Approved Service Unit Count

Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
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. A zero or negative value is not allowed.

Situational

901

Reject Reason Code

X 1

Code identifying reason for rejection as assigned by issuer

SEMANTIC: HCP13 is the rejection message returned from the third party organization.

SEGMENT SYNTAX: R0113

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

CODE

DEFINITION

Cannot Identify Provider as TPO (Third Party Organization) Participant

Claim does not contain enough information for re-pricing

Situational

1526

Policy Compliance Code

O 1

1/2

Code specifying policy compliance

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

CODE

DEFINITION

Procedure Followed (Compliance)

Not Followed - Call Not Made (Non-Compliance Call Not Made)

Not Medically Necessary (Non-Compliance Non-Medically Necessary)

Not Followed Other (Non-Compliance Other)

Emergency Admit to Non-Network Hospital

Situational

1527

Exception Code

O 1

1/2

Code specifying the exception reason for consideration of out-of-network health care services

SEMANTIC: HCP15 is the exception reason generated by a third party organization.

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

CODE

DEFINITION

Non-Network Professional Provider in Network Hospital

Emergency Care

Services or Specialist not in Network

Out-of-Service Area

State Mandates

Other

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 and the Assistant Surgeon (Loop ID-2420C) loop is not present
OR
Required when each of the following conditions apply:
• the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA)
• this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider
• the Assistant Surgeon loop (Loop ID-2420C) is not used.
If not required by this implementation guide, do not send.

TR3 Notes:

See the NUCC website www.nucc.org for the definitions of professional providers.

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

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 Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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: Rendering Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

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:

Required

Segment Repeat:

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

TR3 Notes:

If REF04 is not used, REF02 is a proprietary provider number assigned by the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim.

If REF04 is used, REF02 is a proprietary provider number assigned by the non-destination payer identified in the Other Payer Name loop, Loop ID-2330B, associated with this claim.

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Use when reporting a proprietary provider number assigned by the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim
OR
Use when reporting a proprietary provider number assigned by the non-destination payer identified in REF04-02 of this segment. This is true regardless of whether that payer is a government, private, commercial or any other payer.

Location Number

Use when reporting the provider's location when different than the billing or service location.

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

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

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 the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D.
If not required by this implementation guide, do not send.

TR3 Example:

NM1✱DD✱1✱SMITH✱JOHN✱S✱✱✱XX✱1234567890~

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 the person has a first name. 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 the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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: Assistant Surgeon 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

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 the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.

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

TR3 Notes:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Location Number

Use when reporting the provider's location when different than the billing or service location.

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

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

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 the rendering provider is supervised by a physician or dentist and the supervising physician or dentist for this service line is different than that listed at the claim level. If not required by this implementation guide, do not send.

TR3 Notes:

See the NUCC website www.nucc.org for the definitions of professional providers.

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

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 the person has a first name. 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 the Middle Name or Initial is known to the sender. 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 the Suffix is known to the sender. 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 NM109 is used. 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: Supervising Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF*A6 - 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 NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:

When it is necessary to assign the identifier in REF01 of this segment to one or more non-destination payers, the composite data element in REF04 is used to identify the payer that assigned this identifier.
If REF04 is not used, REF02 is a proprietary provider number assigned by the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim.

If REF04 is used, REF02 is a proprietary provider number assigned by the non-destination payer identified in the Other Payer Name loop, Loop ID-2330B, associated with this claim.

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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

Not Used

352

Description

X 1

1/80

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Maximum length of this element is constrained by B.1.1.3.1.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

NM1*77 - SERVICE 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:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the name and/or the address of Service Location is different than that carried in Loop ID-2310C Service Location
AND
the Service Location is not a subpart of the Billing Provider with its own unique NPI.

OR

Required when Loop ID-2310C is Not Used
AND
the Service Location is not a subpart of the Billing Provider with its own unique NPI
AND
the name and/or the address of Service Location is different than that carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, do not send.

TR3 Notes:

When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.

TR3 Example:

NM1✱77✱2✱ABC CLINIC✱✱✱✱✱XX✱1234567891~

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

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the Service Location is an organization health care provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Location Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

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 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: Service Location 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 - SERVICE LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Service Location Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Service Location Address Line

N4 - SERVICE 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:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱641051909~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Service Location 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: Service Location 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: Service Location 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.

INDUSTRY NAME: Service Location Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Service Location 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 - SERVICE 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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used,
AND
the Billing Provider Loop ID-2010AA NM109 is not used,
AND
an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

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: Service Location 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

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

SVD - LINE ADJUDICATION INFORMATION

X12 Name:

Service Line Adjudication

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the claim has been previously adjudicated by the payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.

TR3 Notes:

Refer to Section 1.4.2.3 Coordination of Benefits - Service Line Procedure Code Bundling and Unbundling.

TR3 Example:

SVD✱1✱50.5✱AD:D0330✱✱1~

SVD

✱

1138

Payer Resp
Seq No Code

✱

✱

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: Other Payer Responsibility Sequence Code

The value reported in this field must match the corresponding Other Payer Responsibility Sequence Code reported in Loop ID-2320 SBR01.

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 adjudicate 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

Use when applicable for Property & Casualty claims

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 payer. 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 payer. 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 payer. 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 payer. 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

Not Used

3-9

1339

Procedure Modifier

O 1

Not Used

3-10

1339

Procedure Modifier

O 1

Not Used

3-11

1339

Procedure Modifier

O 1

Not Used

3-12

1339

Procedure Modifier

O 1

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

This is the number of paid units from the remittance advice. When paid units are not present on the paper remittance advice or known by the provider, the value must be one.
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. A negative value is not allowed.

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

RAS - SERVICE ADJUSTMENT INFORMATION

X12 Name:

Reason Adjustment

X12 Purpose:

To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts must 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 Example:

RAS✱125.32✱PR✱1~RAS✱25✱PR✱3~RAS✱200✱CO✱6^7~RAS✱500✱CO✱45:HE:MA01~RAS✱1225✱CO✱16:HE:M24^15:HE:N517✱2~RAS✱2225✱CO✱16:HE:M44:M45:M49^146:HE:MA63:MA65~RAS✱2100✱OA✱18:HE:N522:N702~

RAS

✱

✱

Claim Adjst
Group Code

✱

✱

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: RAS01 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

This monetary amount is the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment. This amount must not be zero (0).
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

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

C058

Adjustment Reason

M 15

To provide a reason and related explanation for a Health Care Claim or Service change in payment versus the original submitted charges

SEMANTIC: Position of data in the repeating composite data element conveys no significance.

X12 COMPOSITE SYNTAX NOTES:

P0203
If either C05802 or C05803 is present, then the other is required.
C0403
If C05804 is present, then C05803 is required.
C0504
If C05805 is present, then C05804 is required.
C0605
If C05806 is present, then C05805 is required.
C0706
If C05807 is present, then C05806 is required.

X12 COMPOSITE SEMANTIC NOTES: C05802 qualifies C05803, C05804, C05805, C05806 and C05807.

This composite identifies the reason for the adjustment of the dollar amount identified in RAS01.
More than one iteration of this composite may only be provided when the entire service submitted charge is being adjusted by this RAS segment and there are multiple adjustment reasons that are each applicable for the adjustment of that full amount in RAS01.

Required

3-1

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

3-2

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when provided in the RAS Segment of the 835 for the payer identified in the Loop ID-2430 SVD01. If not required by this implementation guide, do not send.

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

National Council for Prescription Drug Programs Reject Codes

CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes

Situational

3-3

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203, C0403

SITUATIONAL RULE: Required when provided in the RAS Segment of the 835 for the payer identified in the Loop ID-2430 SVD01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Situational

3-4

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0403, C0504

SITUATIONAL RULE: Required when provided in the RAS Segment of the 835 for the payer identified in the Loop ID-2430 SVD01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Situational

3-5

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0504, C0605

SITUATIONAL RULE: Required when provided in the RAS Segment of the 835 for the payer identified in the Loop ID-2430 SVD01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Situational

3-6

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0605, C0706

SITUATIONAL RULE: Required when provided in the RAS Segment of the 835 for the payer identified in the Loop ID-2430 SVD01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Situational

3-7

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0706

SITUATIONAL RULE: Required when provided in the RAS Segment of the 835 for the payer identified in the Loop ID-2430 SVD01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: RAS04 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

A positive value decreases the quantity, and a negative value increases the quantity.

DTP*573 - PAYMENT EFFECTIVE 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✱20221030~

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: Payment Effective Date

AMT*B6 - SERVICE ALLOWED AMOUNT

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 submitting a Coordination of Benefits (COB) claim, and:

The Other Payer referenced in SVD01 (of this iteration of Loop ID-2430) has adjudicated this claim and provided the 835 with line level allowed amount information to the submitter.

OR

The Other Payer identified in SVD01 (of this iteration of Loop ID-2430) has adjudicated this claim and the submitter received a paper, virtual, or other alternate format of remittance advice with the allowed amount reported.

OR

The Other Payer referenced in SVD01 (of this iteration of Loop ID-2430) is the same as the submitter reported in Loop ID-1000A.

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

TR3 Notes:

This is the 835 Loop ID-2110 Claim Allowed Amount (AMT02) when the remittance information is reported on an 835.
This is the service line allowed amount when remittance information is reported using other formats.
This amount is not sent if it is not explicitly available on an 835 or other remittance. If the allowed amount is not available, do not calculate the amount.
When the service line allowed amount is zero dollars, report zero (0).

TR3 Example:

AMT✱B6✱425~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Allowed - Actual

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Service Allowed Amount

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

Not Used

478

Credit/Debit Flag Code

O 1

AMT*EAF - REMAINING PATIENT LIABILITY AMOUNT

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 the Other Payer identified in SVD01 of this iteration of Loop ID 2430 has adjudicated the claim,

AND

The claim level (Loop ID-2320) Remaining Patient Liability AMT segment for this other payer is not used,

AND

The provider has the ability to report line item information,

AND

In the provider's opinion, the amount billable to the patient, is different than the sum of the amounts (RAS01) associated with Patient Responsibility (PR) Claim Adjustment Group Code (RAS02) in this 2430 loop. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This segment is not used in Payer-to-Payer Coordination of Benefits (COB).
In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.

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

LQ - HEALTH CARE REMARK CODES

X12 Name:

Industry Code Identification

X12 Purpose:

To identify standard industry codes

X12 Syntax:

C0102
If LQ01 is present, then LQ02 is required.

Loop: