278 Health Care Services Review Notification and Acknowledgment (008020X328)

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

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

CODE

DEFINITION

Health Care Services Review Information (278)

Required

142

Application Sender's Code

M 1

2/15

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

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

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

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

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

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

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

SEMANTIC: GS05 is the group time.

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

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

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

Required

455

Responsible Agency Code

M 1

1/2

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

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

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

INDUSTRY NAME: Version, Release, or Industry Identifier Code

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

CODE SOURCE 881: Version / Release / Industry Identifier Code

CODE

DEFINITION

008020X328

Health Care Services Review Notification and Acknowledgment

ST*278 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

ST✱278✱0002✱008020X328~

✱

✱

✱

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

278

Health Care Services Review Information

Required

329

Transaction Set Control Number

M 1

4/9

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

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

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

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

INDUSTRY NAME: Implementation Guide Version Name

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

CODE

DEFINITION

008020X328

Health Care Services Review Notification and Acknowledgment

BHT*0007 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0007✱14✱199800114000001✱20220101✱1400~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 2000A - NOTIFICATION SENDER LEVEL

Required

1005

Hierarchical Structure Code

M 1

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

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

CODE

DEFINITION

0007

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

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Advance Notification

Use when an administrative notification is needed for admissions, referrals, pre-certifications of future events. For example, use for notification of authorization to admit a patient, notification of authorization to refer a patient, notification of authorization for pre-certification of services.

Information Copy

Use when a courtesy copy of a notification is needed. For example, use to send copies of health care service review decision outcomes from a delegated entity, PCP, or UMO to the service provider.

Completion Notification

Use when an administrative notification is needed for admissions, referrals, pre-certifications associated with completed events. For example, use for Notice of Admission and Notice of Discharge.

Required

127

Reference Identification

O 1

1/80

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

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

INDUSTRY NAME: Submitter Transaction Identifier

If the receiver returns a 278 acknowledgment response, this identifier must be returned in the 278 acknowledgment transaction's BHT03.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Situational

640

Transaction Type Code

O 1

Code specifying the type of transaction

SITUATIONAL RULE: Required when a 278 acknowledgment response to this notification is required. If not required by this implementation guide, do not send.

If BHT06 is not valued, the notification receiver shall assume that a 278 acknowledgment response is not required or desired.

CODE

DEFINITION

Notice

HL - NOTIFICATION SENDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the notification sender hierarchical level. For a notification transaction, this segment corresponds to the identification of the provider, payer, HMO, delegated entity, or other utilization management organization sending this information.

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

Use when reporting the Notification Sender.

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - NOTIFICATION SENDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This loop is required and identifies the notification sender. In most cases, the notification sender is the same entity as the notification source. The notification source is the entity that determined the outcome of a health services review or the owner of the information.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

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 name information is needed to identify the notification sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Source First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Source Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Information Source 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

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

Use when the provider is in the United States or its territories and is eligible to receive a National Provider Identifier (NPI).
OR
Use when the provider is not in the United States or its territories and has received an 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 Notification Sender is eligible to receive a National Provider Identifier (NPI) OR for the Payor Identification OR when the National PlanID is mandated for use. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source 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 - NOTIFICATION SENDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Use when the response contains summary information on the authorizations found.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Source Supplemental Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - NOTIFICATION SENDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Used to identify a specific location when the notification sender has multiple locations and his authority varies based on location.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Information Source Address Line

Use this element for the first line of the notification sender address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Information Source Address Line

N4 - NOTIFICATION SENDER 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 necessary to identify the notification sender by location. If not required, by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Information Source 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: Information Source State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

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: Information Source 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: Notification Sender 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: Notification Sender 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

PER*IC - NOTIFICATION SENDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the notification receiver must direct requests for follow up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 acknowledgment must be directed to a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER04 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Information Source Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER06 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

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

INDUSTRY NAME: Information Source Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

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

INDUSTRY NAME: Information Source Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - NOTIFICATION SENDER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Notes:

PRV02 qualifies PRV03.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

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

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

NM1 - NOTIFICATION SOURCE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the notification receiver needs to identify the notification source name that determined the outcome of the health service review and when it is different from the notification sender Name. If not required by this implementation guide, do not send.

TR3 Notes:

This loop may be used when the notification sender is not the same entity as the notification source, or if there is a need to identify another requesting entity that was neither the notification sender or the notification source.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

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 name information is needed to identify the notification source. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Source First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Source Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Information Source 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

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

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: Information Source 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 - NOTIFICATION SOURCE SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Source Supplemental Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - NOTIFICATION SOURCE ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Used to identify a specific location when the notification source has multiple locations and his authority varies based on location.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Information Source Address Line

Use this element for the first line of the notification source address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Information Source Address Line

N4 - NOTIFICATION SOURCE CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Information Source 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: Information Source State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Information Source 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: Notification Source 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: Notification Source 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

PER*IC - NOTIFICATION SOURCE CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 acknowledgment must be directed to a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER04 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Information Source Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER06 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

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

INDUSTRY NAME: Information Source Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

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

INDUSTRY NAME: Information Source Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - NOTIFICATION SOURCE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop 2000B - NOTIFICATION RECEIVER LEVEL

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Notes:

PRV02 qualifies PRV03.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

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

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - NOTIFICATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the health care services review notification receiver.

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Information Receiver

Use when reporting the Notification Receiver.

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - NOTIFICATION 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.

Loop:

Loop 2010B - NOTIFICATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the receiver of information.

TR3 Example:

NM1✱X3✱2✱ABC PAYER✱✱✱✱✱46✱123450000~

NM1

✱

✱

Loop 2000C - SUBSCRIBER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

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 name information is needed to identify the receiver. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Information Receiver Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Receiver Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Information Receiver 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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Receiver 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 - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

HL✱3✱2✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name and identification number of the subscriber (who may also be the patient), or the Property & Casualty (including Workers' Compensation) entity.
The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02)
Refer to Section 1.11.2.1, Identifying the Subscriber/Patient.
When a Property & Casualty (including Workers' Compensation) entity is the Subscriber, value the Entity Type Qualifier to 2 and the associated Federal Tax ID.

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

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the receiver to identify the subscriber. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by receiver.

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Subscriber Middle Name or Initial

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Subscriber Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Subscriber Name Suffix

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Use when NM102 = 2.

Standard Unique Health Identifier for each Individual in the United States

Member Identification Number

Use when reporting 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: 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

REF - SUBSCRIBER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱1W✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

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

Branch Identifier

Group Number

Department Number

Patient Account Number

Use when reporting the patient account number. The maximum number of characters to be supported in REF02 for this qualifier is '35'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

Health Insurance Claim (HIC) Number

Identity Card Number

Use when the Identity Card Number differs from the Member Identification Number (MI) in NM108.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

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.

Agency Claim Number

Use when reporting the Property & Casualty claim number.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

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

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Subscriber Address Line

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
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 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 birth date is needed to identify the patient or when gender information was used to render a medical decision. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

✱

✱

✱

✱

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

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

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

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 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

INS*Y - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱AO~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

✱

584

Employment
Status Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Chge Identi
Info Code

O 20

✱

1793

Prov Netwrk
Info Code

Loop 2000D - DEPENDENT LEVEL

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

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

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Self

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Required

584

Employment Status Code

O 1

Code indicating the general employment status of an employee/claimant

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

CODE

DEFINITION

Active Military - Overseas

Active Military - USA

Deceased

Retired Military - USA

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Not Used

1470

Number

O 1

1/9

Not Used

1792

Changed Identifying Information Code

O 20

1/2

Not Used

1793

Provider Network Status Information Code

O 1

1/2

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

If the patient has a unique member ID, use Loop 2000C to identify the patient.

TR3 Example:

HL✱4✱3✱23✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*QC - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name of the dependent who is the patient.
The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02)

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

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

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

INDUSTRY NAME: Dependent Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Dependent First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Dependent Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Dependent Name Suffix

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - DEPENDENT SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
If the information sender values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.

TR3 Example:

REF✱EJ✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Employee Identification Number

Patient Account Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty 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: Dependent Supplemental Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - DEPENDENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Dependent Address Line

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

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Dependent Address Line

N4 - DEPENDENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
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 current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Dependent City Name

Situational

156

State or Province Code

X 1

Code 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: Dependent State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Dependent Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Dependent Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Dependent Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DMG*D8 - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the patient or when gender information was used to render a medical decision. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

✱

✱

✱

✱

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: Dependent Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

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

INDUSTRY NAME: Dependent Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 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

INS*N - DEPENDENT RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when patient relationship to insured or birth sequence was used to further identify the dependent. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

INS✱N✱19~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

✱

584

Employment
Status Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Chge Identi
Info Code

O 20

✱

1793

Prov Netwrk
Info Code

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

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

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Spouse

Child

Life Partner

Other Relationship

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Situational

1470

Number

O 1

1/9

A generic number

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

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

INDUSTRY NAME: Birth Sequence Number

Not Used

1792

Changed Identifying Information Code

O 20

1/2

Not Used

1793

Provider Network Status Information Code

O 1

1/2

HL - PATIENT EVENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Loop 2000E identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.
Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only.

TR3 Example:

HL✱5✱4✱EV✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Event

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN*1 - PATIENT EVENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the notification sender needs to assign a unique trace number at the Patient Event level. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

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

TR3 Example:

TRN✱1✱2001042801✱9012345678✱CARDIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Use when reporting the trace number assigned by the creator of this 278.

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Patient Event Trace Number

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

Required

509

Originating Company Identifier

O 1

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

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

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

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: TRN04 identifies a further subdivision within the organization.

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

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

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

AAA - PATIENT EVENT REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a notification of a health care services review that was rejected due to invalid or missing patient event information. If not required by this implementation guide, do not send.

TR3 Notes:

Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request. If not required, may be provided at the sender's discretion.

TR3 Example:

AAA✱N✱✱15~

AAA

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code identifying reason for rejection as assigned by issuer

SITUATIONAL RULE: Required when AAA01 = "N". If not required, may be provided at the sender's discretion.

CODE

DEFINITION

Required application data missing

Use when data is missing in this loop that is not covered by another Reject Reason Code.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Invalid/Missing Provider Specialty

Service Dates Not Within Provider Plan Enrollment

Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.

Invalid/Missing Date(s) of Service

Use when event date is invalid or missing.

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Invalid/Missing Diagnosis Code(s)

Invalid/Missing Onset of Current Condition or Illness Date

Invalid/Missing Accident Date

Invalid/Missing Last Menstrual Period Date

Invalid/Missing Expected Date of Birth

Invalid/Missing Admission Date

Invalid/Missing Discharge Date

Certification Information Missing

Use when reporting missing previous certification number information.

Not Used

889

Follow-up Action Code

O 1

Not Used

1787

Error Reason Code

O 99

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Required to identify the type of health care services in this notification.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Admission Review

Use when reporting an admission to a facility.

Health Services Review

Use when reporting services related to an episode of care.

Specialty Care Review

Use when reporting a referral to a specialty provider.

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Cancel

Extension

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

Notification

Initial

Reconsideration

Renewal

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

Revised

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

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

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

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

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

Situational

C023

Health Care Service Location Information

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

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

Required

4-1

1331

Facility Code Value

M 1

1/3

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

INDUSTRY NAME: Facility Type Code

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

Required

4-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

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

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Situational

1338

Level of Service Code

O 1

1/3

Code specifying the level of service rendered

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

CODE

DEFINITION

Emergency

Elective

Medicare Expedited

Urgent

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review information applies to the event level. If not required by this implementation guide, do not send.

TR3 Notes:

The HCR segment at the 2000E event level contains information relevant to the original decision holder for the event. Certification Action, Review Identification and Review Decision Reason Code data from the original decision maker is made available in the HCR segment to the notification receiver.

TR3 Example:

HCR✱A1✱20020713~

HCR

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Certified in total

Certified - partial

Use when reporting the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

Not Certified

Pended

Modified

Cancelled

Contact Payer

No Action Required

Use when certification is not required.

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: HCR02 is the number assigned by the information source to this review outcome.

SITUATIONAL RULE: Required when HCR01 = A1, A2 or A6. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review 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.

Situational

1271

Industry Code

O 5

1/30

Code indicating a code from a specific industry code list

SEMANTIC: HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886

SITUATIONAL RULE: Required when HCR01 = A3 or A4. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Review Decision Reason Code

The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.

Not Used

1073

Yes/No Condition or Response Code

O 1

REF*BB - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the certification number assigned by the UMO to the original event review outcome was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

REF✱BB✱A123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this notification is related to an acknowledgment received from the notification receiver in a prior acknowledgment transaction. If not required by this implementation guide, do not send.

TR3 Notes:

This is the administrative number assigned by the notification receiver in an acknowledgment from a prior notification. This is not the trace number assigned by the Information receiver.

TR3 Example:

REF✱NT✱123Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Administrative Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

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*484 - LAST MENSTRUAL PERIOD DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱484✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

484

Last Menstrual Period

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Last Menstrual Period Date

DTP*ABC - ESTIMATED BIRTH DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱ABC✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

ABC

Estimated Date of Birth

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Estimated Birth Date

DTP*431 - ONSET OF CURRENT SYMPTOMS OR ILLNESS DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱431✱D8✱20220108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

431

Onset of Current Symptoms or Illness

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Onset Date

DTP*AAH - EVENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

If UM01 = AR use Admit Date.
The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱AAH✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

AAH

Event

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Event Date

DTP*435 - ADMISSION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱435✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

435

Admission

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use when needed to report a range of dates when admission can occur.

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Admission Date

DTP*096 - DISCHARGE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱096✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Discharge Date

DTP*102 - CERTIFICATION ISSUE 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 certification issue date is different than the certification effective date. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱102✱D8✱20221002~

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

102

Issue

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: Certification Issue Date

DTP*036 - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the certification has an expiration date that indicates the date on which the certification will expire. If not required by the implementation guide, do not send.

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱036✱D8✱20221002~

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

036

Expiration

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: Certification Expiration Date

DTP*007 - CERTIFICATION 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 certification is limited by effective dates to indicate the date or date range when the certification is effective. If not required by the implementation guide, do not send.

TR3 Notes:

The total number of DTP segments in the 2000E loop cannot exceed 9.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~

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

007

Effective

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: Certification Effective Date

HI - PATIENT SYMPTOMS, DIAGNOSIS, COMPLAINTS

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 patient's symptoms, complaints and /or diagnosis has a codified value in a code set with values supported by the HI segment.

TR3 Notes:

Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Do not use the MSG segment to relay information if it can be codified using a code set in the HI segment.
There are 2 repetitions of the HI segment to allow for 24 possible occurrences of ICD Diagnosis code information. The first iteration would contain diagnosis code 1-12. When used, the second iteration would contain diagnosis codes 13-24.

TR3 Example:

HI✱ABF:H16013~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

ABJ

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

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

ABK

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1271

Industry Code

X 1

1/30

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

ABJ

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

2-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

2-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

X 1

1/30

Not Used

2-9

1271

Industry Code

X 1

1/30

Not Used

2-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

3-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

3-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

X 1

1/30

Not Used

3-9

1271

Industry Code

X 1

1/30

Not Used

3-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

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

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

4-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

4-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

X 1

1/30

Not Used

4-9

1271

Industry Code

X 1

1/30

Not Used

4-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

5-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

5-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

X 1

1/30

Not Used

5-9

1271

Industry Code

X 1

1/30

Not Used

5-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

6-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

6-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

X 1

1/30

Not Used

6-9

1271

Industry Code

X 1

1/30

Not Used

6-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

7-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

7-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

X 1

1/30

Not Used

7-9

1271

Industry Code

X 1

1/30

Not Used

7-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

8-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

8-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

X 1

1/30

Not Used

8-9

1271

Industry Code

X 1

1/30

Not Used

8-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

9-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

9-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

9-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

9-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

9-5

782

Monetary Amount

O 1

1/18

Not Used

9-6

380

Quantity

O 1

1/15

Not Used

9-7

799

Version Identifier

O 1

1/30

Not Used

9-8

1271

Industry Code

X 1

1/30

Not Used

9-9

1271

Industry Code

X 1

1/30

Not Used

9-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

10-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

10-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

10-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

10-5

782

Monetary Amount

O 1

1/18

Not Used

10-6

380

Quantity

O 1

1/15

Not Used

10-7

799

Version Identifier

O 1

1/30

Not Used

10-8

1271

Industry Code

X 1

1/30

Not Used

10-9

1271

Industry Code

X 1

1/30

Not Used

10-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

11-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

11-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

11-5

782

Monetary Amount

O 1

1/18

Not Used

11-6

380

Quantity

O 1

1/15

Not Used

11-7

799

Version Identifier

O 1

1/30

Not Used

11-8

1271

Industry Code

X 1

1/30

Not Used

11-9

1271

Industry Code

X 1

1/30

Not Used

11-10

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 there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

12-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

APR

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

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

Diagnosis Related Group (DRG)

Required

12-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

12-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

12-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

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

INDUSTRY NAME: Diagnosis Date

Not Used

12-5

782

Monetary Amount

O 1

1/18

Not Used

12-6

380

Quantity

O 1

1/15

Not Used

12-7

799

Version Identifier

O 1

1/30

Not Used

12-8

1271

Industry Code

X 1

1/30

Not Used

12-9

1271

Industry Code

X 1

1/30

Not Used

12-10

1271

Industry Code

O 1

1/30

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.
C0905
If HSD09 is present, then HSD05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
An explanation of the uses of this segment follows.

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

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

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

TR3 Example:

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

HSD

✱

✱

✱

✱

✱

Time Period
Qualifier

✱

✱

Ship/Del or
Calend Code

✱

✱

✱

Situational

673

Quantity Qualifier

X 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD02 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the pattern of delivery has quantity of services authorized. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Situational

355

Unit or Basis for Measurement Code

O 1

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

SITUATIONAL RULE: Required when the services rendered have a time frame which services will be rendered. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Months

Week

Situational

1167

Sample Selection Modulus

O 1

1/6

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

SITUATIONAL RULE: Required when HSD03 is valued to qualify the timeframe of when services will be rendered. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

X 1

1/2

Code specifying periods

SEGMENT SYNTAX: C0605, C0905

SITUATIONAL RULE: Required when the service must be rendered within a specific timeframe, or occurrence. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Episode

Visit

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEMANTIC: HSD06 identifies the number of periods, or the minimum in a range of periods when HSD09 is present.

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when the service must be rendered within a specific timeframe, or occurrence. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code specifying the routine shipments, deliveries, or calendar pattern

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

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Sunday, Monday, Thursday, Friday, Saturday

Tuesday through Saturday

Sunday, Wednesday, Thursday, Friday, Saturday

Monday, Wednesday, Thursday, Friday, Saturday

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

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

Whenever Necessary

Weekend

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

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

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code specifying the time for routine shipments or deliveries

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

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

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

Not Used

616

Number of Periods

O 1

1/3

Not Used

352

Description

O 1

1/80

CL1 - NURSING HOME RESIDENTIAL STATUS

X12 Name:

Claim Codes

X12 Purpose:

To supply information specific to hospital claims

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when certification involves non-institutional services for a nursing home resident and SV2 is not used. If not required by this implementation guide, do not send.

TR3 Example:

CL1✱3✱✱01~

CL1

✱

✱

Admission
Source Code

✱

✱

Nurse Home
Status Code

Not Used

1315

Priority (Type) of Admission or Visit

O 1

Not Used

1314

Point of Origin for Admission or Visit

O 1

Not Used

1352

Patient Discharge Status

O 1

1/2

Required

1345

Nursing Home Residential Status Code

O 1

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

CODE

DEFINITION

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

Newly Admitted

Newly Eligible

No Longer Eligible

Still a Resident

Temporary Absence - Hospital

Temporary Absence - Other

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

Other

CR1 - AMBULANCE TRANSPORT INFORMATION

X12 Name:

Ambulance Certification

X12 Purpose:

To supply information related to the ambulance service rendered to a patient

X12 Syntax:

P0102
If either CR101 or CR102 is present, then the other is required.
P0506
If either CR105 or CR106 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.

TR3 Notes:

When the CR1 segment is used, then Loop 2010EB is required.

TR3 Example:

CR1✱✱✱T✱✱DH✱28~

CR1

✱

✱

✱

✱

Ambulance
Reason Code

✱

✱

✱

✱

✱

✱

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

Weight

X 1

1/10

Required

1316

Ambulance Transport Code

O 1

Code indicating the type of ambulance transport

CODE

DEFINITION

Initial Trip

Return Trip

Transfer Trip

Round Trip

Not Used

1317

Ambulance Transport Reason Code

O 1

Situational

355

Unit or Basis for Measurement Code

X 1

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

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when distance of transportation is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Miles

Kilometers

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CR106 is the distance traveled during transport.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when distance of transportation is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transport Distance

Not Used

166

Address Information

O 1

1/55

Not Used

166

Address Information

O 1

1/55

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR109 is the purpose for the round trip ambulance service.

SITUATIONAL RULE: Required when CR103 (Ambulance Transport Code) = "X Round Trip". If not required by this implementation guide, do not send.

Not Used

352

Description

O 1

1/80

CR2 - SPINAL MANIPULATION SERVICE INFORMATION

X12 Name:

Chiropractic Certification

X12 Purpose:

To supply information related to the chiropractic service rendered to a patient

X12 Syntax:

P0102
If either CR201 or CR202 is present, then the other is required.
C0403
If CR204 is present, then CR203 is required.
P0506
If either CR205 or CR206 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying certification for spinal manipulation services when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.

TR3 Example:

CR2✱1✱5~

CR2

✱

✱

✱

Subluxation
Level Code

2/3

✱

1367

Subluxation
Level Code

✱

✱

✱

✱

✱

✱

✱

✱

Situational

609

Count

X 1

1/9

Occurrence counter

SEMANTIC: CR201 is the number this treatment is in the series.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.

INDUSTRY NAME: Treatment Series Number

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CR202 is the total number of treatments in the series.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.

INDUSTRY NAME: Treatment Count

Situational

1367

Subluxation Level Code

X 1

2/3

Code identifying the specific level of subluxation

COMMENT: When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.

SEGMENT SYNTAX: C0403

SITUATIONAL RULE: Required when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Cervical 1

Cervical 2

Cervical 3

Cervical 4

Cervical 5

Cervical 6

Cervical 7

Coccyx

Ilium

Lumbar 1

Lumbar 2

Lumbar 3

Lumbar 4

Lumbar 5

Occiput

Sacrum

Thoracic 1

T10

Thoracic 10

T11

Thoracic 11

T12

Thoracic 12

Thoracic 2

Thoracic 3

Thoracic 4

Thoracic 5

Thoracic 6

Thoracic 7

Thoracic 8

Thoracic 9

Situational

1367

Subluxation Level Code

O 1

2/3

Code identifying the specific level of subluxation

SEGMENT SYNTAX: C0403

SITUATIONAL RULE: Required when the patient's condition or treatment involves subluxation to express the ending level of subluxation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Cervical 1

Cervical 2

Cervical 3

Cervical 4

Cervical 5

Cervical 6

Cervical 7

Coccyx

Ilium

Lumbar 1

Lumbar 2

Lumbar 3

Lumbar 4

Lumbar 5

Occiput

Sacrum

Thoracic 1

T10

Thoracic 10

T11

Thoracic 11

T12

Thoracic 12

Thoracic 2

Thoracic 3

Thoracic 4

Thoracic 5

Thoracic 6

Thoracic 7

Thoracic 8

Thoracic 9

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

380

Quantity

X 1

1/15

Not Used

380

Quantity

O 1

1/15

Not Used

1342

Nature of Condition Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

352

Description

O 1

1/80

Not Used

352

Description

O 1

1/80

Not Used

1073

Yes/No Condition or Response Code

O 1

CR5 - HOME OXYGEN THERAPY INFORMATION

X12 Name:

Oxygen Therapy Certification

X12 Purpose:

To supply information regarding certification of medical necessity for home oxygen therapy

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying initial, extended, or revised certification of home oxygen therapy. If not required by this implementation guide, do not send.

TR3 Notes:

Use the UM segment data element UM02 instead of CR501 to specify the Certification Type Code.
Use the HSD segment instead of CR502 to specify the treatment period.

TR3 Example:

CR5✱✱✱D✱✱✱1✱✱✱✱✱✱✱✱✱✱2✱A~

CR5

✱

1322

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Oxygen Test
Cond Code

✱

1350

Oxygen Test
Find Code

✱

1350

Oxygen Test
Find Code

✱

1350

Oxygen Test
Find Code

✱

✱

✱

Not Used

1322

Certification Type Code

O 1

Not Used

380

Quantity

O 1

1/15

Required

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

Situational

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

SITUATIONAL RULE: Required when CR503 is present and more than one type of equipment was identified to administer the oxygen therapy. If not required by this implementation guide, do not send.

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

Not Used

352

Description

O 1

1/80

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR506 is the oxygen flow rate in liters per minute.

INDUSTRY NAME: Oxygen Flow Rate

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR507 is the number of times per day the patient must use oxygen.

SITUATIONAL RULE: Required when daily oxygen use count is relevant to the type of home oxygen therapy identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Daily Oxygen Use Count

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR508 is the number of hours per period of oxygen use.

SITUATIONAL RULE: Required when daily oxygen use count is relevant to the type of home oxygen therapy identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Oxygen Use Period Hour Count

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR509 is the special orders for the respiratory therapist.

SITUATIONAL RULE: Required when necessary to convey special orders for the respiratory therapist. If not required by this implementation guide, do not send.

INDUSTRY NAME: Respiratory Therapist Order Text

Not Used

380

Quantity

O 1

1/15

Not Used

380

Quantity

O 1

1/15

Not Used

1349

Oxygen Test Condition Code

O 1

Not Used

1350

Oxygen Test Findings Code

O 1

Not Used

1350

Oxygen Test Findings Code

O 1

Not Used

1350

Oxygen Test Findings Code

O 1

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.

SITUATIONAL RULE: Required when either CR503, CR504 or CR518 = "D" (Liquid Portable) or "E" (Gaseous Portable). If not required by this implementation guide, do not send.

INDUSTRY NAME: Portable Oxygen System Flow Rate

Required

1382

Oxygen Delivery System Code

O 1

Code indicating if a particular form of delivery was prescribed

CODE

DEFINITION

Nasal Cannula

Oxygen Conserving Device

Oxygen Conserving Device with Oxygen Pulse System

Oxygen Conserving Device with Reservoir System

Transtracheal Catheter

Situational

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

SITUATIONAL RULE: Required when CR503 and CR504 are present and more than two types of equipment are required to administer the oxygen therapy. If not required by this implementation guide, do not send.

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

CR6 - HOME HEALTH CARE INFORMATION

X12 Name:

Home Health Care Certification

X12 Purpose:

To supply information related to the certification of a home health care patient

X12 Syntax:

P0304
If either CR603 or CR604 is present, then the other is required.
P091011
If either CR609, CR610 or CR611 are present, then the others are required.
P151617
If either CR615, CR616 or CR617 are present, then the others are required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.

TR3 Example:

CR6✱1✱20130502✱RD8✱20220502-20220801✱✱✱W✱I~

Required

923

Prognosis Code

M 1

Code indicating physician's prognosis for the patient

CODE

DEFINITION

Poor

Guarded

Fair

Good

Very Good

Excellent

Less than 6 Months to Live

Terminal

Required

373

Date

M 1

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

SEMANTIC: CR602 is the date covered home health services began.

INDUSTRY NAME: Home Health Start Date

Situational

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the event date has not been identified in DTP, Event Date in this loop and the duration of this plan of treatment is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1251

Date Time Period

X 1

1/35

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

SEMANTIC: CR604 is the certification period covered by this plan of treatment.

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Home Health Certification Period

Not Used

373

Date

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.

INDUSTRY NAME: Medicare Coverage Indicator

CODE

DEFINITION

Not Applicable

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

This element must have the same value as UM02.

CODE

DEFINITION

Appeal - Immediate

Appeal - Standard

Cancel

Extension

Notification

Initial

Reconsideration

Renewal

Revised

Not Used

373

Date

X 1

Not Used

235

Product/Service ID Qualifier

X 1

Not Used

1137

Medical Code Value

X 1

1/15

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

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

1384

Patient Location Code

X 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

PWK - ADDITIONAL PATIENT INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting specific documentation requirements, formats, or forms. If not required by this implementation guide, do not send.

TR3 Notes:

This PWK segment is utilized to identify the type of additional information being sent, how that information is being sent, and includes a unique identifier (Attachment Control Number) to associate the information with the notification.

Refer to Section 1.11.6.1 for more information on using this PWK segment.

TR3 Example:

PWK✱OB✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Use when reporting expected outcomes of rehabilitative services.

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use when reporting a medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Use when there is a certificate of medical necessity for an ambulance trip.

Admission Summary

Use when an admission summary exists; listing the patient's complaints and the reasons for admitting the patient to the hospital.

Purchase Order Attachment

Use when medical or dental equipment was purchased.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Use when reporting the reasons chiropractic is a just and appropriate treatment.

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

History and Physical

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Therapy Notes

Other Type of Report

Death Notification

Photographs

Required

756

Report Transmission Code

O 1

1/2

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

CODE

DEFINITION

Available on Request at Provider Site

By Mail

Electronically Only

Use when reporting the attachment is being transmitted in a separate X12 functional group.

E-Mail

File Transfer

By Fax

On-Line

Voice

Use when communication is by voice mail or phone.

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 PWK06 is valued. 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 equals BM, EL, EM, FT, FX or OL. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Attachment Control Number

Situational

352

Description

O 1

1/80

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

COMMENT: PWK07 may be used to indicate special information to be shown on the specified report.

SITUATIONAL RULE: Required when needed to add any additional information about the attachment described in this segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Description

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.

TR3 Notes:

Free form text or description fields are not recommended because they require human interpretation.
Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.

TR3 Example:

MSG✱This is a free-form text message~

MSG

✱

933

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

X 1

Not Used

1470

Number

O 1

1/9

NM1 - PATIENT EVENT PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.

TR3 Notes:

If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Attending Physician

Operating Physician

Other Physician

Service Location

Admitting Physician

Assistant Surgeon

Ordering Physician

Referring Provider

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

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 identifying a specific person, facility, group practice, or clinic and NM108/NM109 are not present. Not used if identifying a specialty entity utilizing the PRV segment. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Patient Event Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Event 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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

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 identifying the services of a specific person, facility, group practice, or clinic and the provider ID is known by the notification sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - PATIENT EVENT PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when the Patient Event Provider has not been assigned an NPI or the Notification Receiver in loop 2010B has assigned its own identifier for this provider.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Event Provider Supplemental Identifier

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

Situational

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

Not Used

C040

Reference Identifier

O 1

N3 - PATIENT EVENT PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Address Line

Use this element for the first line of the patient event provider's address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Event Provider Address Line

N4 - PATIENT EVENT PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Patient Event Provider City Name

Situational

156

State or Province Code

X 1

Code 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 Event 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)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Patient Event Provider Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Patient Event Provider Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Patient Event Provider Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*IC - PATIENT EVENT PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a contact name and/or communication number for the provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 acknowledgment must be directed to a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

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

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Patient Event Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER06 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Uniform Resource Locator (URL)

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

INDUSTRY NAME: Patient Event Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Uniform Resource Locator (URL)

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

INDUSTRY NAME: Patient Event Provider Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

AAA - PATIENT EVENT PROVIDER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱43~

AAA

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Invalid Participant Identification

Use when reporting invalid/missing service provider supplemental identifier.

Invalid or Missing Provider Address

Inappropriate Provider Role

Not Used

889

Follow-up Action Code

O 1

Not Used

1787

Error Reason Code

O 99

PRV - PATIENT EVENT PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Hospital

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

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

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

NM1*L5 - ADDITIONAL INFORMATION CONTACT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when additional information is sent by an information contact that is different from the notification sender identified in loop 2010AA. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱L5✱2✱ACME THIRD PARTY ADMINISTRATOR~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Contact

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Use when the destination is an individual, such as an individual primary care physician.

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 notification sender needs to identify the destination by name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the destination is an individual (NM102 = 1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Response Contact Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Response Contact 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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

Use when the destination is a payer.

CODE SOURCE: 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

Use when the destination is a provider.

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 notification sender needs to identify the destination. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact 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 - ADDITIONAL INFORMATION CONTACT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

TR3 Notes:

Sometimes there is not a true address in an area where there is no street address, 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: Response Contact Address Line

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

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Response Contact Address Line

N4 - ADDITIONAL INFORMATION CONTACT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Additional Patient Information Contact 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: Additional Patient Information Contact State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Additional Patient Information Contact 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: Additional Patient Information 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: Additional Patient Information 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

PER*IC - ADDITIONAL INFORMATION 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 the request for additional patient information must be routed to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
By definition of the standard, if PER03 is used, PER04 is required.

TR3 Example:

PER✱IC✱MARY✱FX✱3135551212~

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 acknowledgment must be directed to a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

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

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Response Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER06 is used. 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 a telephone extension or multiple communication types are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

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

INDUSTRY NAME: Response Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1 - PATIENT EVENT TRANSPORT INFORMATION

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when requesting transport of the patient. If not required by this implementation guide, do not send.

TR3 Notes:

At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop

TR3 Example:

NM1✱PW✱2✱PATIENT DIALYSIS CENT~
NM1✱FS✱2~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Drop-off Location

Final Scheduled Destination

Next Destination

Pickup Address

Next Scheduled Destination

Required

1065

Entity Type Qualifier

M 1

Code 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 name of the location for which the patient is being transported is known. If not required by this implementation, do not send.

INDUSTRY NAME: Patient Event Provider Transport Location Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Situational

Entity Identifier Code

O 1

2/3

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

SEGMENT SYNTAX: C1110

SITUATIONAL RULE: Required when the location category is needed by the UMO to render a medical decision. If not required by this implementation guide, do not send.

INDUSTRY NAME: Location Category Code

CODE

DEFINITION

Oncology Center

Acute Care Hospital

Military Facility

Outpatient Surgicenter

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Federal, State, County or City Facility

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

Department of Justice Facility

General Medical and Surgical Facility

Hospital Unit of an Institution (prison hospital, college infirmary, etc.)

Hospital Unit Within an Institution for the Mentally Retarded

Psychiatric Facility

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

Arthritis Treatment Center

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Trauma Center (Certified)

Fitness Center

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Comprehensive Geriatric Assessment Facility

Geriatric Clinics

Respite Care Facility

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Hisopathology Laboratory

Therapeutic Radioisotope Facility

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Orthopedic Surgery Facility

Cardiac Rehabilitation Program Facility

Federally Chartered Facility

Hospital

Primary Residence

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Migrant Health Clinic

Oxygen Therapy Facility

Patient Facility

Dialysis Centers

Rural Health Clinic

Skilled Nursing Facility

Nursing Home

Durable Medical Equipment Supplier

Mutually Defined

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - PATIENT EVENT TRANSPORT LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Transport Location Address Line

Use this element for the first line of the transport location address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Event Provider Transport Location Address Line

N4 - PATIENT EVENT TRANSPORT LOCATION CITY/STATE/ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

✱

✱

✱

✱

✱

✱

✱

✱

Situational

City Name

O 1

2/30

Free-form text for city name

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

SITUATIONAL RULE: Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

SITUATIONAL RULE: Required when N401 and N402 are not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Patient Event Transport Country Code

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

Not Used

1715

Country Subdivision Code

X 1

1/3

Not Used

1702

Postal Code-Formatted

X 1

3/20

AAA - PATIENT EVENT TRANSPORT INFORMATION REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

AAA✱N✱✱47✱C~

AAA

✱

Loop 2010ED - PATIENT EVENT OTHER UMO NAME

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code identifying reason for rejection as assigned by issuer

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the transport information.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Invalid/Missing Provider State

Use when the transport location state is invalid or missing.

Invalid or Missing Provider Address

Use when the transport location address is invalid or missing.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Not Used

1787

Error Reason Code

O 99

NM1 - PATIENT EVENT OTHER UMO NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱CA✱2~

NM1

✱

✱

Loop 2010ED - PATIENT EVENT OTHER UMO NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Alternate Insurer

Use when reporting the other UMO is commercial insurance.

Carrier

Use when reporting the other UMO is Medicare Part B.

Intermediary

Use when reporting the other UMO is Medicare Part A.

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 NM101 is equal to "00" to indicate the name of the other UMO. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other UMO Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF*ZZ - OTHER UMO DENIAL REASON

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱ZZ✱0M~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Use when reporting a Health Care Service Review Decision Reason Code from Code Source 886.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other UMO Denial Reason

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

Not Used

352

Description

X 1

1/80

Situational

C040

Reference Identifier

O 1

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

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

X12 COMPOSITE SYNTAX NOTES:

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

SITUATIONAL RULE: Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Use when reporting a Health Care Service Review Decision Reason Code from Code Source 886.

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Other UMO Denial Reason

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

Situational

4-3

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the other UMO denied the request for more than two reasons. If not required by this implementation guide, do not send.

CODE

DEFINITION

Mutually Defined

Use when reporting a Health Care Service Review Decision Reason Code from Code Source 886.

Situational

4-4

127

Reference Identification

X 1

1/80

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the other UMO denied the request for more than two reasons. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other UMO Denial Reason

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

Situational

4-5

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

COMPOSITE SYNTAX: P0506

SITUATIONAL RULE: Required when the other UMO denied the request for more than three reasons. If not required by this implementation guide, do not send.

CODE

DEFINITION

Mutually Defined

Use when reporting a Health Care Service Review Decision Reason Code from Code Source 886.

Situational

4-6

127

Reference Identification

X 1

1/80

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

COMPOSITE SYNTAX: P0506

SITUATIONAL RULE: Required when the other UMO denied the request for more than three reasons. If not required by this implementation guide, do not send.

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

DTP*598 - OTHER UMO DENIAL DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2010ED - PATIENT EVENT OTHER UMO NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱598✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

598

Rejected

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Other UMO Denial Date

HL - SERVICE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when identifying specific services associated with this patient event. If not required by this implementation guide, do not send.

TR3 Notes:

This segment identifies the service(s) and conveys the review outcome related to that service(s).

TR3 Example:

HL✱6✱5✱SS✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Services

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

TRN - SERVICE TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
This enables the requester to
• uniquely identify this service line request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional service information related to this service line request.
If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.
Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.

TR3 Example:

TRN✱1✱111099✱9012345678✱RADIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Use when reporting the trace number assigned by the creator of this 278.

Referenced Transaction Trace Numbers

Use when reporting the trace number from the original 278 transaction.

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Service Trace Number

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

Required

509

Originating Company Identifier

O 1

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

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction. If TRN01 is "1", use this information to identify the UMO organization that assigned this trace number.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when necessary to further identify a specific component, such as a specific division or group, of the company identified in the previous data element (TRN03). If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

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

AAA - SERVICE REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a notification of a health care services review that was rejected due to invalid or missing service information. If not required by this implementation guide, do not send.

TR3 Notes:

If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.

TR3 Example:

AAA✱N✱✱52~

AAA

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code identifying reason for rejection as assigned by issuer

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing in this loop that is not covered by another Reject Reason Code.

Input Errors

Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid procedure codes and procedure dates.

Service Dates Not Within Provider Plan Enrollment

Invalid/Missing Date(s) of Service

Use when service dates are invalid or missing.

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Invalid/Missing Procedure Code(s)

Certification Information Missing

Use when reporting missing previous certification number information.

Not Used

889

Follow-up Action Code

O 1

Not Used

1787

Error Reason Code

O 99

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Health Services Review

Use when reporting services related to an episode of care.

Specialty Care Review

Use when reporting a referral to a specialty provider.

Situational

1322

Certification Type Code

O 1

Code indicating the type of certification

SITUATIONAL RULE: Required when different from the UM02 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

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

Notification

Initial

Reconsideration

Renewal

Revised

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

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

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

SITUATIONAL RULE: Required when different from the UM03 value at the Patient Event level (Loop 2000E) or when the SV1, or SV2, or SV3 is not valued in this Service loop. If not required by this implementation guide, do not send.Values at the Service Level override the values entered at the Patient Event Level for this service.

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

Situational

C023

Health Care Service Location Information

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when different from the UM04 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

For this service, values at the Service Level override values at the Patient Event Level.

Required

4-1

1331

Facility Code Value

M 1

1/3

INDUSTRY NAME: Facility Type Code

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

Required

4-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

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

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the HCR segment is not used in 2000E, or if HCR01 in 2000E is A2. If not required by this implementation guide, do not send.

TR3 Notes:

If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.

TR3 Example:

HCR✱A1✱20020713~

HCR

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Certified in total

Not Certified

Pended

Modified

Cancelled

Contact Payer

No Action Required

Use when certification is not required.

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: HCR02 is the number assigned by the information source to this review outcome.

SITUATIONAL RULE: Required when HCR01 = A1 or A6. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review 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.

Situational

1271

Industry Code

O 5

1/30

Code indicating a code from a specific industry code list

SEMANTIC: HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886

SITUATIONAL RULE: Required when HCR01 = A3 or A4. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Review Decision Reason Code

The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.

Not Used

1073

Yes/No Condition or Response Code

O 1

REF*BB - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

REF✱BB✱A123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

This is the administrative number assigned by the notification receiver for the original acknowledgment of the notification associated with this service review. This is not the trace number assigned by the requester.

TR3 Example:

REF✱NT✱123Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Administrative Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment for the valid date(s) during which the service can be performed.

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: Proposed or Actual Service Date

DTP*102 - CERTIFICATION ISSUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Certification Issue Date is different from the Patient Event Certification Issue Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment for the date when the certification was issued.

TR3 Example:

DTP✱102✱D8✱20221002~

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

102

Issue

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: Certification Issue Date

DTP*036 - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Certification Expiration Date is different from the Patient Event Certification Expiration Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱036✱D8✱20221002~

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

036

Expiration

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: Certification Expiration Date

DTP*007 - CERTIFICATION 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:

Situational

Segment Repeat:

Situational Rule:

Required when different from the Certification Effective Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~

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

007

Effective

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: Certification Effective Date

HI - ADDITIONAL SERVICE DESCRIPTION

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an additional service description is needed to clarify the services identified in the 2000F UM03, SV1, SV2, SV3, or DRA segments. If not required by this implementation guide, do not send.

TR3 Example:

HI✱AAA:422011000124105~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description 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 service description and the preceding HI data elements have been used to report other service descriptions. If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description 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

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description 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

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description 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

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

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

5-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

5-4

1251

Date Time Period

X 1

1/35

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

X 1

1/30

Not Used

5-9

1271

Industry Code

X 1

1/30

Not Used

5-10

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

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

6-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

6-4

1251

Date Time Period

X 1

1/35

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

X 1

1/30

Not Used

6-9

1271

Industry Code

X 1

1/30

Not Used

6-10

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

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

7-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

7-4

1251

Date Time Period

X 1

1/35

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

X 1

1/30

Not Used

7-9

1271

Industry Code

X 1

1/30

Not Used

7-10

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

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

8-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

8-4

1251

Date Time Period

X 1

1/35

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

X 1

1/30

Not Used

8-9

1271

Industry Code

X 1

1/30

Not Used

8-10

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

9-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

9-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

9-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

9-4

1251

Date Time Period

X 1

1/35

Not Used

9-5

782

Monetary Amount

O 1

1/18

Not Used

9-6

380

Quantity

O 1

1/15

Not Used

9-7

799

Version Identifier

O 1

1/30

Not Used

9-8

1271

Industry Code

X 1

1/30

Not Used

9-9

1271

Industry Code

X 1

1/30

Not Used

9-10

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

10-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

10-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

10-4

1251

Date Time Period

X 1

1/35

Not Used

10-5

782

Monetary Amount

O 1

1/18

Not Used

10-6

380

Quantity

O 1

1/15

Not Used

10-7

799

Version Identifier

O 1

1/30

Not Used

10-8

1271

Industry Code

X 1

1/30

Not Used

10-9

1271

Industry Code

X 1

1/30

Not Used

10-10

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

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

11-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

11-4

1251

Date Time Period

X 1

1/35

Not Used

11-5

782

Monetary Amount

O 1

1/18

Not Used

11-6

380

Quantity

O 1

1/15

Not Used

11-7

799

Version Identifier

O 1

1/30

Not Used

11-8

1271

Industry Code

X 1

1/30

Not Used

11-9

1271

Industry Code

X 1

1/30

Not Used

11-10

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

12-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

12-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

12-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

12-4

1251

Date Time Period

X 1

1/35

Not Used

12-5

782

Monetary Amount

O 1

1/18

Not Used

12-6

380

Quantity

O 1

1/15

Not Used

12-7

799

Version Identifier

O 1

1/30

Not Used

12-8

1271

Industry Code

X 1

1/30

Not Used

12-9

1271

Industry Code

X 1

1/30

Not Used

12-10

1271

Industry Code

O 1

1/30

SV1 - PROFESSIONAL SERVICE

X12 Name:

Professional Service

X12 Purpose:

To specify the service line item detail for a health care professional

X12 Syntax:

P0304
If either SV103 or SV104 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific Professional Service. If not required by this implementation guide, do not send.

TR3 Notes:

In cases where a drug is reported, the DRA segment of Service Level Loop ID-2000F can be utilized in place of this segment to further specify drug reporting.

TR3 Example:

SV1✱HC:99211:25✱12.25✱UN✱1✱✱✱1:2:3✱✱✱✱N~

SV1

✱

C003

✱

✱

✱

✱

✱

✱

Diagnosis
Code Pointr

✱

✱

✱

✱

✱

✱

✱

✱

✱

Healthcare
Short Code

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Use when reporting the Device Identifier of Unique Device Identifier.

Prior to the mandated implementation date for the Unique Device Identifier, willing trading partners may agree to follow an early implementation approach.

Code Source: FDA Global Unique Device Identifier Database (GUDID) http://accessgudid.nlm.nih.gov/
Available from:
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894

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 the notification sender needs to convey additional clarification to miscellaneous, unspecified, or non descriptive procedures or modifiers. If not required by this implementation guide, do not send.

Use this data element for the first procedure code modifier.

Situational

1-4

1339

Procedure Modifier

O 1

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

Use this data element for the second procedure code modifier.

Situational

1-5

1339

Procedure Modifier

O 1

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

Use this data element for the third procedure code modifier.

Situational

1-6

1339

Procedure Modifier

O 1

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

Use this data element for the fourth procedure code modifier.

Situational

1-7

352

Description

O 1

1/80

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

INDUSTRY NAME: Procedure Code Description

Situational

1-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when the information source has not determined the intensity or complexity of the services and therefore identifies a range of procedures. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV101-02 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

Situational

1-9

1339

Procedure Modifier

O 1

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

Situational

1-10

1339

Procedure Modifier

O 1

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

Situational

1-11

1339

Procedure Modifier

O 1

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

Situational

1-12

1339

Procedure Modifier

O 1

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

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV102 is the submitted service line item amount.

SITUATIONAL RULE: Required when the Notification or Information Copy had monetary limitations for the service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

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

Situational

355

Unit or Basis for Measurement Code

X 1

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

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when service units were not provided in the HSD segment and a specific number of services are being identified for this procedure. If not required by this implementation guide, do not send.

CODE

DEFINITION

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Minutes

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Service Unit Count

Not Used

1331

Facility Code Value

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

Situational

1328

Diagnosis Code Pointer

O 12

1/2

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

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

SITUATIONAL RULE: Required when the notification sender wants to indicate that a specific procedure only relates to a specific diagnosis reported in HI Loop 2000E. If not required by this implementation guide, do not send.

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1340

Multiple Procedure Code

O 1

1/2

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.

SITUATIONAL RULE: Required when the review decision is based on EPSDT. If not required by this implementation guide, do not send.

INDUSTRY NAME: EPSDT Indicator

CODE

DEFINITION

Yes

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1364

Review Code

O 1

1/2

Not Used

1341

National or Local Assigned Review Value

O 1

1/2

Not Used

1327

Copay Status Code

O 1

Not Used

1334

Health Care Professional Shortage Area Code

O 1

Not Used

127

Reference Identification

O 1

1/80

Not Used

116

Postal Code

O 1

3/15

Not Used

782

Monetary Amount

O 1

1/18

Situational

1337

Level of Care Code

O 1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when needed to further clarify the level of care in which a patient resides. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

Not Used

1360

Provider Agreement Code

O 1

SV2 - INSTITUTIONAL SERVICE

X12 Name:

Institutional Service

X12 Purpose:

To specify the service line item detail for a health care institution

X12 Syntax:

R0102
At least one of SV201 or SV202 is required.
P0405
If either SV204 or SV205 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific Institutional Service, or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

TR3 Notes:

In cases where a drug is reported, the DRA segment of Service Level Loop ID-2000F can be utilized in place of this segment to further specify drug reporting.

TR3 Example:

SV2✱120✱✱1500✱DA✱5✱300~
SV2✱300✱HC:80019✱73.42✱UN✱1~

SV2

✱

✱

✱

✱

✱

✱

✱

✱

✱

1345

Nurse Home
Status Code

✱

Situational

234

Product/Service ID

X 1

1/80

Identifying number for a product or service

SEMANTIC: SV201 is the revenue code.

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required when the service review decision was determined using a revenue code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Revenue Code

See Code Source 132: National Uniform Billing Committee (NUBC) Codes.

Situational

C003

Composite Medical Procedure Identifier

X 1

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

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when identifying a specific procedure code. If not required by this implementation guide, do not send.

Required

2-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

CODE SOURCE: 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Required

2-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

2-3

1339

Procedure Modifier

O 1

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

Use this data element for the first procedure code modifier.

Situational

2-4

1339

Procedure Modifier

O 1

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

Use this data element for the second procedure code modifier.

Situational

2-5

1339

Procedure Modifier

O 1

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

Use this data element for the third procedure code modifier.

Situational

2-6

1339

Procedure Modifier

O 1

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

Use this data element for the fourth procedure code modifier.

Situational

2-7

352

Description

O 1

1/80

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

INDUSTRY NAME: Procedure Code Description

Situational

2-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when the notification sender has not determined the intensity or complexity of the service to be performed and therefore identifies a range of procedures. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV202-02 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Situational

2-9

1339

Procedure Modifier

O 1

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

Situational

2-10

1339

Procedure Modifier

O 1

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

Situational

2-11

1339

Procedure Modifier

O 1

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

Situational

2-12

1339

Procedure Modifier

O 1

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

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV203 is the submitted service line item amount.

SITUATIONAL RULE: Required when the Notification or Information Copy had monetary limitations for the service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

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

Situational

355

Unit or Basis for Measurement Code

X 1

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

SEGMENT SYNTAX: P0405

CODE

DEFINITION

Days

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

INDUSTRY NAME: Service Unit Count

Situational

1371

Unit Rate

O 1

1/10

The rate per unit of associate revenue for hospital accommodation

SITUATIONAL RULE: Required when SV201 is used and the Notification or Information Copy had monetary limitations on the accommodation rate. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Rate

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1345

Nursing Home Residential Status Code

O 1

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

SITUATIONAL RULE: Required when identifying services for Long Term Care. If not required by this implementation guide, do not send.

CODE

DEFINITION

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

Newly Admitted

Newly Eligible

No Longer Eligible

Still a Resident

Temporary Absence - Hospital

Temporary Absence - Other

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

Other

Situational

1337

Level of Care Code

O 1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when needed to further clarify the level of care being identified for admissions to a nursing facility, or for identification for a non-nursing facility and the level of care in which the patient resides is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific Dental Service. If not required by this implementation guide, do not send.

TR3 Example:

SV3✱AD:D2150✱80~

SV3

✱

C003

✱

✱

✱

Oral Cavity
Designat.

✱

1358

Prosthesis/
Inlay Code

✱

✱

✱

✱

✱

✱

1328

Diagnosis
Code Pointr

O 12

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

A modifier must be from code source 135 (American Dental Association) found in the 'Code on Dental Procedures and Nomenclature'.
Use this data element for the first procedure code modifier.

Situational

1-4

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the 'Code on Dental Procedures and Nomenclature'.
Use this data element for the second procedure code modifier.

Situational

1-5

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the 'Code on Dental Procedures and Nomenclature'.
Use this data element for the third procedure code modifier.

Situational

1-6

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the 'Code on Dental Procedures and Nomenclature'.
Use this data element for the fourth procedure code modifier.

Situational

1-7

352

Description

O 1

1/80

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

SITUATIONAL RULE: Required when the service information is for a "Not Otherwise Classified" (NOC) or "By Report" procedure code or to report the following information on this service line: Date of Initial Impression, Date of Initial Preparation Crown, Initial Preparation Crown Tooth Number, or Initial Endodontic Treatment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Situational

1-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

Use SV301-02 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Situational

1-9

1339

Procedure Modifier

O 1

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

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

Situational

1-10

1339

Procedure Modifier

O 1

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

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

Situational

1-11

1339

Procedure Modifier

O 1

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

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

Situational

1-12

1339

Procedure Modifier

O 1

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

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

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

SITUATIONAL RULE: Required when the Notification or Information Copy had monetary limitations for the service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

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

Not Used

1331

Facility Code Value

O 1

1/3

Situational

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when necessary to report areas of the mouth that are being treated. If not required by this implementation guide, do not send.

Required

4-1

1361

Oral Cavity Designation Code

M 1

1/3

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

CODE SOURCE 135: American Dental Association

Situational

4-2

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

4-3

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

4-4

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

4-5

1361

Oral Cavity Designation Code

O 1

1/3

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

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

1358

Prosthesis, Crown or Inlay Code

O 1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when needed to indicate the placement status of the prosthetic for this service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

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

INDUSTRY NAME: Service Unit Count

Number of procedures

Situational

352

Description

O 1

1/80

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

SEMANTIC: SV307 is the reason for replacement.

SITUATIONAL RULE: Required when necessary to describe the reason for replacement. If not required by this implementation guide, do not send.

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1328

Diagnosis Code Pointer

O 12

1/2

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

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

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

TOO*JP - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when reporting tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.

Code source 135: American Dental Association Codes

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a second tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a third tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a fourth tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a fifth tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SV3 is valued and certification of a missing tooth, extracted tooth, tooth to be extracted, or impacted tooth is being identified. If not required by this implementation guide, do no 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

Impacted

Missing

Extracted

Not Used

380

Quantity

O 1

1/15

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Required

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

DRA - DRUG AUTHORIZATION

X12 Name:

Drug Authorization

X12 Purpose:

To specify a drug for which authorization is being requested

X12 Syntax:

P0405
If either DRA04 or DRA05 is present, then the other is required.
P080910
If either DRA08, DRA09 or DRA10 are present, then the others are required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting drug, biologic, medical or surgical supply authorization and more detailed information is necessary in addition to the product identifier reported in SV1 or SV2.
OR
When reporting drug, biologic, medical or surgical supply authorization and the SV1 or SV2 was not used. If not required by this implementation guide, do not send.

TR3 Notes:

If the request is for a compound drug, repeat the segment for each ingredient in the compound.

TR3 Example:

DRA✱INFLIXIMAB 10 MG✱I✱N4:57894003001✱UN✱20✱INFUSE OVER AT LEAST 2 HOURS. BEGIN AT 40 ML/HR FOR 15 MINUTES, THEN INCREASE RATE TO 80 ML/HR FOR 30 MINUTES. IF TOLERATED INCREASE TO 160 ML/HR FOR THE DURATION OF INFUSION✱N✱N✱✱✱✱✱✱43~

DRA

✱

✱

✱

C003

✱

✱

✱

1/264

✱

✱

✱

✱

✱

✱

✱

✱

✱

O 999

1/264

Required

352

Description

M 2

1/80

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

SEMANTIC: DRA01 is the drug name. Position of data in the repeating data element conveys no significance.

INDUSTRY NAME: Drug Name

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

SEMANTIC: DRA02 is the drug therapy type.

INDUSTRY NAME: Drug Therapy Type

CODE

DEFINITION

Extension

Use when this is the extension of the first use of this drug or its therapeutic equivalent as a supplemental therapy for treatment of this condition.

Initial

Use when this is the first use of this drug or its therapeutic equivalent for treatment of this condition.

Renewal

Use when this is for continuation of the use of this drug or its therapeutic equivalent for treatment of this condition.

Revised

Use when this is the first use of this drug or its therapeutic equivalent to replace a previous unsuccessful or non-optimal therapy for treatment of this condition.

Situational

C003

Composite Medical Procedure Identifier

O 2

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

SEMANTIC: DRA03 Position of data in the repeating data element conveys no significance.

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when a specific packaging of a drug is being requested or when using a representative NDC. If not required by this implementation guide, do not send.

Required

3-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Required

3-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: National Drug Code or Device Identifier of the Unique Device Identifier

Not Used

3-3

1339

Procedure Modifier

O 1

Not Used

3-4

1339

Procedure Modifier

O 1

Not Used

3-5

1339

Procedure Modifier

O 1

Not Used

3-6

1339

Procedure Modifier

O 1

Not Used

3-7

352

Description

O 1

1/80

Not Used

3-8

234

Product/Service ID

O 1

1/80

Not Used

3-9

1339

Procedure Modifier

O 1

Not Used

3-10

1339

Procedure Modifier

O 1

Not Used

3-11

1339

Procedure Modifier

O 1

Not Used

3-12

1339

Procedure Modifier

O 1

Required

355

Unit or Basis for Measurement Code

X 1

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

SEGMENT SYNTAX: P0405

CODE

DEFINITION

International Unit

Gram

Milligram

Milliliter

Unit

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: DRA05 is the quantity being requested.

SEGMENT SYNTAX: P0405

INDUSTRY NAME: National Drug Unit Count

Required

933

Free-form Message Text

O 1

1/264

Free-form message text

SEMANTIC: DRA06 is the Sig (The Sig is a Latin term used in the pharmacy industry that represents theinstructions/directions that are printed on the drug label.)

INDUSTRY NAME: Sig

If the Sig is not known at the the time of the request, send unknown in this data element.

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: DRA07 is the self administer indicator. A "Y" value indicates that the drug can be administered by the patient. An "N" value indicates that the drug can not be administered by the patient.

INDUSTRY NAME: Self Administered Drug Indicator

CODE

DEFINITION

Yes

Required

1073

Yes/No Condition or Response Code

X 1

Code indicating a Yes or No condition or response

SEMANTIC: DRA08 is the end stage renal disease (ESRD) indicator. A "Y" value indicates that the patient has ESRD. An "N" value indicates that the patient does not have ESRD.

SEGMENT SYNTAX: P080910

INDUSTRY NAME: ESRD Indicator

CODE

DEFINITION

Unknown

Yes

Situational

374

Date/Time Qualifier

X 1

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

SEGMENT SYNTAX: P080910

SITUATIONAL RULE: Required when the patient has ESRD certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

458

Certification

Situational

373

Date

X 1

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

SEMANTIC: DRA10 is the ESRD certification date.

SEGMENT SYNTAX: P080910

SITUATIONAL RULE: Required when DRA09 is used. If not required by this implementation guide do not send.

INDUSTRY NAME: ESRD Certification Date

Situational

933

Free-form Message Text

O 999

1/264

Free-form message text

SEMANTIC: DRA11 is for questions that are related to the authorization of the drug. Position of data in the repeating data element conveys no significance.

SITUATIONAL RULE: Required when UMO policy has defined additional information necessary for the completion of the authorization. If not required by this implementation guide, do not send.

INDUSTRY NAME: Drug Authorization Question/Answer

Use this data element to convey the UMO question and the answer.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DRA12 is the number of refills requested.

SITUATIONAL RULE: Required when refills are ordered. If not required by this implementation guide, do not send.

Situational

C060

Question and Answer

O 999

Used to supply the answers to pre-defined questions

SEMANTIC: DRA13 Position of data in the repeating data element conveys no significance.

X12 COMPOSITE SEMANTIC NOTES:

C060-01 is the question number from a pre-defined questionnaire.
C060-02 is the answer to the pre-defined question. A "Y" value indicates the answer to the question is yes. A "N" value indicates the answer to the question is no.

SITUATIONAL RULE: Required when the UMO has a pre-defined set of a yes/no answer questions that must be answered. If not required by this implementation guide, do not send.

Required

13-1

350

Assigned Identification

M 1

1/20

Alphanumeric characters assigned for differentiation within a transaction set

INDUSTRY NAME: Pre-Defined Question Indicator

Required

13-2

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Pre-Defined Question Response

CODE

DEFINITION

Unknown

Not Applicable

Yes

Required

1330

Dosage Form Code

O 1

Code indicating the form in which the drug is dispensed

CODE SOURCE 985: NCPDP Dosage Form Code

CODE

DEFINITION

Tablet

Capsule

Lozenge or Troche

Internal Powder

Injectable Lyophilized Powder

Elixir

Suspension

Syrup

Solution

Emulsion

Liquid

Rectal Cream or Ointment

Rectal Suppository

Vaginal Suppository

Vaginal Cream

Urethral Suppository

Enema

Vaginal Ointment

External Ointment

External Cream

External Powder

Not Used

933

Free-form Message Text

O 999

1/264

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.
C0905
If HSD09 is present, then HSD05 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

An explanation of the uses of this segment follows.

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

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

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

TR3 Example:

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

HSD

✱

✱

✱

✱

✱

Time Period
Qualifier

✱

✱

Ship/Del or
Calend Code

✱

✱

✱

Situational

673

Quantity Qualifier

X 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD02 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the pattern of delivery has quantity of services authorized. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Situational

355

Unit or Basis for Measurement Code

O 1

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

SITUATIONAL RULE: Required when the services rendered have a time frame which services will be rendered. If not required by this implementation guide, do not send.

If HSD02 is not valued, do not use.

CODE

DEFINITION

Days

Months

Week

Situational

1167

Sample Selection Modulus

O 1

1/6

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

SITUATIONAL RULE: Required when HSD03 is valued to qualify the timeframe of when services will be rendered. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

X 1

1/2

Code specifying periods

SEGMENT SYNTAX: C0605, C0905

SITUATIONAL RULE: Required when HSD06 is valued to qualify the time period in which the quantity of services (HSD02) will be continued. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Episode

Visit

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEMANTIC: HSD06 identifies the number of periods, or the minimum in a range of periods when HSD09 is present.

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to indicate the number of time periods in HSD05 that are requested. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code specifying the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when needed to indicate the calendar delivery pattern for the services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Sunday, Monday, Thursday, Friday, Saturday

Tuesday through Saturday

Sunday, Wednesday, Thursday, Friday, Saturday

Monday, Wednesday, Thursday, Friday, Saturday

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

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

Whenever Necessary

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

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

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code specifying the time for routine shipments or deliveries

SITUATIONAL RULE: Required when needed to indicate the time delivery pattern for the services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

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

Not Used

616

Number of Periods

O 1

1/3

Not Used

352

Description

O 1

1/80

CR8 - IMPLANT CERTIFICATION

X12 Name:

Implant Certification

X12 Purpose:

To supply information related to medical implant registries

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when data related to implant services is known by the sender. If not required by this implementation guide, do not send.

TR3 Example:

CR8✱E✱1✱20340401✱20220401✱5693510292✱LT578✱246794839267~

CR8

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1403

Implant Type Code

M 1

Code identifying implant components

CODE

DEFINITION

Pulse Generator

Atrial Lead

Ventricular Lead

Implantable Cardioverter Defibrillator (ICDs)

Implantable Cardiac Pacemaker (ICPs)

Cardiac Resynchronization Therapy Devices (CRTs)

Pacing Leads

Pacing Battery

Coronary Stent

Peripheral Stent

Heart Valve

Ventricular-Assist Device

Implantable Heart Monitor

Knee

Hip

Shoulder

Elbow

Ankle

Toe

Finger

Spinal

Orthobiologic

Tissue

Facial

Dental

Ophthalmic

Gynecologic

Urogynecologic

Drug

Otolaryngeal

Cochlear

Cosmetic

Gastroenterologic

Urologic

Other

Required

1404

Implant Status Code

M 1

Code identifying the status of implant components

CODE

DEFINITION

Implanted

Explanted

Situational

373

Date

O 1

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

SEMANTIC: CR803 is the warranty expiration date.

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

INDUSTRY NAME: Warranty Expiration Date

Situational

373

Date

O 1

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

SEMANTIC: CR804 is the implant date.

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

INDUSTRY NAME: Implant Date

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: CR805 is the manufacturer identification.

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

INDUSTRY NAME: Manufacturer Identification

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

Situational

127

Reference Identification

O 1

1/80

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

SEMANTIC: CR806 is the model number.

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

INDUSTRY NAME: Model 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.

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: CR807 is the serial number.

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

INDUSTRY NAME: Serial 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.

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CR808 indicates if leads were left in the patient. A "Y" value indicates leads were left in patient; an "N" value indicates leads were not left in patient.

SITUATIONAL RULE: Required only if the implant has leads as part of the actual device. If not required by this implementation guide, do not send.

INDUSTRY NAME: Implant Leads Remain in Patient Indicator

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CR809 indicates if the pacemaker was returned to the manufacturer. A "Y" value indicates the pacemaker was returned to the manufacturer; an "N" value indicates the pacemaker was not returned to the manufacturer.

SITUATIONAL RULE: Required only if the implant device was for a pacemaker. If not required by this implementation guide, do not send.

INDUSTRY NAME: Pacemaker Returned to Manufacturer Indicator

PWK - ADDITIONAL SERVICE INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that cannot otherwise be provided in the notification. If not required by this implementation guide, do not send.

TR3 Notes:

This PWK segment is utilized to identify the type of additional information being sent, how that information is being sent, and includes a unique identifier (Attachment Control Number) to associate the information with the notification.

Refer to Section 1.11.6.1 for more information on using this PWK segment.
Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.

TR3 Example:

PWK✱OB✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Use when reporting expected outcomes of rehabilitative services.

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use when reporting a medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Use when there is a certificate of medical necessity for an ambulance trip.

Admission Summary

Use when an admission summary exists; listing the patient's complaints and the reasons for admitting the patient to the hospital.

Purchase Order Attachment

Use when medical or dental equipment was purchased.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Use when reporting the reasons chiropractic is a just and appropriate treatment.

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

History and Physical

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Quality Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Therapy Notes

Other Type of Report

Death Notification

Photographs

Required

756

Report Transmission Code

O 1

1/2

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

CODE

DEFINITION

Available on Request at Provider Site

Use when the paperwork is not being sent with the request at this time. It will be made available to the UMO (or approving entity) upon request.

By Mail

Electronically Only

Use when reporting the attachment is being transmitted in a separate X12 functional group.

E-Mail

File Transfer

By Fax

On-Line

Voice

Use when communication is by voice mail or phone.

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 PWK06 is valued. 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 equals BM, EL, EM, FT, FX or OL. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Attachment Control Number

The notification sender can use when PWK02 equals "AA" if the notification sender wants to send a document control number for an attachment remaining at the Provider's office.

Situational

352

Description

O 1

1/80

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

COMMENT: PWK07 may be used to indicate special information to be shown on the specified report.

SITUATIONAL RULE: Required when needed to add any additional information about the attachment described in this segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Description

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to transmit a message to the notification receiver about the service. If not required by this implementation guide, do not send.

TR3 Notes:

Free form text or description fields are not recommended because they require human interpretation.
Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.

TR3 Example:

MSG✱This is a free-form text message~

MSG

✱

933

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

X 1

Not Used

1470

Number

O 1

1/9

NM1 - SERVICE PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when identifying a service provider, specialist, or specialty entity for this service and is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Physician, Clinic or Group Practice

Operating Physician

Other Physician

Service Location

Admitting Physician

Assistant Surgeon

Ordering Physician

Supervising Physician

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Service Provider Last or Organization Name

Not Used if identifying a specialty entity.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Service Provider Middle Name or Initial

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 needed to further identify the Service Provider: e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code 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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

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

INDUSTRY NAME: Service Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - SERVICE PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when reporting the provider ID as assigned by the UMO identified in Loop 2000A.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Provider Supplemental Identifier

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

Situational

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

See Code Source 22: State and Outlying Areas of the US.

Not Used

C040

Reference Identifier

O 1

N3 - SERVICE PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Service Provider Address Line

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

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Service Provider Address Line

N4 - SERVICE PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Service Provider City Name

Situational

156

State or Province Code

X 1

Code 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 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)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Service Provider Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Service Provider Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Service Provider Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*IC - SERVICE PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 acknowledgment must be directed to a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

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

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Service Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER06 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Uniform Resource Locator (URL)

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

INDUSTRY NAME: Service Provider Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Telephone

Uniform Resource Locator (URL)

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

INDUSTRY NAME: Service Provider Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

AAA - SERVICE PROVIDER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

AAA✱N✱✱43~

AAA

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code identifying reason for rejection as assigned by issuer

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the service provider.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Invalid Participant Identification

Invalid or Missing Provider Address

Not Used

889

Follow-up Action Code

O 1

Not Used

1787

Error Reason Code

O 99

PRV - SERVICE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Assistant Surgeon

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

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

SE - TRANSACTION SET TRAILER

X12 Name:

Transaction Set Trailer

X12 Purpose:

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

X12 Comments:

SE is the last segment of each transaction set.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SE✱24✱0002~

✱

✱

Required

Number of Included Segments

M 1

1/10

Total number of segments included in a transaction set including ST and SE segments

INDUSTRY NAME: Transaction Segment Count

Required

329

Transaction Set Control Number

M 1

4/9

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

The Transaction Set Control Number in ST02 and SE02 must be identical.

GE - FUNCTIONAL GROUP TRAILER

X12 Name:

Functional Group Trailer

X12 Purpose:

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

X12 Comments:

The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GE✱1✱1~

✱

Number of
TS Included

✱

Required

Number of Transaction Sets Included

M 1

1/6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

IEA - INTERCHANGE CONTROL TRAILER

X12 Name:

Interchange Control Trailer

X12 Purpose:

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Example:

IEA✱1✱000000905~

IEA

✱

I16

Num of Incl
Funct Group

✱

Required

I16

Number of Included Functional Groups

M 1

1/5

A count of the number of functional groups included in an interchange

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

The Value in IEA02 must be identical to the value in ISA13.

278 Health Care Services Review Notification and Acknowledgment (008020X328)

JANUARY 2022

Copyright © 2008-22, X12 Incorporated, Format © 2008-22 Washington Publishing Company. Exclusively published by the Washington Publishing Company. No part of this publication may be distributed, posted, reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written permission of the copyright owner.

Abstract

The Health Care Services Review - Notification Implementation Guide describes the use of the X12 Health Care Services Review Information (278) transaction set for the following business usage:

Notification of interested parties concerning events related to a health care services review such as:
- Patient arrival notice
- Patient discharge notice
- Patient transfer notice
- Notification of certification to primary care physcian (PCP), utilization management organization (UMO), or other service providers
- Certification notice change

Preface

X12 standards are developed to identify the broadest data requirements for a transaction set. Type 3 Technical Reports (TR3), also known as implementation guides, define the explicit data requirements for a specific business purpose. Trading partners who implement according to the instructions in this TR3 can exchange data consistently with multiple trading partners.

As X12 does not define transport requirements, trading partners define their specific transport requirements separately.

1.1 Implementation Purpose and Scope

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

The purpose of this implementation guide is to provide standardized data requirements and content for all users who send and receive notifications using the X12, Health Care Services Review Information (278). This implementation guide provides a detailed explanation of the transaction set by defining data content, identifying valid code tables, and specifying values that are applicable for electronic health care service review notification. The intention of the developers of the 278 is represented in this guide.

This implementation guide is designed to assist those who send, receive and/or route notifications associated with health care review services that include the following:

Advance Notification of authorizations for planned or scheduled admissions, health services, specialty referrals.
Completion Notification of admissions and discharges that have occurred or the completion of the delivery of previously authorized health care services.
Information Copy or courtesy copy to notify a receiving entity of a health care services review outcome.
Acknowledgment of receipt of a health care services review notification or information copy.

Notifications do not necessarily require a response because the decision outcome has already been established. Similarly, an information copy does not require verification, or approval. A participant who is the recipient of the information may acknowledge they received the data, or reject the data due to specific application layer processing, but may not respond with any review decision outcome.

Health care entities that use this implementation of the 278 include, but are not limited to the following:

Utilization Management Organizations (UMOs) (e.g., insurance companies, health maintenance organizations, preferred provider organizations, health care purchasers, professional review organizations, other providers, and other utilization review entities) that send, or receive notifications regarding Health Care Services review information.
Providers (e.g., physicians, medical groups, independent physician associations, facilities) who send notifications regarding Health Care Services review information to UMOs, or to other providers.
Providers who receive notifications.

1.2 Version Information

This implementation guide is based on the October 2020 X12 standards, referred to as Version 8, Release 2 (008020).

The unique Version/Release/Industry Identifier Code for transaction sets that are defined by this implementation guide is 008020X328.

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

HI Health Care Services Review Information (278)

The Version/Release/Industry Identifier Code and the applicable Functional Identifier Code must be transmitted in the Functional Group Header (GS segment) that begins a functional group of these transaction sets. For more information, see the descriptions of GS01 and GS08 in Appendix C EDI Control Directory.

1.3.1 Batch and Real-Time Usage

There are multiple methods available for sending and receiving business transactions electronically. Two common modes for EDI transactions are batch and real-time.

Batch - In a batch mode the sender does not remain connected while the receiver processes the transactions. Processing is usually completed according to a set schedule. If there is an associated business response transaction (such as a 271 Response to a 270 Request for Eligibility), the receiver creates the response transaction and stores it for future delivery or transmits the response transaction back to the sender of the original transaction. The sender of the original transmission reconnects at a later time and picks up the response transaction. Note: The sender of the original transmission may not always be the entity that picks up the response transaction at a later time (e.g. Provider submitting through a clearinghouse.)

Real-Time - In real-time mode the sender remains connected while the receiver processes the transactions and returns a response transaction to the sender. This implementation guide does not set specific response time parameters for implementers.

This implementation guide was based on requirements for batch mode. Willing trading partners may use batch or real-time mode.

1.3.2 Other Usage Limitations

Real-Time Delivery of the 278
A 278 real-time notification transaction and its associated acknowledgment response must contain only one patient event. A patient event is represented by a single ST to SE loop containing one subscriber loop as follows:

One subscriber loop (Loop 2000C) if the subscriber is the patient
One subscriber loop (Loop 2000C) if the dependent is the patient and has a unique member ID
One subscriber loop and one dependent loop (Loop 2000D) if the dependent is the patient and the dependent does not have a unique (different from the subscriber) member ID

This subscriber/patient information is followed by one occurrence of the 2000E Loop. One or more 2000F Loops may follow containing associated services.

Batch Delivery of the 278
This implementation guide requires the use of a separate transaction set (ST to SE) for each patient event as defined in Section 1.3.2.

This implementation supports the sending and receiving of multiple patient events in one transmission, where each patient event represents a single 278 transaction with multiple transactions in a single GS to GE loop.

1.4 Business Usage

The 278 has the flexibility to accommodate the exchange of information between providers and review entities. This section introduces the business events and processes associated with the 278.

1.4.1 Health Care Transaction Flow

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

1.4.2 Business Events Supported in this Guide

This implementation guide supports the following health care service review business events.

1.4.2.1 Notification

The 278 can be used to send unsolicited information among providers, payers, delegated UMO entities and/or other providers. This information can take the form of copies of health service reviews or notification of scheduled, or the beginning and end of treatment. A participant who is the recipient of the information may acknowledge they received the data, or reject the data due to specific application layer processing, but may not respond with any review decision outcome. This implementation guide supports the following categories of notifications.

Advance Notification for:

scheduled inpatient admissions
scheduled health services events
scheduled specialty care services

Completion Notification for:

patient arrival at a facility
patient discharge from a facility
services completion notice for any specific episode of care

Information Copy for any Health Services Review information sent to primary provider(s), service provider(s), or other Health Care entities requiring the information for specific purposes.

Change Notification to report changes to the detail of a previously sent notification or information copy.

1.4.2.2 Acknowledgment

Acknowledgments are sent from a notification receiver to the notification sender to indicate the successful receipt or rejection of a notification or information copy.

This implementation guide does not require that the notification receiver return a 278 acknowledgment response for notifications received. Acknowledgments are required only if the notification sender has indicated that a receipt acknowledgment is required.

The notification process transfers data from one source to another. In most instances, a simple acknowledgment from the receiver to the sender is sufficient to verify that the receiver has received and processed the data content of the notification. The notification receiver has the flexibility to either respond at a high level for successful transaction processing, or at a detail level when the data received produced specific application layer processing errors.

In addition, this implementation guide supports the ability to indicate the acceptance or rejection of the notification based on its application data content. The notification receiver can return one of the following types of 278 acknowledgments, as specified in the BHT02.

Completion: BHT02 = 53 (Completion) indicates the successful receipt of a notification. Its content identifies the acknowledgment receiver, acknowledgment sender and the subscriber/patient. It supports a reference segment (Notification Receipt Number) at the patient level to enable the acknowledgment sender to return a receipt number associated with this patient event notification. The acknowledgment sender can return service provider and service information, along with a service notification receipt number, to indicate successful receipt of the information at the service detail.

Rejection: In many business scenarios, the notification receiver verifies the application data before accepting the notification or information copy from the notification sender. The notification receiver can reject the notification based on invalid or missing data content or discrepancies between the patient's coverage and the service detail reported. BHT02 = 44 (Rejection) indicates that the acknowldegment receiver rejected the notification due to system errors or errors in the application data content. It reports the reasons for rejection at the appropriate hierarchical level.

1.4.3 Business Events Supported in Other 278 Implementation Guides

The 278 transaction set accommodates additional health care services review business events that are covered in separate 278 implementation guides. A brief description of these business events follows.

Request for Review and Response
Health Care Services Review - Request and Response includes the following business events:

admission certification review request and associated response
referral review request and associated response
health care services certification review request and associated response
extend certification review request and associated response
certification appeal review request and associated response

The exchange of information is between the primary parties, the provider and the UMO.

Review Inquiry and Response
The 278 Health Care Services Review - Inquiry and Response implementation guide handles informational inquiries and their related responses. It enables a participant to inquire about existing certifications and authorizations. The primary participants are providers and UMOs. The entity initiating the inquiry is either the primary provider or the service provider.

Examples of the types of inquiries supported in this implementation include the following:

Specialty care referral inquiry
Admission certification inquiry
Health care service certification inquiry
All patient certifications inquiry

1.4.4 Notification Information Flows

Figure 1.1 Information Flows, illustrates various examples of information flow for different business needs requiring the health care services review notification.

Example 1: Advance Notification
A provider notifies the UMO of an inpatient stay to occur in the future. The UMO returns an acknowledgment indicating that the notice has been received.

Figure 1.1 - Advance Notification

Advance Notification

Example 2: Completion Notification
A delegated entity notifies the UMO of all discharges that have occurred for a given date span. The UMO acknowledges receipt by returning a receipt number for each discharge notification. The receipt number indicates that the UMO has stored data to support the claims payment process.

Figure 1.2 - Completion Notification

Completion Notification

Example 3: Information Copy
A delegated entity notifies the payer of all authorized services for multiple patients for a particular time span.

Figure 1.3 - Information Copy

Information Copy

Example 4: Information Copy
UMO notifying a preferred special review organization on specific patient events to support proactive disease management and/or other preventative care programs.

Figure 1.4 - Information Copy

Information Copy

1.5 Business Terminology

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

1.6 Transaction Acknowledgments

The purpose of transaction acknowledgments is to report to the sender whether the transaction being acknowledged was accepted or rejected.

The X12 Technical Report Type 2, Acknowledgment Reference Model provides guidance on several control structures and transaction set standards intended to augment EDI auditing and control systems.

1.7 Related Transactions

There are no transactions related to the transactions described in this implementation guide.

1.8 Trading Partner Agreements

Trading partner agreements are used to establish and document the relationship between trading partners. A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide.

1.9 Transaction Compliance

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

Compliance with implementation guide requirements

Compliance with state and federal regulation

Compliance with trading partner contractual agreements

1.9.1 Transaction Compliance with Implementation Guide Requirements

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

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

The following X12 work products can be viewed online at https://products.x12.org:
Interchange Control Structure (X12.5)
Application Control Structure (X12.6)
Interconnect Mailbag Control Structures (X12.56)
Security Structures (X12.58)
Implementation of EDI Structures - Semantic Impact (X12.59)
Design Rules and Guidelines (X12.61)
Acknowledgment Reference Model
Reference Model for Inclusion of Sender and Receiver Identification in XML
Compliance in X12.
The X12 Request for Interpretation (RFI) viewer may be searched: https://rfi.x12.org. If existing RFI responses do not clarify the outstanding issue, a new RFI may be submitted.

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

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

1.9.2 Transaction Compliance with State and Federal Regulations

This implementation guide has been developed for use as an insurance industry implementation guide. At the time of publication it has not been adopted as a state or federal standard. Should this implementation guide be adopted as a standard, the adopting authority will establish compliance dates for its use by impacted entities.

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

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

1.9.3 Transaction Compliance with Contractual Requirements

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

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

1.10 Data Overview

The 278 can be exchanged between interested participants in either a uni-directional or bi-directional mode of operation. In the uni-directional mode the notification is sent from the notification sender to the notification receiver and there is no 278 response. In the bi-directional mode, the notification sender sends a notification or information copy and the notification receiver acknowledges receipt of that notification. This implementation guide does not require that the notification receiver acknowledge receipt of a notification unless required by the notification sender.

However, it addresses this bi-directional use to support cases when:

the notification receiver returns rejection information to indicate that it was unable to receive the notification or information copy, or
the notification sender has indicated that a receipt acknowledgment is required.

This section provides general information on the structure of the transaction set as represented in this implementation guide.

NOTE
See Appendix B, X12 Control and Guidance, to review the transaction set structure, including descriptions of segments, data elements, levels, and loops.

1.10.1 Overall Data Architecture

The 278 is divided into two levels, or tables. See Chapter 2, Transaction Set, for a description of the format presented in the Transaction Set Listing. The Header level, Table 1, contains the purpose code for the transaction set as well as date and time stamps. For the notification portion of this implementation guide, BHT02 is either an Advance Notification (14), Completion Notification (CN) or an Information Copy (22). In addition, a BHT06 value of NO (Notice) indicates that the notification sender expects an acknowledgment of receipt. For the acknowledgment response, BHT02 indicates that this is either an acknowledgment indicating a successful receipt (BHT02 = 53, Completion) or a rejection (BHT02 = 44, Rejection) of the notification.

The Detail level, Table 2, contains all data relating to the notification, including transaction participants, the patient, all providers, and services detail information. Table 2 uses a hierarchical data structure to identify all the information associated with a health care services review for a patient event. Patient event in this guide refers to the service or group of services associated with a single episode of care. See X12 Wordbook for examples of patient events. The 278 supports multiple types of service review requests. Due to the multiplicity of uses of the 278, the implementation guide's developers require that separate transaction sets be used for different patients and events. This can be thought of as a one-to-one style relationship: one transaction set for one patient event.

For the types of business transactions that this implementation guide addresses, the following hierarchical levels (loops) apply:

Loop 2000A contains the Notification Sender/Acknowledgment Receiver

Loop 2000B contains the Notification Receiver/Acknowledgment Sender

Loop 2000C contains the Subscriber

Loop 2000D contains the Dependent

Loop 2000E contains the Patient Event

Loop 2000F contains the Services

Service Review Participants
Loop 2000A in the Notification represents the notification sender and in the Acknowledgment represents the acknowledgment receiver. Loop 2000B in the Notification represents the notification receiver and in the Acknowledgment represents the acknowledgment sender.

Notification Sender: The notification sender, identified in Loop 2000A of the Notification, may be a delegated utilization management entity that determined the outcome of a health care service review who has the knowledge of an event.

Acknowledgment Sender: The acknowledgment sender, identified in Loop 2000B of the Acknowledgment, is the entity that acknowledges receipt of the notification.

Notification Receiver: The notification receiver, identified in Loop 2000B of the Notification, is the partner who needs to know of the decision or result of an event.

Acknowledgment Receiver: The acknowledgment receiver, identified in 2000A of the Acknowledgment, is the entity that receives the acknowledgment.

Patient: Loop 2000C and Loop 2000D represent the subscriber and dependent. If the subscriber is the patient or if the patient has a unique identification number, only Loop 2000C is required.

Patient Event: Loop 2000E identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.

Services
Loop 2000F identifies the category of services and the specific services associated with this patient event. It may also include decision review outcomes and associated reason codes and authorization numbers if applicable.

1.10.2 Sample Table 2 Configurations

The following are sample Table 2 configurations.

The following example represents an advance notification of service, such as ambulance transport, for a dependent of a subscriber.

Notification Sender (Loop 2000A)

Notification Receiver (Loop 2000B)

Subscriber (Loop 2000C)

Dependent (Loop 2000D)

Patient Event (Loop 2000E)

Service (Loop 2000F)

The following example represents an acknowledgment of receipt of a notification of service, such as ambulance transport, for a dependent of a subscriber. The notification receiver acknowledges receipt at the patient level.

Acknowledgment Receiver (Loop 2000A)

Acknowledgment Sender (Loop 2000B)

Subscriber (Loop 2000C)

Dependent (Loop 2000D)

The following example represents an advance notification of authorization for multiple services performed by the same service provider for a subscriber who is the patient.

Notification Sender (Loop 2000A)

Notification Receiver (Loop 2000B)

Subscriber (Loop 2000C)

Patient Event (Loop 2000E)

Service (Loop 2000F)

The following example represents an acknowledgment of receipt of a notification of service for multiple services for a subscriber who is the patient. The notification receiver acknowledges receipt of each service.

Acknowledgment Receiver (Loop 2000A)

Acknowledgment Sender (Loop 2000B)

Subscriber (Loop 2000C)

Patient Event (Loop 2000E)

Service (with Review Outcome Data) (Loop 2000F)

1.10.3 Intended Segment Use

Each hierarchical level (loop) in this implementation consists of multiple segments and is based on the same standard hierarchical structure of segments. An implementation specifies the maximum segments you can include, per hierarchical level, to describe the service review participants, Patient Event, and services.

Notification/Information Copy
For a Notification or Information Copy transaction, Table 1.1 - Intended Segment Use for a 278 Notification Transaction, identifies the intended segment use by hierarchical level.

Table 1.1 - Intended Segment Use for a 278 Notification Transaction

Segment Position	Segment ID	Notif Sender HL	Notif Receiver HL	Subscriber HL	Dependent HL	Patient Event HL	Service HL
0100	HL	YES	YES	YES	YES	YES	YES
0200	TRN					YES	YES
0300	AAA					YES	YES
0400	UM					YES	YES
0500	HCR					YES	YES
0600	REF					YES	YES
0700	DTP					YES	YES
0800	HI					YES
0810	SV1						YES
0820	SV2						YES
0830	SV3						YES
0840	TOO						YES
0900	HSD					YES	YES
1000	CRC
1100	CL1					YES
1200	CR1					YES
1300	CR2					YES
1350	CR4
1400	CR5					YES
1500	CR6					YES
1520	CR7
1530	CR8
1550	PWK					YES	YES
1600	MSG					YES	YES
1700	NM1	YES	YES	YES	YES	YES	YES
1800	REF	YES		YES	YES	YES	YES
1900	N2
2000	N3	YES		YES	YES	YES	YES
2100	N4	YES		YES	YES	YES	YES
2200	PER	YES				YES	YES
2300	AAA					YES	YES
2400	PRV	YES				YES	YES
2500	DMG			YES	YES
2600	INS			YES	YES
2700	DTP

Acknowledgment
For an Acknowledgment transaction, Table 1.2 - Intended Segment Use for a 278 Acknowledgment Transaction, identifies the intended segment use by hierarchical level.

Table 1.2 - Intended Segment Use for a 278 Acknowledgment Transaction

Segment Position	Segment ID	Ack Receiver HL	Ack Sender HL	Subscriber HL	Dependent HL	Patient Event HL	Service HL
0100	HL	YES	YES	YES	YES	YES	YES
0200	TRN			YES	YES	YES	YES
0300	AAA	YES		YES	YES	YES	YES
0400	UM					YES	YES
0500	HCR					YES	YES
0600	REF			YES	YES	YES	YES
0700	DTP					YES	YES
0800	HI					YES
0810	SV1						YES
0820	SV2						YES
0830	SV3						YES
0840	TOO						YES
0900	HSD
1000	CRC
1100	CL1
1200	CR1
1300	CR2
1350	CR4
1400	CR5
1500	CR6
1520	CR7
1530	CR8
1550	PWK
1600	MSG					YES
1700	NM1	YES	YES	YES	YES	YES	YES
1800	REF	YES		YES	YES	YES	YES
1900	N2
2000	N3
2100	N4
2200	PER		YES
2300	AAA	YES	YES	YES	YES	YES	YES
2400	PRV	YES				YES	YES
2500	DMG			YES	YES
2600	INS			YES	YES
2700	DTP

1.10.4 Matching the Acknowledgment with its Notification

This implementation guide provides several methods to enable sources, receivers, and clearinghouses to trace the transaction or match the 278 acknowledgment, if returned, to the original notification. This section describes the segments and data elements that carry these identifiers.

BHT03 - Submitter Transaction Identifier
BHT03 identifies the transaction at its highest level. This is particularly useful in reconciling 278 rejection transactions that may not contain all of the HL Loops. The receiver of the 278 notification transaction must return this identifier in the 278 acknowledgment BHT03.

TRN Segment
The Patient Event loop (2000E) and the Service loop (Loop 2000F) each contain a TRN segment. This segment enables organizations to uniquely identify the notification. The TRN at the Patient Event level uniquely identifies the patient event request. The Service level TRN uniquely identifies the request at its lowest logical level, the service. Both the notification sender and the clearinghouse can add a TRN segment to the notification. The acknowledgment sender can assign its own trace number to the Patient Event loop and/or Service loop of the acknowledgment if returned.

The notification/acknowledgment sender can use this TRN segment to meet several needs, including the following:

uniquely identify this notification within the notification sender's environment
uniquely identify each service. A single notification transaction can contain multiple services represented by multiple occurrences of Loop 2000F. The notification receiver might receive some of these services and/or reject others due to data content errors.
match the associated acknowledgment to the notification
facilitate routing of this acknowledgment in a large health care environment. For example, it might be necessary for the acknowledgment sender to identify the department within the provider environment that originated the transaction.

NOTE
The notification sender cannot use this trace number to report the certification number to the notification receiver.

Clearinghouses can provide their own trace numbers in a separate TRN segment at the Patient Event level and at the Service level on the request to use for transaction tracking and matching purposes.

If the TRN segment is used on the notification, the acknowledgment sender must return the trace information in the 278 acknowledgment transaction.

The acknowledgment sender can add a trace number in their own TRN segment at the Patient Event level (Loop 2000E) and Service level (Loop 2000F) on the acknowledgment.

NOTE
The acknowledgment sender cannot use this trace number to report a receipt number to the notification sender.

If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:

If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment.
If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 notification back in the 278 acknowledgment transaction. If the 278 notification passes through a clearinghouse that adds their own TRN in addition to a notification sender TRN, the clearinghouse will receive an acknowledgment from the acknowledgment sender containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the notification receiver TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the notification sender, the clearinghouse must change the value in their TRN01 to "1" because, from the notification sender perspective, this is not a referenced transaction trace number.

1.11 Data Use By Business Use

The segments referenced in Table 1.1 - Intended Segment Use for a 278 Notification Transaction and Table 1.2 - Intended Segment Use for a 278 Acknowledgment Transaction carry the data content of the health care services review. This section provides examples of the segments and data element values used in the hierarchical levels. The use of notification sender of the Notification, acknowledgment receiver of the Acknowledgment, notification receiver of the Notification, acknowledgment sender of the Acknowledgment, subscriber, dependent, patient event, and service is consistent across types of health care services reviews. However, the use of the patient event and service levels differ across types of health care services reviews. Therefore, the patient event and service level discussions in this section contain multiple examples. In addition, the minimum data necessary for an acknowledgment differs from that required for a notification. The descriptions of each hierarchical level describe these differences.

Minimum Data Requirements - Notifications
Factors such as the type of health care services review, the condition of the patient, and the individual UMO's rules for processing notifications make it difficult to identify a single set of data elements that are required for all types of certifications. To meet these needs, this guide includes many data elements and segments marked "situational".

Minimum Data Requirements - Acknowledgments
The 278 acknowledgment is used to report any invalid or missing data that prevented the transaction from successfully being processed. The minimum data necessary to report a rejection are the loops hierarchically necessary to report the rejection information. For example, if the error is detected in Loop 2000E of the notification, the acknowledgment must contain the minimum information (segments and data elements) necessary to return valid loops 2000A, 2000B, 2000C, 2000D, and the rejection reason in Loop 2000E.

The use of the 278 acknowledgment to report the successful receipt of a notification is optional and must be established by trading partner agreement between the notification sender and the notification receiver. This implementation guide limits the information from the notification that the notification receiver must return on the acknowledgment. If the notification receiver acknowledges successful receipts of notifications, the minimum data necessary on the acknowledgment are loops 2000A, 2000B, and the patient (Loop 2000C/2000D).

NOTE
This section provides examples of types of health care service reviews and the minimum data required. Refer to Chapter 2, Transaction Set of this guide for detailed information on valuing specific data elements within the segments.

1.11.1 Transaction Participants (Loop 2000A, Loop 2000B)

The Loop 2000A and Loop 2000B hierarchical levels are used to convey information about the two primary participants in a health care service review transaction. Figure 1.5 - Notification Sender and Receiver Levels, presents the Loop 2000A and Loop 2000B levels.

NOTE
The entity in Loop 2000A of the Acknowledgment is always the same as the entity that was in Loop 2000A of the Notification. The entity in Loop 2000B of the Acknowledgment is always the same as the entity that was in Loop 2000B of the Notification.

Figure 1.5 - Notification Sender and Receiver Levels

Notification Sender and Receiver Levels

Hierarchy Usage Chart for Transaction Participants
The various utilization management entities may appear in either the Loop 2000A or Loop 2000B hierarchical levels depending on the transaction usage. Table 1.3 - Notification Sources and Notification Receivers, identifies some of the possible entities exchanging a health care services review notification. This matrix is by no means exhaustive.

Table 1.3 - Notification Sources and Notification Receivers

Transaction Use	HL Notification Sender NM1	HL Notification Source NM1	HL Notification Receiver NM1	Physical Transmitter	Physical Receiver
Notice of Admission to UMO	Hospital	PCP	UMO	Hospital	UMO
Notification to UMO regarding transfer or discharge	Hospital	PCP	UMO	Hospital	UMO
Notification of services from a Provider to a Service Provider	PCP	UMO	SCP	PCP	SCP
Notification of services from a UMO to a Service Provider	UMO	PCP	SCP	UMO	SCP
Notification of authorization for services from a Delegated Entity to a Payer	Delegated Entity	Provider	Payer	Delegated Entity	Payer
Notification of services from a UMO to a Third-party Administrator	UMO	Provider	TPA	UMO	TPA
* UMO - Utilization Management Organization * PCP - Primary Care Provider * SCP - Specialty Care Provider

1.11.1.1 Notification Sender (Loop 2000A)

The Loop 2000A hierarchical level is used to identify the notification sender. The notification sender is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information.

The following example demonstrates a minimum way of identifying a Notification Sender:

HL*1**20*1~
NM1*X3*2******46*123450~

As indicated in Figure 1.5 - Notification Sender and Receiver Levels, 2010AA loop is used to identify the notification sender. 2010AB loop is used by the notification sender to identify an additional entity as the source of this health care services review information. For example, in a notification of a referral from the UMO to the service provider, the UMO (notification sender) may identify itself in the 2010AA loop and the requesting provider (source) in the 2010AB loop. Or, in a notification of authorization to admit the patient sent from the PCP to the hospital, the PCP (notification sender) can use the 2010AA loop to identify itself as the sender and the 2010AB loop to identify the UMO as the source of the authorization.

Loop 2010AA also supports the following additional segments:

REF Segment: Use this segment to provide supplementary identifiers for the notification sender when required.

PER Segment: Use this segment to identify a specific individual within the notification sender who can be contacted concerning the notification.

N3 and N4 Segments: Use the address segments, only when necessary, to further identify the notification sender or to provide notification sender address information to the receiver. These segments are supported on the 278 notification but are not supported on the 278 acknowledgment.

PRV Segment: If the notification sender is a provider, use this segment to identify the provider's role in the care of the patient or the provider's specialty.

Loop 2010AB also supports the following additional segments:

PER Segment: Use this segment to identify a specific individual within the notification sender who can be contacted concerning the notification.

PRV Segment: If the source is a provider, use this segment to identify the provider's role in the care of the patient or the provider's specialty.

1.11.1.2 Notification Receiver (Loop 2000B)

The Loop 2000B hierarchical level identifies the intended receiver of the notification. The following example demonstrates a minimum way of identifying an notification receiver:

HL*2*1*21*1~
NM1*1P*1******XX*1234567890~

NM1 Segment: As with the HL20 hierarchical level, the NM1 segment is usually sufficient to identify the notification receiver when the trading partners are known. The NM1 segment should always be used to carry the primary identifier of the notification receiver (see NM108 and NM109).

The 278 notification supports only the HL and NM1 segments. Loop 2010B of the 278 acknowledgment supports the following additional segments:

PER Segment: The notification receiver should value this segment only if the notification source must direct requests for additional information to a specific contact, electronic mail, facsimile, or phone number.

1.11.2 Patient (Loop 2000C and Loop 2000D)

Subscriber Loop 2000C and Dependent Loop 2000D identify the patient. Loop 2000C is always required. Loop 2000D is used only when necessary to identify a patient who is a dependent. Figure 1.6 - Subscriber and Dependent Levels shows the structure of these loops.

Figure 1.6 - Subscriber and Dependent Levels

Subscriber and Dependent Levels

When the subscriber is the patient or when the patient has a unique identification number (different from the subscriber), only Loop 2000C is used. This situation is common when an insurance company issues a unique insurance identification card to each individual insured. In all other cases, Loop 2000C is used to identify the subscriber. Loop 2000D is used to identify the subscriber's dependent, who is the patient. This structure is more common in traditional group insurance where a patient is uniquely identified within the primary subscriber identifier.

The Subscriber Name Loop 2010C and Dependent Name Loop 2010D contain the segments and data elements that hold this patient identification information. The NM1 and DMG segments contain all the data needed for the notification receiver to identify the patient.

1.11.2.1 Identifying the Subscriber/Patient

In Subscriber Name Loop 2010C, the member ID (NM108/NM109) is required and may be adequate to identify the subscriber to the notification receiver. However, the notification receiver can require additional information. The maximum data elements that the notification receiver can require to identify the subscriber, in addition to the member ID, are as follows:

Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02)

The data requirements are the same for a dependent patient who has a unique identification number (different from the subscriber). In those cases where the subscriber is the patient or the patient has a unique identification number (different from the subscriber), only Loop 2000C is used.

The following example demonstrates a sufficient way of identifying a patient who has a unique identification number:

HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~

1.11.2.2 Identifying the Dependent

If the dependent has been issued a unique member ID, the Dependent Loop (2000D) is not used.

If the dependent has not been issued a unique member ID, the Dependent Loop (2000D) is required in addition to Loop 2000C. Loop 2000C conveys insurance information and Loop 2000D conveys patient-related information. The maximum data elements that can be required by an notification receiver in loop 2010C and 2010D to identify a patient are as follows:

Loop 2010C
Subscriber's Member ID

Loop 2010D
Dependent Last Name
Dependent First Name
Dependent Birth Date

All UMOs are required to support the above search option if their system does not have unique Member Identifiers assigned to dependents.

The following example demonstrates a sufficient way of identifying a patient who is the dependent of a subscriber. The example also illustrates the use of other segments.

HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*23*1~
NM1*QC*1*SMITH*SEAN~
DMG*D8*19881229*M~
INS*N*19~

Patient Account Number
The notification sender can supply the patient account number as a supplemental identifier for the patient on the notification. This value is carried in a REF segment where REF01 = "EJ" in Loop 2000C - Subscriber or Loop 2000D - Dependent, whichever is the patient. This information is optional for the notification sender. However, if the notification receiver receives the patient account number, they must return it in the 278 acknowledgment transaction in the event an acknowledgment is returned.

1.11.2.3 Supplying Other Patient Information on the Notification

In addition to the patient identification segments provided in loops 2010C and 2010D, the 278 notification also supports the ability to provide address information, date of birth, gender and relationship in the following segments:

N3 and N4 Segments: Use the address segments, only when necessary, to further identify the subscriber or dependent to the notification receiver.

DMG Segment: Use the DMG segment when birth date is needed to identify the patient or when gender information was used to render a medical decision.oes not have unique Member Identifiers assigned to dependents.

INS Segment: Use the INS segment when patient relationship to insured or birth sequence was used to to further identify the subscriber.

1.11.2.4 Acknowledging Patient Information Received

This implementation guide limits the acknowledgment to return the minimum data necessary to indicate the receipt or rejection of the notification. The notification receiver can return the following acknowledgment information, in addition to the segments that identify the patient.

AAA Segment: The notification receiver must return a 278 acknowledgment response if the notification receiver is unable to process the application data at subscriber or dependent level. The response must contain a AAA segment at the level of the failure that reports the error condition that prohibits the receiver system from processing the notification. Two AAA segments are provided. The first AAA identifies error conditions in the data contained in Loop 2000C/2000D. These pertain to invalid or missing diagnosis codes and dates and patient condition dates. The second AAA in Loop 2010C/2010D identifies invalid or missing subscriber or dependent identification information.

Notification Receipt Number REF: This REF is required if the notification receiver returns a receipt number to indicate receipt of the notification.

1.11.3 Services (Loop 2000F)

The Service level (Loop 2000F) is not required on the 278 notification. This loop should only be valued if the notification includes specific services or procedures. If the 278 request does not include this loop, it must specify all the information pertaining to the category of services requested at the Patient Event level (Loop 2000E). As illustrated in Table 1.1 - Intended Segment Use for a 278 Notification Transaction and Table 1.2 - Intended Segment Use for a 278 Acknowledgment Transaction, many of the segments used in Loop 2000F are the same as those available in Loop 2000E.

Figure 1.7 - Services Level

Services Level

Guidelines for Using the Service Level

Use only if the services or procedures identified are for the same patient event identified in Loop 2000E.
Use only if at least one of the following situations exists.
- You are indicating a type of service (UM03) in addition to the category or type of service specified in the patient event, or
- You are identifying a specific service or procedure code or a range of service or procedure codes.
If this loop is valued, one of the following must be valued.
- UM segment where UM03 is valued
- SV1 where SV101 is valued
- SV2 where either SV201 or SV202 is valued
- SV3 where SV301 is valued
- DRA where DRA03-02 is valued
Specify only one procedure or procedure code range in an occurrence of Loop 2000F. If you are identifying multiple procedures or procedure code ranges, use a separate occurrence of Loop 2000F for each procedure code or code range.
Data values at the Service level override data values provided at the Patient Event level for the same data element for this service only.
If this patient event includes requests for multiple services (more than one Loop 2000F), the TRN segment may be used in each Loop 2000F of the request to assign a unique trace number to each service. This enables you to trace the transaction or match the acknowledgment to the notification. Use of trace numbers at this level can facilitate matching these different responses to the original request.

The HI segment "Additional Service Description" is used to further define the service/procedure identified in UM03, SV1, SV2, SV3 or DRA. The segment uses SNOMED (and/or other as yet unspecified code set) codes to provide added granularity regarding the planned, requested or approved service. Use is particularly beneficial for services that are broadly defined such as Consultation, Targeted Medication Review, Chronic Care Coordination Services, Transitional Care Management and Medication Therapy Management.

For example:

UM03 = 3 (Consultation)
HI01-01 = AAA
HI01-02 = 422011000124105 (Geriatric syndrome education)
OR
SV101-01 = HC
SV01-02 = 99496 (Transitional Care Management Services)
HI01-01 = AAA
HI01-02 = 1871000124103 (Transition from acute care to home-health care)
HI02-01 = AAA
HI02-02 = 429111000124101 (Documentation of care summary)
HI03-01 = AAA
HI03-02 = 431531000124101 (Health literacy assessment)
HI04-01 = AAA
HI04-02 = 417011000124102 (Gastrointestinal disorder education)
HI05-01 = AAA
HI05-02 = (473230005 Gastrointestinal disorder medication review)

1.11.3.1 Returning Service Details on the Acknowledgment

This implementation does not require the notification receiver to return Loop 2000F when acknowledging the successful receipt of a notification.

BHT02 = 44, Rejection
Loop 2000F is required only when necessary to report invalid or missing application data at this level of the notification that prevented the notification receiver from accepting the notification into their system. To facilitate the identification of the data in error, the acknowledgment can return service detail information reported in the notification.

BHT02 = 53, Completion
If the notification receiver chooses to acknowledge receipt of each service loop on the notification, they must return the segments that carried service level identification information on the notification.

1.11.4 Examples of Service Level Notifications

This section provides some examples of Service level segment values for the different types of notifications and information copies.

1.11.4.1 Advance Notification (BHT02 = 14)

Specialty Referral
Specialty care referral notifications encompass those transactions where a provider requests or grants permission to refer or send a patient to another provider, generally a specialist. These types of transactions generally are shared between a primary care physician and a UMO. However, they may just as easily be shared between any two providers or UMOs. The following example contains a notification of authorization for an initial service consisting of a single office visit for a consultation at the provider's office.

HL*5*4*SS*0~
UM*SC*I*3*11:B~
HCR*A1*0081096G~
HSD*VS*1~

The UM segment is used to identify the type of health care services.

UM01 = SC (Specialty Care Review)
UM02 = I (Initial Request)
UM03 = 3 (Consultation)
UM04 = 11:B (Physician's Office)

The HCR segment provides the results of the review as well as a review identification number. This set of values indicates approval of the request in full. A review identification number of 0081096G is supplied and is critical if the notification sender wishes to initiate further transactions concerning this service.

The HSD segment identifies the number of visits authorized.

Health Services Review
The term "health services review" identifies a notification of authorization for specific treatments or more extended care. Extended care refers to treatment for a condition requiring prolonged rehabilitation therapy. This transaction set supports a notification for authorization of services related to specific treatment or extended care associated with a single patient event. Complex treatment plans represent multiple patient events. Use a separate notification transaction for each patient event.

This is an example of a notification indicating a certified in total decision for chiropractic services of the spine. The UMO is notifying the chiropractor that it has authorized 24 visits to occur twice per week over a (3) month period.

HL*5*4*SS*0~
UM*HS*I*33~
HCR*A1*2011082001~
HSD*VS*2*WK**34*3~

The UM segment is used to identify the type of health care services.

UM01 = HS (Health Services Review)
UM02 = I (Initial Request)
UM03 = 33 (Chiropractic)

The HSD Segment specifies the pattern of delivery for the requested services. The request for spinal manipulation services will include 2 visits per week over a 3 month period.

Admission Review
The term "admission review" identifies a notification of authorization for admission to a facility for treatment (pre-certification). The transaction set enables the notification sender to specify both the admission to the facility and the associated inpatient procedures authorized within the same transaction. In this scenario, the specialist requested authorization to admit the patient for a surgical procedure. The UMO has authorized the request and sends a notification of the authorization to the facility. The notification contains one occurrence of Loop 2000E, one occurrence of Loop 2010EA, one occurrence of Loop 2000F and one occurrence of Loop 2010F:

Loop 2000E (Service Provider - Facility)
Loop 2000F (Admission Review)
Loop 2000E (Service Provider - Operating Surgeon)
Loop 2000F (Health Services Review for surgical procedure)

The following example demonstrates a notification of authorization for the facility portion of an admission review.

HL*4*3*EV*1~
TRN*1*211099*9012345678~
UM*HS*I*33~
HCR*A1*IP2003073101~
DTP*435*RD8*20110820-20110826~
CL1*2~

The UM segment identifies the type of health care services.

UM01 = AR (Admission Review)
UM02 = I (Initial Request)
UM03 = 2 (Surgical)
UM04 = 21:B (Hospital - inpatient)

The DTP segment carries the anticipated date range of the admission and the CL1 value indicates the priority of the admission.

Revisions
To revise a specific procedure code that was previously approved, UM02 in Loop 2000E will equal S (Revised) and the authorization number being revised will appear in the REF Previous Review Authorization Number if the authorization was granted at the Event Level. In the 2000F loop, UM02 will equal 3 (Cancel) in the first iteration of the service loop and the procedure code that is being changed from the original request is reported. If the authorization was granted at the Service Level, the previous review authorization number is reported in the REF Previous Review Authorization Number in Loop 2000F. In a second iteration of the 2000F loop, the new procedure code is reported. UM02 will equal S (Revised) to indicate that this loop will contain the revised procedure.

2000E Loop

UM*SC*S*3~
REF*BB*20111109ABCD~

First iteration of 2000F Loop

UM*SC*3~
SV1*HC:99211~

Second iteration of 2000F Loop

UM*SC*S~
SV1*HC:99212~

The response will acknowledge the cancellation of the old procedure and the action on the new procedure.

1.11.4.2 Completion Notification (BHT02 = 14)

A completion notification advises the notification receiver that an authorized patient event has occurred. For example, the UMO may require the facility to return a notification of admission when it admits the patient. The UMO may also require notification when the facility discharges the patient, notice of discharge. The following example demonstrates the use of the notice of admission to advise the UMO that the patient, whose admission was pre-authorized, has been admitted.

HL*4*3*EV*0~
TRN*1*20110820*123456789~
UM*AR**2*21:B~
REF*BB*IP2003073101~
DTP*435*D8*20110821~
CL1*2~

The REF segment identifies the previous certification identifier (the value of HCR02) assigned to the admission review previously authorized. The DTP segment identifies the actual date of admission (DTP01 = 435).

When the facility discharges the patient, it sends another completion notification to notify the UMO of the discharge. Loop 2000E of the discharge notification is identical to the notice of admission with the exception of the DTP segment. On a discharge notice, DTP01 has the value "096" to indicate a discharge date.

1.11.4.3 Information Copy (BHT02 = 22)

The Service loop of courtesy copies of advance or completion notifications are identical in content to the notifications. The business event that triggers this transfer of information and the entities sending and receiving the information determine if the requirement is to notify the receiver, or provide information copies. The primary use of the information copy is to forward from a delegated entity to the Payer a copy of the contents of service reviews that were certified, or not certified by the notification sender/delegated entity. The following example demonstrates an information copy of a service review that was rejected based on the data content of Loop 2000F of the health care services review request.

HL*5*4*SS*0~
AAA*N**52~
UM*HS*I*6~

The AAA segment indicates that the source rejected the service review request for radiation therapy due to an invalid or missing date of service.

1.11.4.4 Acknowledgment of Receipt (BHT02 = 53)

The notification receiver can return a 278 acknowledgment to indicate the successful receipt of the notification. The acknowledgment sender can assign a receipt number to the acknowledgment at the Patient level and/or at each Service level associated with the notification. The following example demonstrates an acknowledgment of receipt of a notice of admission.

HL*4*3*EV*0~
TRN*2*20110820*123456789~
UM*AR*I*2~
REF*NT*IP2003073101~
DTP*435*D8*20110821~

The acknowledgment echoes back the notification sender trace number and other identifying information associated with the service notification. In addition, the acknowledgment sender has assigned an administrative reference number (REF01 = NT) to acknowledge receipt of the notice of admission.

1.11.4.5 Negative Acknowledgment (BHT02 = 44)

The notification receiver must return a negative acknowledgment if it detects invalid or missing data at the Event, or Service level of the notification. The negative acknowledgment must identify the reasons for rejection in the AAA segment at the appropriate level. The following example demonstrates an acknowledgment indicating that the notification contained errors at the Service level.

HL*4*3*SS*0~
AAA*N**52*Y~
UM*HS*I*79~
HCR*A1*3082001~
DTP*472*RD8*20110901-20111130~

The negative acknowledgment echoes back event or service level identification information from the notification. It indicates that the service dates on the notification are not within the provider plan enrollment for the service provider assigned in Loop 2000E. It returns the date in question and the certification number provided in the HCR02 field of the notification.

1.11.5 Additional Service Review Information

Under some circumstances, it may be necessary to augment the information contained in the notification transaction. This additional information concerns patient condition and service detail data not supported in the 278.

1.11.5.1 Referencing Additional Information on the 278 Notification

The 278 notification contains PWK segments that the notification sender may use to reference additional information associated with the Notification.

PWK Segments
The 278 notification supports 10 occurrences of the PWK segment at the Patient level and at each Service level (Loop 2000F). This enables the notification sender to attach up to 10 items pertaining to the patient's condition and/or up to 10 items pertaining to each occurrence of Loop 2000F of the notification.

Guidelines for Using the PWK Segment on the Notification

The PWK segment is required if the notification sender has additional documentation (electronic, paper, or other medium) associated with this notification that applies to the patient and/or the services and the 278 notification transaction (ST to SE) does not support this information.
Use the PWK segment at the Patient level if the attachment pertains to this patient event and/or all the services.
Use the PWK segment at the Service level if the information pertains to a specific service identified in Loop 2000F.
PWK06 is required to identify the additional documentation and should be included as part of the submission.

2. Transaction Set

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

2.1 Presentation Examples

The X12 standards are generic. For example, multiple trading communities use the same PER segment to specify administrative communication contacts. Each community decides which elements to use and which code values in those elements are applicable.

This implementation guide uses a format that depicts both the generalized standard and the insurance industry-specific implementation. In this implementation guide, IMPLEMENTATION specifies the requirements for this implementation. X12 STANDARD is included as a reference only.

The transaction set presentation is comprised of two main sections with subsections within the main sections:

Transaction Set Listing

There are two sub-sections under this general title. The first sub-section concerns this implementation of a generic X12 transaction set. The second sub-section concerns the generic X12 standard itself.

This section lists the levels, loops, and segments contained in this implementation. It also serves as an index to the segment detail.

This section is included as a reference.

Segment Detail

There are three sub-sections under this general title. This section repeats once for each segment used in this implementation providing segment specific detail and X12 standard detail.

This section is included as a reference.

This section is included as a reference. It provides a pictorial view of the standard and shows which elements are used in this implementation.

This section specifies the implementation details of each data element.

These illustrations (Figures 2.1 through 2.5) are examples and are not extracted from the Section 2 detail in this implementation guide. Annotated illustrations, presented below in the same order they appear in this implementation guide, describe the format of the transaction set that follows.

Figure 2.1 - Transaction Set Key - Implementation

Transaction Set Key - Implementation

Figure 2.2 - Transaction Set Key - Standard

Transaction Set Key - Standard

Figure 2.3 - Segment Key - Implementation

Segment Key - Implementation

Figure 2.4 - Segment Key - Diagram

Segment Key - Diagram

Figure 2.5 - Segment Key - Element Summary

Segment Key - Element Summary

2.2.1 Industry Usage

Industry Usage describes when loops, segments, and elements are to be sent when complying with this implementation guide. The three choices for Usage are required, not used, and situational. To avoid confusion, these are named differently than the X12 standard Condition Designators (mandatory, optional, and relational).

Required

This loop/segment/element must always be sent.

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

Required elements in Situational segments only occur when the segment is used.

Required component elements in Situational composite elements only occur when the composite element is used.

Not Used

This element must never be sent.

Situational

Use of this loop/segment/element varies, depending on data content and business context as described in the defining rule. The defining rule is documented in a Situational Rule attached to the item.

There are two forms of Situational Rules.

"Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver."

The data qualified by such a situational rule cannot be required, requested or rejected by the receiver when the condition is not applicable. Transmission of this data is solely at the sender's discretion when the stated condition does not apply.

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

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

2.2.1.1 Determining Transaction Compliance with Industry Usage Requirements

A transmitted transaction complies with the governing implementation guide when it satisfies the requirements as defined within the implementation guide. Specifically, the presence or absence of an item (loop, segment, or element) complies with the industry usage specified by this implementation guide according to the following table.

Industry Usage	Business Condition is	Item is	Transaction Complies with Implementation Guide?
Required	N/A	Sent	Yes
Required	N/A	Not Sent	No
Not Used	N/A	Sent	No
Not Used	N/A	Not Sent	Yes
Situational (Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.)	True	Sent	Yes
	True	Not Sent	No
	Not True	Sent	Yes
	Not True	Not Sent	Yes
Situational (Required when <explicit condition statement>. If not required by this implementation guide, do not send.)	True	Sent	Yes
	True	Not Sent	No
	Not True	Sent	No
	Not True	Not Sent	Yes

2.2.2 Loops

Loop requirements depend on the context or location of the loop within the transaction. See Appendix B for more information on loops.

A nested loop can be used only when the associated higher level loop is used.
The usage of a loop is the same as the usage of its beginning segment.
- If a loop's beginning segment is Required, the loop is Required and must occur at least once unless it is nested in a loop that is not being used.
- If a loop's beginning segment is Situational, the loop is Situational.
Subsequent segments within a loop can be sent only when the beginning segment is used.
Required segments in Situational loops occur only when the loop is used.

2.6 278 Acknowledgment Detail

This section specifies the segments, data elements, and codes for this implementation. Refer to Section 2.1 Presentation Examples for detailed information on the components of the Segment Detail section.

SEGMENT DETAIL

ST - 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 Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment indicates the start of a health care services review notification acknowledgment response transaction set with all the supporting information. This transaction set is the electronic equivalent of a phone, fax, or paper-based receipt acknowledgment.

TR3 Example:

ST✱278✱0002✱008020X328~


DIAGRAM

✱

ST01		143
TS ID Code
M 1	ID	3/3

✱

ST02		329
TS Control Number
M 1	AN	4/9

✱

ST03		1705
Imple Conv Reference
O 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

ST01

143

Transaction Set Identifier Code

M 1

3/3

Code identifying a Transaction Set

CODE

DEFINITION

278

Health Care Services Review Information

REQUIRED

ST02

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

REQUIRED

ST03

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

INDUSTRY NAME: Implementation Guide Version Name

This element must be populated with the guide identifier named in Section 1.2.

This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

SEGMENT DETAIL

BHT - 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 Repeat:

Usage:

REQUIRED

TR3 Example:

BHT✱0007✱53✱199800114000001✱20220101✱1400~


DIAGRAM

BHT

✱

BHT01		1005
Hierarch Struct Code
M 1	ID	4/4

✱

BHT02		353
TS Purpose Code
M 1	ID	2/2

✱

BHT03		127
Reference Ident
O 1	AN	1/80

✱

BHT04		373
Date
O 1	DT	8/8

✱

BHT05		337
Time
O 1	TM	4/8

✱

BHT06		640
~~Transaction~~ ~~Type Code~~
O 1	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

BHT01

1005

Hierarchical Structure Code

M 1

4/4

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

CODE

DEFINITION

0007

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

REQUIRED

BHT02

353

Transaction Set Purpose Code

M 1

2/2

Code identifying purpose of transaction set

CODE

DEFINITION

Rejection

Use when the transaction acknowledges a notification that was rejected due to data errors at this level or non-availability of the receiving system.

Completion

Use when the acknowledgment was a successful receipt of a notification.

REQUIRED

BHT03

127

Reference Identification

O 1

1/80

1/50

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

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

INDUSTRY NAME: Submitter Transaction Identifier

Return the transaction identifier entered in BHT03 on the 278 notification.

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

BHT04

373

Date

O 1

8/8

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

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

INDUSTRY NAME: Transaction Set Creation Date

REQUIRED

BHT05

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

NOT USED

BHT06

640

Transaction Type Code

O 1

2/2

SEGMENT DETAIL

HL - ACKNOWLEDGMENT RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

2000A — ACKNOWLEDGMENT RECEIVER LEVEL
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment indicates the acknowledgment receiver hierarchical level. The acknowledgment receiver corresponds to the source of the notification or information copy.

TR3 Example:

HL✱1✱✱20✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
~~Hierarch~~ ~~Parent ID~~
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

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.

NOT USED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Source

Use when reporting the Acknowledgement Receiver.

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

AAA - NOTIFICATION VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2000A — ACKNOWLEDGMENT RECEIVER LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱42✱Y~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use when the notification transaction has been rejected as identified by the code in AAA03.

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Authorized Quantity Exceeded

Use when the functional group exceeds the maximum number of transactions as specified by agreement between the application sender GS02 and application receiver GS03.

Authorization/Access Restrictions

Use when the application sender (GS02) and application receiver (GS03) do not have a trading partner agreement for the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02. The 278 transaction set has three different implementations. The transaction set purpose, as identified in BHT02, specifies the implementation.

Unable to Respond at Current Time

Use when the entity responsible for forwarding the request to the notification receiver (Loop 2010B) is unable to process the transaction at the current time. This indicates a problem in the system forwarding the notification transaction and not in the notification receiver's system.

Invalid Participant Identification

Use when the identifier used in GS02 or GS03 is invalid or unknown.

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

NM1 - ACKNOWLEDGMENT RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010AA — ACKNOWLEDGMENT RECEIVER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This loop is required when the 2010AB loop is being utilized on the notification. It should be returned on the acknowledgment as it was sent on the notification. If not required by this implementation guide, do not send.

TR3 Example:

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


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the responder needs to identify the acknowledgment receiver by name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Source First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Source Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Information Source Name Suffix

REQUIRED

NM108

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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

CODE SOURCE 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Source Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - ACKNOWLEDGMENT RECEIVER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010AA — ACKNOWLEDGMENT RECEIVER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and used by the receiver to identify the notification sender or notification source. If not required by this implementation guide, do not send.

TR3 Example:

REF✱ZH✱A12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Source Supplemental Identifier

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

AAA - ACKNOWLEDGMENT RECEIVER VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2010AA — ACKNOWLEDGMENT RECEIVER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to convey rejection information regarding the entity that initiated a notification or information copy transaction.

TR3 Example:

AAA✱N✱✱46✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Ineligible for Inquiries

Use when the provider is not authorized for notifications.

Provider Not on File

Invalid Participant Identification

Use when there is an invalid/missing notification sender or notification source supplemental identifier.

Invalid or Missing Provider Address

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

PRV - ACKNOWLEDGMENT RECEIVER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

2010AA — ACKNOWLEDGMENT RECEIVER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/80

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

REQUIRED

PRV02

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

PRV03

127

Reference Identification

X 1

1/80

1/50

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

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

NM1 - ACKNOWLEDGMENT SOURCE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010AB — ACKNOWLEDGMENT SOURCE NAME
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification source name was submitted with the notification and was different than the notification sender. If not required by this implementation guide do not send.

TR3 Notes:


1.	This loop is required when the 2010AB loop is being utilized on the notification. It should be returned on the acknowledgment as it was sent on the notification. If not required by this implementation guide, do not send.

TR3 Example:

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


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the responder needs to identify the acknowledgment source by name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Source First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Source Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Information Source Name Suffix

REQUIRED

NM108

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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

CODE SOURCE 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Source Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - ACKNOWLEDGMENT SOURCE SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010AB — ACKNOWLEDGMENT SOURCE NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and used by the receiver to identify the notification sender or notification source. If not required by this implementation guide, do not send.

TR3 Example:

REF✱ZH✱A12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Source Supplemental Identifier

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

AAA - ACKNOWLEDGMENT SOURCE VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2010AB — ACKNOWLEDGMENT SOURCE NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to convey rejection information regarding the entity that initiated a notification or information copy transaction.

TR3 Example:

AAA✱N✱✱46✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Ineligible for Inquiries

Use when the provider is not authorized for notifications.

Provider Not on File

Invalid Participant Identification

Use when there is an invalid/missing notification sender or notification source supplemental identifier.

Invalid or Missing Provider Address

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

PRV - ACKNOWLEDGMENT SOURCE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

2010AB — ACKNOWLEDGMENT SOURCE NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/80

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

REQUIRED

PRV02

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

PRV03

127

Reference Identification

X 1

1/80

1/50

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

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

HL - ACKNOWLEDGMENT SENDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

2000B — ACKNOWLEDGMENT SENDER LEVEL
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification receiver's system processed any of the information contained in Loop 2000B of the notification. If not required by this implementation guide, do not send.

TR3 Notes:


1.	This segment indicates the acknowledgment sender. The acknowledgment sender is the entity that sent the acknowledgment.

TR3 Example:

HL✱2✱1✱21✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

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

HL02

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

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Use when reporting the Acknowledgment Sender.

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

NM1 - ACKNOWLEDGMENT SENDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010B — ACKNOWLEDGMENT SENDER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This NM1 loop identifies the acknowledgment sender.

TR3 Example:

NM1✱X3✱2✱ABC PAYER✱✱✱✱✱46✱123450000~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the acknowledgment sender needs to identify itself to the acknowledgment receiver by name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the acknowledgment sender is an individual (NM102 = 1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Receiver Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Information Receiver Name Suffix

REQUIRED

NM108

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

Employer's Identification Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

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

Standard Unique Health Plan Identifier (HPID)

CODE SOURCE 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Receiver Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

PER - ACKNOWLEDGMENT SENDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

2010B — ACKNOWLEDGMENT SENDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the acknowledment receiver must direct requests for follow-up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

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


DIAGRAM

PER

✱

PER01		366
Contact Funct Code
M 1	ID	2/2

✱

PER02		93
Name
O 1	AN	1/60

✱

PER03		365
Comm Number Qual
X 1	ID	2/2

✱

PER04		364
Comm Number
X 1	AN	1/2048

✱

PER05		365
Comm Number Qual
X 1	ID	2/2

✱

PER06		364
Comm Number
X 1	AN	1/2048

✱

PER07		365
Comm Number Qual
X 1	ID	2/2

✱

PER08		364
Comm Number
X 1	AN	1/2048

✱

PER09		443
~~Contact Inq~~ ~~Reference~~
O 1	AN	1/20

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PER01

366

Contact Function Code

M 1

2/2

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

CODE

DEFINITION

Information Contact

SITUATIONAL

PER02

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the acknowledgment must be directed to a particular contact. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Contact Name

SITUATIONAL

PER03

365

Communication Number Qualifier

X 1

2/2

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER04 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Use when reporting a URL. The URL must not contain any characters used as delimiters in this transaction.

SITUATIONAL

PER04

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER03 is valued. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Contact Communication Number

SITUATIONAL

PER05

365

Communication Number Qualifier

X 1

2/2

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER06 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

SITUATIONAL

PER06

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

INDUSTRY NAME: Information Receiver Contact Communication Number

SITUATIONAL

PER07

365

Communication Number Qualifier

X 1

2/2

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

SITUATIONAL

PER08

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

INDUSTRY NAME: Information Receiver Contact Communication Number

NOT USED

PER09

443

Contact Inquiry Reference

O 1

1/20

SEGMENT DETAIL

AAA - ACKNOWLEDGMENT SENDER NOTIFICATION VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2010B — ACKNOWLEDGMENT SENDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this AAA segment to report the reasons why the notification receiver cannot receive the notification at a system or application level based on the notification sender or notification source identified in Loop 2010AA or 2010AB.

TR3 Example:

AAA✱N✱✱42✱Y~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Authorized Quantity Exceeded

Use when the transaction exceeds a single patient event.

Authorization/Access Restrictions

Use when the sender, as identified in ISA06 or GS02 is not authorized to send the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02 to the notification receiver identified in Loop 2010B. The 278 transaction set has three different implementations. The transaction set purpose as identified in BHT02 specifies the implementation.

Unable to Respond at Current Time

Use when the notification receiver identified in Loop 2010B is unable to process the transaction at the current time. This indicates that there is a problem within the receiver's system.

Invalid Participant Identification

Use when the notification receiver identifier in Loop 2010B NM109 is invalid.

No Response received - Transaction Terminated

Use when the trading partner/application system responsible for sending the notification to the notification receiver has not received a response in the expected timeframe and therefore has terminated the notification.

Payer Name or Identifier Missing

Use when either the name or identifier for the notification receiver identified in Loop 2010B is missing.

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Resubmission Not Allowed

Please Resubmit Original Transaction

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

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:

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

Loop:

2000C — SUBSCRIBER LEVEL
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification receiver has detected no errors at the parent level (Loop 2000B) of the notification. If not required by this implementation guide, do not send.

TR3 Notes:


1.	This segment indicates the subscriber hierarchical level. The subscriber could also be the patient. If the subscriber is the patient, then the dependent hierarchical level (Loop 2000D) is not used.

TR3 Example:

HL✱3✱2✱22✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

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

HL02

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

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

REF - NOTIFICATION RECEIPT NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000C — SUBSCRIBER LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the acknowledgment sender returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BAF✱0307801~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BAF

Receipt Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Notification Receipt 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

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010C — SUBSCRIBER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	When a Property and Casualty (including Workers' Compensation) entity is the Subscriber, value the Entity Type Code Qualifier to 2 and the associated Federal Tax ID.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
Name Prefix
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

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

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

SITUATIONAL

NM106

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when valued on the notification and used by the notification receiver to further identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Prefix

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

REQUIRED

NM108

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

Federal Taxpayer's Identification Number

Use when NM102 = 2.

Member Identification Number

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

Mutually Defined

Use when reporting the "HIPAA Individual Identifier" once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - SUBSCRIBER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send.

TR3 Notes:

Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is provided in the NM1 segment as a Member Identification Number when it is the primary number by which the UMO knows the member (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless it is different from the Member Identification Number provided in the NM1 segment.

TR3 Example:

REF✱1W✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

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

Branch Identifier

Group Number

Department Number

Patient Account Number

Health Insurance Claim (HIC) Number

Use when the payer has a different member number, and there is also a need to pass the subscriber's HIC number in NM108, MI (Member Identification Number).

Identity Card Number

Use when the Identity Card Number differs from the Member Identification Number (MI) in NM108.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

AAA - SUBSCRIBER NOTIFICATION VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱67✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code and there is not enough data to identify the subscriber.

Invalid/Missing Date-of-Birth

Invalid/Missing Patient ID

Invalid/Missing Patient Name

Invalid/Missing Patient Gender Code

Patient Not Found

Duplicate Patient ID Number

Patient Birth Date Does Not Match That for the Patient on the Database

Invalid/Missing Subscriber/Insured ID

Invalid/Missing Subscriber/Insured Name

Invalid/Missing Subscriber/Insured Gender Code

Subscriber/Insured Not Found

Duplicate Subscriber/Insured ID Number

Subscriber Found, Patient Not Found

Subscriber/Insured Not in Group/Plan Identified

Invalid Participant Identification

Use when the subscriber supplemental identifier is invalid/missing.

Patient Not Eligible

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the notification receiver to identify the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19690815✱M~


DIAGRAM

DMG

✱

DMG01		1250
Date Time Format Qual
X 1	ID	2/3

✱

DMG02		1251
Date Time Period
X 1	AN	1/35

✱

DMG03		1068
Gender Code
O 1	ID	1/1

✱

DMG04		1067
~~Marital~~ ~~Status Code~~
O 1	ID	1/1

✱

DMG05		C056
~~Comp Race~~ ~~or Ethn Inf~~
X 25

✱

DMG06		1066
~~Citizenship~~ ~~Status Code~~
O 1	ID	1/2

✱

DMG07		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

DMG08		659
~~Basis of~~ ~~Verif Code~~
O 1	ID	1/2

✱

DMG09		380
~~Quantity~~
O 1	R	1/15

✱

DMG10		1270
~~Code List~~ ~~Qual Code~~
X 1	ID	1/3

✱

DMG11		1271
~~Industry~~ ~~Code~~
X 1	AN	1/30

✱

DMG12		26
~~Country~~ ~~Code~~
O 1	ID	2/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DMG01

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

DMG02

1251

Date Time Period

X 1

1/35

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

SEGMENT SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

INDUSTRY NAME: Subscriber Birth Date

SITUATIONAL

DMG03

1068

Gender Code

O 1

1/1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when valued on the notification and used by the notification receiver to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

NOT USED

DMG04

1067

Marital Status Code

O 1

1/1

NOT USED

DMG05

C056

Composite Race or Ethnicity Information

X 25

NOT USED

DMG06

1066

Citizenship Status Code

O 1

1/2

NOT USED

DMG07

Country Code

O 1

2/3

NOT USED

DMG08

659

Basis of Verification Code

O 1

1/2

NOT USED

DMG09

380

Quantity

O 1

1/15

NOT USED

DMG10

1270

Code List Qualifier Code

X 1

1/3

NOT USED

DMG11

1271

Industry Code

X 1

1/30

NOT USED

DMG12

Country Code

O 1

2/3

SEGMENT DETAIL

INS - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

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

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and used by the notification receiver to further identify the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱AO~


DIAGRAM

INS

✱

INS01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

INS02		1069
Individual Relat Code
M 1	ID	2/2

✱

INS03		875
~~Maintenance~~ ~~Type Code~~
O 1	ID	3/3

✱

INS04		1203
~~Maintain~~ ~~Reason Code~~
O 1	ID	2/3

✱

INS05		1216
~~Benefit~~ ~~Status Code~~
O 1	ID	1/1

✱

INS06		C052
~~Medicare~~ ~~Status Code~~
O 1

✱

INS07		1219
~~COBRA Qual~~ ~~Event Code~~
O 1	ID	1/2

✱

INS08		584
Employment Status Code
O 1	ID	2/2

✱

INS09		1220
~~Student~~ ~~Status Code~~
O 1	ID	1/1

✱

INS10		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

INS11		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

INS12		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

INS13		1165
~~Confident~~ ~~Code~~
O 1	ID	1/1

✱

INS14		19
~~City~~ ~~Name~~
O 1	AN	2/30

✱

INS15		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

INS16		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

INS17		1470
~~Number~~
O 1	N0	1/9

✱

INS18		1792
~~Chge Identi~~ ~~Info Code~~
O 20	ID	1/2

✱

INS19		1793
~~Prov Netwrk~~ ~~Info Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

INS01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

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

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

REQUIRED

INS02

1069

Individual Relationship Code

M 1

2/2

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Self

NOT USED

INS03

875

Maintenance Type Code

O 1

3/3

NOT USED

INS04

1203

Maintenance Reason Code

O 1

2/3

NOT USED

INS05

1216

Benefit Status Code

O 1

1/1

NOT USED

INS06

C052

Medicare Status Code

O 1

NOT USED

INS07

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

REQUIRED

INS08

584

Employment Status Code

O 1

2/2

Code indicating the general employment status of an employee/claimant

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

CODE

DEFINITION

Active Military - Overseas

Active Military - USA

Deceased

Retired Military - USA

NOT USED

INS09

1220

Student Status Code

O 1

1/1

NOT USED

INS10

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

INS11

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

INS12

1251

Date Time Period

X 1

1/35

NOT USED

INS13

1165

Confidentiality Code

O 1

1/1

NOT USED

INS14

City Name

O 1

2/30

NOT USED

INS15

156

State or Province Code

O 1

2/2

NOT USED

INS16

Country Code

O 1

2/3

NOT USED

INS17

1470

Number

O 1

1/9

NOT USED

INS18

1792

Changed Identifying Information Code

O 20

1/2

NOT USED

INS19

1793

Provider Network Status Information Code

O 1

1/2

SEGMENT DETAIL

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

2000D — DEPENDENT LEVEL
Loop Repeat: 1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the UMO system processed any of the information contained in Loop 2000D of the notification. If not required by this implementation guide, do not send.

TR3 Example:

HL✱4✱3✱23✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

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

HL02

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

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

AAA - DEPENDENT NOTIFICATION VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2000D — DEPENDENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this AAA segment to identify the reasons why the notification could not be processed based on the contents of the HI Dependent Diagnosis Segment or the DTP date segments in Loop 2000D of the notification.

TR3 Example:

AAA✱N✱✱15✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Required application data missing

Use when diagnosis codes or dates are missing.

Input Errors

Use for invalid diagnosis codes and dates.

Inappropriate Date

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

REF - NOTIFICATION RECEIPT NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000D — DEPENDENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the acknowledgment sender returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BAF✱0307801~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BAF

Receipt Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Notification Receipt 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

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

NM1 - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010D — DEPENDENT NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment conveys the name of the dependent who is the patient.

2.	NM108 and NM109 are situational on the acknowledgment but Not Used on the notification. This enables the acknowledgment sender (UMO for example) to return a unique member ID for the dependent that was not known to the notification sender at the time of the review. Normally, if the dependent has a unique member ID, Loop 2000D is not used.

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Name Suffix

SITUATIONAL

NM108

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

Member Identification Number

Use when reporting the payer-assigned identifier for the dependent, even if the payer calls its number a policy number, recipient number, HIC number, or some other synonym.

Mutually Defined

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the dependent has a unique member ID that is known by the acknowledgment sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - DEPENDENT SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010D — DEPENDENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

REF✱EJ✱660415~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Employee Identification Number

Patient Account Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Supplemental Identifier

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DMG - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

2010D — DEPENDENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the notification receiver to identify the patient. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19690815✱M~


DIAGRAM

DMG

✱

DMG01		1250
Date Time Format Qual
X 1	ID	2/3

✱

DMG02		1251
Date Time Period
X 1	AN	1/35

✱

DMG03		1068
Gender Code
O 1	ID	1/1

✱

DMG04		1067
~~Marital~~ ~~Status Code~~
O 1	ID	1/1

✱

DMG05		C056
~~Comp Race~~ ~~or Ethn Inf~~
X 25

✱

DMG06		1066
~~Citizenship~~ ~~Status Code~~
O 1	ID	1/2

✱

DMG07		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

DMG08		659
~~Basis of~~ ~~Verif Code~~
O 1	ID	1/2

✱

DMG09		380
~~Quantity~~
O 1	R	1/15

✱

DMG10		1270
~~Code List~~ ~~Qual Code~~
X 1	ID	1/3

✱

DMG11		1271
~~Industry~~ ~~Code~~
X 1	AN	1/30

✱

DMG12		26
~~Country~~ ~~Code~~
O 1	ID	2/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DMG01

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

DMG02

1251

Date Time Period

X 1

1/35

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

SEGMENT SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

INDUSTRY NAME: Dependent Birth Date

SITUATIONAL

DMG03

1068

Gender Code

O 1

1/1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when valued on the notification and used by the notification receiver to identify the patient. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Gender Code

CODE

DEFINITION

Female

Male

Unknown

NOT USED

DMG04

1067

Marital Status Code

O 1

1/1

NOT USED

DMG05

C056

Composite Race or Ethnicity Information

X 25

NOT USED

DMG06

1066

Citizenship Status Code

O 1

1/2

NOT USED

DMG07

Country Code

O 1

2/3

NOT USED

DMG08

659

Basis of Verification Code

O 1

1/2

NOT USED

DMG09

380

Quantity

O 1

1/15

NOT USED

DMG10

1270

Code List Qualifier Code

X 1

1/3

NOT USED

DMG11

1271

Industry Code

X 1

1/30

NOT USED

DMG12

Country Code

O 1

2/3

SEGMENT DETAIL

INS - DEPENDENT RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

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

Loop:

2010D — DEPENDENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and used by the notification receiver to identify the patient. If not required by this implementation guide, do not send.

TR3 Example:

INS✱N✱19~


DIAGRAM

INS

✱

INS01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

INS02		1069
Individual Relat Code
M 1	ID	2/2

✱

INS03		875
~~Maintenance~~ ~~Type Code~~
O 1	ID	3/3

✱

INS04		1203
~~Maintain~~ ~~Reason Code~~
O 1	ID	2/3

✱

INS05		1216
~~Benefit~~ ~~Status Code~~
O 1	ID	1/1

✱

INS06		C052
~~Medicare~~ ~~Status Code~~
O 1

✱

INS07		1219
~~COBRA Qual~~ ~~Event Code~~
O 1	ID	1/2

✱

INS08		584
~~Employment~~ ~~Status Code~~
O 1	ID	2/2

✱

INS09		1220
~~Student~~ ~~Status Code~~
O 1	ID	1/1

✱

INS10		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

INS11		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

INS12		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

INS13		1165
~~Confident~~ ~~Code~~
O 1	ID	1/1

✱

INS14		19
~~City~~ ~~Name~~
O 1	AN	2/30

✱

INS15		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

INS16		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

INS17		1470
Number
O 1	N0	1/9

✱

INS18		1792
~~Chge Identi~~ ~~Info Code~~
O 20	ID	1/2

✱

INS19		1793
~~Prov Netwrk~~ ~~Info Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

INS01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

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

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

REQUIRED

INS02

1069

Individual Relationship Code

M 1

2/2

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Spouse

Grandfather or Grandmother

Grandson or Granddaughter

Nephew or Niece

Adopted Child

Foster Child

Ward

Stepson or Stepdaughter

Child

Employee

Unknown

Handicapped Dependent

Sponsored Dependent

Dependent of a Minor Dependent

Significant Other

Mother

Father

Other Adult

Organ Donor

Cadaver Donor

Injured Plaintiff

Child Where Insured Has No Financial Responsibility

Life Partner

Other Relationship

NOT USED

INS03

875

Maintenance Type Code

O 1

3/3

NOT USED

INS04

1203

Maintenance Reason Code

O 1

2/3

NOT USED

INS05

1216

Benefit Status Code

O 1

1/1

NOT USED

INS06

C052

Medicare Status Code

O 1

NOT USED

INS07

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

NOT USED

INS08

584

Employment Status Code

O 1

2/2

NOT USED

INS09

1220

Student Status Code

O 1

1/1

NOT USED

INS10

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

INS11

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

INS12

1251

Date Time Period

X 1

1/35

NOT USED

INS13

1165

Confidentiality Code

O 1

1/1

NOT USED

INS14

City Name

O 1

2/30

NOT USED

INS15

156

State or Province Code

O 1

2/2

NOT USED

INS16

Country Code

O 1

2/3

SITUATIONAL

INS17

1470

Number

O 1

1/9

A generic number

SITUATIONAL RULE: Required when valued on the notification and used by the notification receiver to identify a dependent child from a multiple birth. If not required by this implementation guide, do not send.

INDUSTRY NAME: Birth Sequence Number

NOT USED

INS18

1792

Changed Identifying Information Code

O 20

1/2

NOT USED

INS19

1793

Provider Network Status Information Code

O 1

1/2

SEGMENT DETAIL

HL - PATIENT EVENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

2000E — PATIENT EVENT LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification receiver has detected errors at the patient event or subsequent service levels of the notification or when a receipt number is assigned at the event level of a received notification. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Loop 2000E identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.

2.	Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only.

TR3 Example:

HL✱5✱4✱EV✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

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

HL02

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

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Event

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

TRN - PATIENT EVENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the acknowledgment sender or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.

2.	If the 278 notification passes through a clearinghouse that adds their own TRN in addition to a notification sender's TRN, the clearinghouse will receive an acknowledgment from the acknowledgment sender containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the acknowledgment sender has assigned a TRN, the acknowledgment sender's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the acknowledgment receiver's perspective, this is not a referenced transaction trace number.

3.	Any trace numbers provided at this level on the notification must be returned by the acknowledgment sender at this level of the 278 notification.

TR3 Example:

TRN✱1✱2001042801✱9012345678✱CARDIOLOGY~


DIAGRAM

TRN

✱

TRN01		481
Trace Type Code
M 1	ID	1/2

✱

TRN02		127
Reference Ident
M 1	AN	1/80

✱

TRN03		509
Originating Company ID
O 1	AN	10/10

✱

TRN04		127
Reference Ident
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TRN01

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Use when reporting the trace number assigned by the creator of this 278.

Referenced Transaction Trace Numbers

Use when reporting the trace number from the original 278 transaction.

REQUIRED

TRN02

127

Reference Identification

M 1

1/80

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Patient Event Trace Number

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

REQUIRED

TRN03

509

Originating Company Identifier

O 1

10/10

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

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the acknowledgment sender of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.

The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

SITUATIONAL

TRN04

127

Reference Identification

O 1

1/80

1/50

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

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when TRN01 = 2 and TRN04 was valued on the notification or if TRN01 = 1 if necessary to further identify a specific component, such as a specific division or group, of the company identified in the previous data element (TRN03). If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

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

SEGMENT DETAIL

AAA - PATIENT EVENT REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱15✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

SITUATIONAL

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing in this loop that is not covered by another Reject Reason Code.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Invalid/Missing Provider Specialty

Service Dates Not Within Provider Plan Enrollment

Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the notification is inconsistent with the patient condition or services requested.

Invalid/Missing Date(s) of Service

Use when event date is invalid or missing.

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Certification Not Required for this Service

Requested Information Not Received

Invalid/Missing Diagnosis Code(s)

Invalid/Missing Onset of Current Condition or Illness Date

Invalid/Missing Accident Date

Invalid/Missing Last Menstrual Period Date

Invalid/Missing Expected Date of Birth

Invalid/Missing Admission Date

Invalid/Missing Discharge Date

Certification Information Missing

Use when reporting missing previous certification number information.

SITUATIONAL

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	Required to identify the type of health care services review notification to which this acknowledgment pertains.

TR3 Example:

UM✱SC✱I✱3~


DIAGRAM

✱

UM01		1525
Request Categ Code
M 1	ID	1/2

✱

UM02		1322
Certificate Type Code
O 1	ID	1/1

✱

UM03		1271
Industry Code
O 1	AN	1/30

✱

UM04		C023
Health Care Serv Loc.
O 1

✱

UM05		C024
~~Related~~ ~~Causes Info~~
O 1

✱

UM06		1338
Level of Serv Code
O 1	ID	1/3

✱

UM07		1213
~~Current~~ ~~Health Code~~
O 1	ID	1/1

✱

UM08		923
~~Prognosis~~ ~~Code~~
O 1	ID	1/1

✱

UM09		1363
~~Release of~~ ~~Info Code~~
O 1	ID	1/1

✱

UM10		1514
~~Delay~~ ~~Reason Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

UM01

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Admission Review

Use this value to identify admission to a facility.

Health Services Review

Use when reporting services related to an episode of care.

Specialty Care Review

Use when reporting a referral to a specialty provider.

REQUIRED

UM02

1322

Certification Type Code

O 1

1/1

Code indicating the type of certification

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

Use this value to identify an extension request to a prior approved service.

Notification

Initial

Reconsideration

Renewal

Revised

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

SITUATIONAL

UM03

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

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

SITUATIONAL RULE: Required when necessary to identify a service type code at the event level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

SITUATIONAL

UM04

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

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

Values entered at the Service Level for this data element override values at the Patient Event Level for that service only.

REQUIRED

UM04-01

1331

Facility Code Value

1/3

INDUSTRY NAME: Facility Type Code

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

REQUIRED

UM04-02

1332

Facility Code Qualifier

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE 237: Place of Service Codes for Professional Claims

NOT USED

UM04-03

1325

Claim Frequency Type Code

1/1

NOT USED

UM05

C024

Related Causes Information

O 1

SITUATIONAL

UM06

1338

Level of Service Code

O 1

1/3

Code specifying the level of service rendered

SITUATIONAL RULE: Required when valued on the notification. If not required by this implementation guide, do not send.

CODE

DEFINITION

Emergency

Elective

Medicare Expedited

Urgent

NOT USED

UM07

1213

Current Health Condition Code

O 1

1/1

NOT USED

UM08

923

Prognosis Code

O 1

1/1

NOT USED

UM09

1363

Release of Information Code

O 1

1/1

NOT USED

UM10

1514

Delay Reason Code

O 1

1/2

SEGMENT DETAIL

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.

2.	If the acknowledgment contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.

TR3 Example:

HCR✱A1✱20020713~


DIAGRAM

HCR

✱

HCR01		306
Action Code
M 1	ID	1/2

✱

HCR02		127
Reference Ident
O 1	AN	1/80

✱

HCR03		1271
Industry Code
O 5	AN	1/30

✱

HCR04		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HCR01

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Certified in total

Certified - partial

Use when reporting the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

Not Certified

Pended

Modified

Cancelled

Contact Payer

No Action Required

Use when certification is not required.

SITUATIONAL

HCR02

127

Reference Identification

O 1

1/80

1/50

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

SEMANTIC: HCR02 is the number assigned by the information source to this review outcome.

SITUATIONAL RULE: Required when this segment is valued on the notification and the notification contains a value in HCR02 element at the event level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review 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.

SITUATIONAL

HCR03

1271

Industry Code

O 5

1/30

Code indicating a code from a specific industry code list

SEMANTIC: HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886

SITUATIONAL RULE: Required when this segment is valued on the notification and the notification contains a value in HCR03 element at the event level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review Decision Reason Code

NOT USED

HCR04

1073

Yes/No Condition or Response Code

O 1

1/1

SEGMENT DETAIL

REF - ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the acknowledgment sender assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	This is the administrative number assigned by the acknowledgment sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the acknowledgment sender.

TR3 Example:

REF✱NT✱123Z~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Administrative Reference Number

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification at the Event Level or if the acknowledgment sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BB✱A123~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DTP - EVENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment for the valid date(s) during which this event can occur. If not required, do not send.

TR3 Example:

DTP✱AAH✱D8✱20220930~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

AAH

Event

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Event Date

SEGMENT DETAIL

DTP - ADMISSION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment for the proposed or actual date of admission.

TR3 Example:

DTP✱435✱D8✱20220930~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

435

Admission

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use when needed to report a range of dates when admission can occur.

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Admission Date

SEGMENT DETAIL

DTP - DISCHARGE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment for the proposed or actual date of discharge from a facility.

TR3 Example:

DTP✱096✱D8✱20220930~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Discharge Date

SEGMENT DETAIL

DTP - CERTIFICATION ISSUE 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:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment for the date when the certification was issued.

TR3 Example:

DTP✱102✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

REQUIRED

DTP02

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

DTP03

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: Certification Issue Date

SEGMENT DETAIL

DTP - CERTIFICATION EXPIRATION 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:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱036✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

REQUIRED

DTP02

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

DTP03

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: Certification Expiration Date

SEGMENT DETAIL

DTP - CERTIFICATION 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:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

REQUIRED

DTP02

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

DTP03

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: Certification Effective Date

SEGMENT DETAIL

HI - PATIENT SYMPTOMS, DIAGNOSIS, COMPLAINTS

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	This segment is used to hold the event level diagnosis code information that was part of the notification transaction.

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

3.	There are 2 repetitions of the HI segment to allow for 24 possible occurrences of ICD Diagnosis code information. The first iteration would contain diagnosis code 1-12. When used, the second iteration would contain diagnosis codes 13-24.

TR3 Example:

HI✱ABF:H16013~


DIAGRAM

✱

HI01		C022
Health Care Code Info.
M 1

✱

HI02		C022
Health Care Code Info.
O 1

✱

HI03		C022
Health Care Code Info.
O 1

✱

HI04		C022
Health Care Code Info.
O 1

✱

HI05		C022
Health Care Code Info.
O 1

✱

HI06		C022
Health Care Code Info.
O 1

✱

HI07		C022
Health Care Code Info.
O 1

✱

HI08		C022
Health Care Code Info.
O 1

✱

HI09		C022
Health Care Code Info.
O 1

✱

HI10		C022
Health Care Code Info.
O 1

✱

HI11		C022
Health Care Code Info.
O 1

✱

HI12		C022
Health Care Code Info.
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HI01

C022

Health Care Code Information

M 1

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

REQUIRED

HI01-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

ABJ

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

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

ABK

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

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

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI01-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI01-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI01-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI01-05

782

Monetary Amount

1/18

NOT USED

HI01-06

380

Quantity

1/15

NOT USED

HI01-07

799

Version Identifier

1/30

NOT USED

HI01-08

1271

Industry Code

1/30

NOT USED

HI01-09

1271

Industry Code

1/30

NOT USED

HI01-10

1271

Industry Code

1/30

SITUATIONAL

HI02

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI02-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

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

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

ABJ

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

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

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI02-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI02-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI02-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI02-05

782

Monetary Amount

1/18

NOT USED

HI02-06

380

Quantity

1/15

NOT USED

HI02-07

799

Version Identifier

1/30

NOT USED

HI02-08

1271

Industry Code

1/30

NOT USED

HI02-09

1271

Industry Code

1/30

NOT USED

HI02-10

1271

Industry Code

1/30

SITUATIONAL

HI03

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI03-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI03-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI03-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI03-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI03-05

782

Monetary Amount

1/18

NOT USED

HI03-06

380

Quantity

1/15

NOT USED

HI03-07

799

Version Identifier

1/30

NOT USED

HI03-08

1271

Industry Code

1/30

NOT USED

HI03-09

1271

Industry Code

1/30

NOT USED

HI03-10

1271

Industry Code

1/30

SITUATIONAL

HI04

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI04-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI04-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI04-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI04-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI04-05

782

Monetary Amount

1/18

NOT USED

HI04-06

380

Quantity

1/15

NOT USED

HI04-07

799

Version Identifier

1/30

NOT USED

HI04-08

1271

Industry Code

1/30

NOT USED

HI04-09

1271

Industry Code

1/30

NOT USED

HI04-10

1271

Industry Code

1/30

SITUATIONAL

HI05

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI05-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI05-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI05-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI05-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI05-05

782

Monetary Amount

1/18

NOT USED

HI05-06

380

Quantity

1/15

NOT USED

HI05-07

799

Version Identifier

1/30

NOT USED

HI05-08

1271

Industry Code

1/30

NOT USED

HI05-09

1271

Industry Code

1/30

NOT USED

HI05-10

1271

Industry Code

1/30

SITUATIONAL

HI06

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI06-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI06-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI06-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI06-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI06-05

782

Monetary Amount

1/18

NOT USED

HI06-06

380

Quantity

1/15

NOT USED

HI06-07

799

Version Identifier

1/30

NOT USED

HI06-08

1271

Industry Code

1/30

NOT USED

HI06-09

1271

Industry Code

1/30

NOT USED

HI06-10

1271

Industry Code

1/30

SITUATIONAL

HI07

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI07-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

AAF

Current Liability Type

CODE SOURCE 661: Financial Statement Code Lists

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI07-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI07-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI07-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI07-05

782

Monetary Amount

1/18

NOT USED

HI07-06

380

Quantity

1/15

NOT USED

HI07-07

799

Version Identifier

1/30

NOT USED

HI07-08

1271

Industry Code

1/30

NOT USED

HI07-09

1271

Industry Code

1/30

NOT USED

HI07-10

1271

Industry Code

1/30

SITUATIONAL

HI08

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI08-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI08-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI08-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI08-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI08-05

782

Monetary Amount

1/18

NOT USED

HI08-06

380

Quantity

1/15

NOT USED

HI08-07

799

Version Identifier

1/30

NOT USED

HI08-08

1271

Industry Code

1/30

NOT USED

HI08-09

1271

Industry Code

1/30

NOT USED

HI08-10

1271

Industry Code

1/30

SITUATIONAL

HI09

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI09-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI09-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI09-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI09-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI09-05

782

Monetary Amount

1/18

NOT USED

HI09-06

380

Quantity

1/15

NOT USED

HI09-07

799

Version Identifier

1/30

NOT USED

HI09-08

1271

Industry Code

1/30

NOT USED

HI09-09

1271

Industry Code

1/30

NOT USED

HI09-10

1271

Industry Code

1/30

SITUATIONAL

HI10

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI10-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI10-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI10-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI10-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI10-05

782

Monetary Amount

1/18

NOT USED

HI10-06

380

Quantity

1/15

NOT USED

HI10-07

799

Version Identifier

1/30

NOT USED

HI10-08

1271

Industry Code

1/30

NOT USED

HI10-09

1271

Industry Code

1/30

NOT USED

HI10-10

1271

Industry Code

1/30

SITUATIONAL

HI11

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI11-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

REQUIRED

HI11-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI11-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI11-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI11-05

782

Monetary Amount

1/18

NOT USED

HI11-06

380

Quantity

1/15

NOT USED

HI11-07

799

Version Identifier

1/30

NOT USED

HI11-08

1271

Industry Code

1/30

NOT USED

HI11-09

1271

Industry Code

1/30

NOT USED

HI11-10

1271

Industry Code

1/30

SITUATIONAL

HI12

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI12-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

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)

APR

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

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

Diagnosis Related Group (DRG)

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE 663: Logical Observation Identifier Names and Codes (LOINC)

REQUIRED

HI12-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

SITUATIONAL

HI12-03

1250

Date Time Period Format Qualifier

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

SITUATIONAL

HI12-04

1251

Date Time Period

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

NOT USED

HI12-05

782

Monetary Amount

1/18

NOT USED

HI12-06

380

Quantity

1/15

NOT USED

HI12-07

799

Version Identifier

1/30

NOT USED

HI12-08

1271

Industry Code

1/30

NOT USED

HI12-09

1271

Industry Code

1/30

NOT USED

HI12-10

1271

Industry Code

1/30

SEGMENT DETAIL

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

1.	C0302 If MSG03 is present, then MSG02 is required.

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Free form text or description fields are not recommended because they require human interpretation.

2.	Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.

TR3 Example:

MSG✱This is a free-form text message~


DIAGRAM

MSG

✱

MSG01		933
Free-Form Message Txt
M 1	AN	1/264

✱

MSG02		934
~~Printer~~ ~~Ctrl Code~~
X 1	ID	2/2

✱

MSG03		1470
~~Number~~
O 1	N0	1/9

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

MSG01

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

NOT USED

MSG02

934

Printer Carriage Control Code

X 1

2/2

NOT USED

MSG03

1470

Number

O 1

1/9

SEGMENT DETAIL

NM1 - PATIENT EVENT PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010EA — PATIENT EVENT PROVIDER NAME
Loop Repeat: 12

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Physician, Clinic or Group Practice

Attending Physician

Operating Physician

Other Physician

Admitting Physician

Assistant Surgeon

Ordering Physician

Referring Provider

Facility

Primary Care Provider

Purchase Service Provider

Service Provider

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and NM102 = 1 and the Notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the Notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the notification receiver uses the name suffix to further identify the individual provider and the Notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Name Suffix

SITUATIONAL

NM108

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

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - PATIENT EVENT PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when used by the notification receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
Description
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when reporting the provider ID as assigned by the UMO identified in Loop 2000A.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Event Provider Supplemental Identifier

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

SITUATIONAL

REF03

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number and the notification is not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

AAA - PATIENT EVENT PROVIDER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱43✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

SITUATIONAL

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Invalid Participant Identification

Use when reporting invalid/missing service provider supplemental identifier.

SITUATIONAL

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

PRV - PATIENT EVENT PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

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

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/80

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Hospital

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

REQUIRED

PRV02

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

PRV03

127

Reference Identification

X 1

1/80

1/50

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

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

NM1 - PATIENT EVENT TRANSPORT INFORMATION

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

2010EB — PATIENT EVENT TRANSPORT INFORMATION
Loop Repeat: 5

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification receiver has detected errors at the Patient Event Transportation Information level. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱PW✱2✱PATIENT DIALYSIS CENT~

TR3 Example:

NM1✱FS✱2~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
~~Name~~ ~~First~~
O 1	AN	1/35

✱

NM105		1037
~~Name~~ ~~Middle~~
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
~~Name~~ ~~Suffix~~
O 1	AN	1/10

✱

NM108		66
~~ID Code~~ ~~Qualifier~~
X 1	ID	1/2

✱

NM109		67
ID ~~Code~~
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
Entity ID Code
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Drop-off Location

Final Scheduled Destination

Next Destination

Pickup Address

Next Scheduled Destination

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when received on the Notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Transport Location Name

NOT USED

NM104

1036

Name First

O 1

1/35

NOT USED

NM105

1037

Name Middle

O 1

1/25

NOT USED

NM106

1038

Name Prefix

O 1

1/10

NOT USED

NM107

1039

Name Suffix

O 1

1/10

NOT USED

NM108

Identification Code Qualifier

X 1

1/2

NOT USED

NM109

Identification Code

X 1

2/80

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

SITUATIONAL

NM111

Entity Identifier Code

O 1

2/3

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

SEGMENT SYNTAX: C1110

SITUATIONAL RULE: Required when the location category was used by the UMO to render a medical decision. If not required by this implementation guide do not send.

INDUSTRY NAME: Location Category Code

CODE

DEFINITION

Oncology Center

Acute Care Hospital

Military Facility

Outpatient Surgicenter

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Federal, State, County or City Facility

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

Department of Justice Facility

General Medical and Surgical Facility

Hospital Unit of an Institution (prison hospital, college infirmary, etc.)

Hospital Unit Within an Institution for the Mentally Retarded

Psychiatric Facility

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

Arthritis Treatment Center

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Trauma Center (Certified)

Fitness Center

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Comprehensive Geriatric Assessment Facility

Geriatric Clinics

Respite Care Facility

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Hisopathology Laboratory

Therapeutic Radioisotope Facility

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Orthopedic Surgery Facility

Cardiac Rehabilitation Program Facility

Federally Chartered Facility

Hospital

Primary Residence

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Migrant Health Clinic

Oxygen Therapy Facility

Patient Facility

Dialysis Centers

Rural Health Clinic

Skilled Nursing Facility

Nursing Home

Durable Medical Equipment Supplier

Mutually Defined

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

N3 - PATIENT EVENT TRANSPORT LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2010EB — PATIENT EVENT TRANSPORT INFORMATION

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Transport Location Address Line

Use this element for the first line of the transport location address.

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Event Transport Location Address Line

SEGMENT DETAIL

N4 - PATIENT EVENT TRANSPORT LOCATION CITY/STATE/ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

2010EB — PATIENT EVENT TRANSPORT INFORMATION

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
X 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
~~Country Sub~~ ~~Code~~
X 1	ID	1/3

✱

N408		1702
~~Postal Code~~ ~~Formatted~~
X 1	AN	3/20

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

SITUATIONAL

N401

City Name

O 1

2/30

Free-form text for city name

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

SITUATIONAL RULE: Required when received on the Notification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Transport Location City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

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 Event Transport Location State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

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 Event Transport Location Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Patient Event Transport Location Country Code

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

NOT USED

N407

1715

Country Subdivision Code

X 1

1/3

NOT USED

N408

1702

Postal Code-Formatted

X 1

3/20

SEGMENT DETAIL

AAA - PATIENT EVENT TRANSPORT LOCATION REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2010EB — PATIENT EVENT TRANSPORT INFORMATION

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱47✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the transport information.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Invalid/Missing Provider State

Use when the transport location state is invalid or missing.

Invalid or Missing Provider Address

Use when the transport location address is invalid or missing.

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

HL - SERVICE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

2000F — SERVICE LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the acknowledgment sender has detected errors at this level of the notification, or assigns a receipt number to each service level on the notification that it receives. If not required by this implementation guide, do not send.

TR3 Example:

HL✱6✱5✱SS✱0~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

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

HL02

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

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Services

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

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.

SEGMENT DETAIL

TRN - SERVICE TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when this Service level is returned and any trace numbers were provided at this level on the notification, or if the acknowledgment sender or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.

2.	If the 278 notification passes through a clearinghouse that adds their own TRN in addition to a notification sender's TRN, the clearinghouse will receive an acknowledgment from the acknowledgment sender containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the acknowledgment sender has assigned a TRN, the acknowledgment sender's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the acknowledgment receiver's perspective, this is not a referenced transaction trace number.

3.	Any trace numbers provided at this level on the notification must be returned by the acknowledgment sender at this level of the 278 notification.

TR3 Example:

TRN✱2✱111099✱9012345678✱RADIOLOGY~


DIAGRAM

TRN

✱

TRN01		481
Trace Type Code
M 1	ID	1/2

✱

TRN02		127
Reference Ident
M 1	AN	1/80

✱

TRN03		509
Originating Company ID
O 1	AN	10/10

✱

TRN04		127
Reference Ident
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TRN01

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Use when reporting the trace number assigned by the creator of this 278.

Referenced Transaction Trace Numbers

Use when reporting the trace number from the original 278 transaction.

REQUIRED

TRN02

127

Reference Identification

M 1

1/80

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Service Trace Number

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

REQUIRED

TRN03

509

Originating Company Identifier

O 1

10/10

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

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

SITUATIONAL

TRN04

127

Reference Identification

O 1

1/80

1/50

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

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when TRN01 = 2 and TRN04 was valued on the notification at the service level or if TRN01 = 1 and necessary to further identify a specific component, such as a specific division or group, of the company identified in the previous data element (TRN03). If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

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

SEGMENT DETAIL

AAA - SERVICE REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

AAA✱N✱✱52✱C~


DIAGRAM

AAA

✱

AAA01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

AAA02		559
~~Agency~~ ~~Qual Code~~
O 1	ID	2/2

✱

AAA03		901
Reject Reason Code
O 1	ID	2/2

✱

AAA04		889
Follow-up Act Code
O 1	ID	1/1

✱

AAA05		1787
~~Error~~ ~~Reason Code~~
O 99	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

AAA01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

NOT USED

AAA02

559

Agency Qualifier Code

O 1

2/2

REQUIRED

AAA03

901

Reject Reason Code

O 1

2/2

Code identifying reason for rejection as assigned by issuer

CODE

DEFINITION

Required application data missing

Use when data is missing in this loop that is not covered by another Reject Reason Code.

Input Errors

Use when input errors in this loop are not covered by the other reject reason codes.

Service Dates Not Within Provider Plan Enrollment

Invalid/Missing Date(s) of Service

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Certification Not Required for this Service

Requested Information Not Received

Invalid/Missing Procedure Code(s)

Certification Information Missing

Use when reporting missing previous certification number information.

REQUIRED

AAA04

889

Follow-up Action Code

O 1

1/1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NOT USED

AAA05

1787

Error Reason Code

O 99

2/2

SEGMENT DETAIL

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. If not required by this implementation guide, do not send.

TR3 Example:

UM✱SC✱I✱3~


DIAGRAM

✱

UM01		1525
Request Categ Code
M 1	ID	1/2

✱

UM02		1322
Certificate Type Code
O 1	ID	1/1

✱

UM03		1271
Industry Code
O 1	AN	1/30

✱

UM04		C023
Health Care Serv Loc.
O 1

✱

UM05		C024
~~Related~~ ~~Causes Info~~
O 1

✱

UM06		1338
~~Level of~~ ~~Serv Code~~
O 1	ID	1/3

✱

UM07		1213
~~Current~~ ~~Health Code~~
O 1	ID	1/1

✱

UM08		923
~~Prognosis~~ ~~Code~~
O 1	ID	1/1

✱

UM09		1363
~~Release of~~ ~~Info Code~~
O 1	ID	1/1

✱

UM10		1514
~~Delay~~ ~~Reason Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

UM01

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Health Services Review

Required when this is an acknowledgment to a notification of services related to an episode of care.

Specialty Care Review

Use when reporting a referral to a specialty provider.

SITUATIONAL

UM02

1322

Certification Type Code

O 1

1/1

Code indicating the type of certification

SITUATIONAL RULE: Required when different from the UM02 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

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

Notification

Initial

Reconsideration

Renewal

Revised

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

SITUATIONAL

UM03

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

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

SITUATIONAL RULE: Required when necessary to identify why a service type code was rejected at the service level if different from the UM03 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

SITUATIONAL

UM04

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

SITUATIONAL RULE: Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

REQUIRED

UM04-01

1331

Facility Code Value

1/3

INDUSTRY NAME: Facility Type Code

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

REQUIRED

UM04-02

1332

Facility Code Qualifier

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE 237: Place of Service Codes for Professional Claims

NOT USED

UM04-03

1325

Claim Frequency Type Code

1/1

NOT USED

UM05

C024

Related Causes Information

O 1

NOT USED

UM06

1338

Level of Service Code

O 1

1/3

NOT USED

UM07

1213

Current Health Condition Code

O 1

1/1

NOT USED

UM08

923

Prognosis Code

O 1

1/1

NOT USED

UM09

1363

Release of Information Code

O 1

1/1

NOT USED

UM10

1514

Delay Reason Code

O 1

1/2

SEGMENT DETAIL

HCR - CERTIFICATION ACTION CODE

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.

TR3 Example:

HCR✱A1✱20020713~


DIAGRAM

HCR

✱

HCR01		306
Action Code
M 1	ID	1/2

✱

HCR02		127
Reference Ident
O 1	AN	1/80

✱

HCR03		1271
Industry Code
O 5	AN	1/30

✱

HCR04		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HCR01

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Certified in total

Not Certified

Pended

Modified

Cancelled

Contact Payer

No Action Required

SITUATIONAL

HCR02

127

Reference Identification

O 1

1/80

1/50

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

SEMANTIC: HCR02 is the number assigned by the information source to this review outcome.

SITUATIONAL RULE: Required when this segment is valued on the notification and the notification contains a value in HCR03 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review 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.

SITUATIONAL

HCR03

1271

Industry Code

O 5

1/30

Code indicating a code from a specific industry code list

SEMANTIC: HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886

INDUSTRY NAME: Review Decision Reason Code

NOT USED

HCR04

1073

Yes/No Condition or Response Code

O 1

1/1

SEGMENT DETAIL

REF - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification at the Service Level or if the acknowledgment sender has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BB✱A123~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the acknowledgment sender assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.

TR3 Notes:


1.	This is the administrative number assigned by the acknowledgment sender in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the acknowledgment sender.

2.	This number can be used by the notification sender on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.

TR3 Example:

REF✱NT✱123Z~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Administrative Reference Number

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

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DTP - 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:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to indicate the service dates that prohibits the notification receiver from accepting this notification.

TR3 Example:

DTP✱472✱D8✱20221030~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

REQUIRED

DTP02

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

DTP03

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Proposed or Actual Service Date

SEGMENT DETAIL

DTP - CERTIFICATION ISSUE 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:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to indicate the certification issue dates that prohibits the notification receiver from accepting this notification.

TR3 Example:

DTP✱102✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

REQUIRED

DTP02

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

DTP03

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: Certification Issue Date

SEGMENT DETAIL

DTP - CERTIFICATION EXPIRATION 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:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to indicate the certification expiration dates that prohibits the notification receiver from accepting this notification.

TR3 Example:

DTP✱036✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

REQUIRED

DTP02

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

DTP03

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: Certification Expiration Date

SEGMENT DETAIL

DTP - CERTIFICATION 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:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to indicate the certification effective dates that prohibits the notification receiver from accepting this notification.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

REQUIRED

DTP02

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

DTP03

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: Certification Effective Date

SEGMENT DETAIL

HI - ADDITIONAL SERVICE DESCRIPTION

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

TR3 Example:

HI✱AAA:422011000124105~


DIAGRAM

✱

HI01		C022
Health Care Code Info.
M 1

✱

HI02		C022
Health Care Code Info.
O 1

✱

HI03		C022
Health Care Code Info.
O 1

✱

HI04		C022
Health Care Code Info.
O 1

✱

HI05		C022
Health Care Code Info.
O 1

✱

HI06		C022
Health Care Code Info.
O 1

✱

HI07		C022
Health Care Code Info.
O 1

✱

HI08		C022
Health Care Code Info.
O 1

✱

HI09		C022
Health Care Code Info.
O 1

✱

HI10		C022
Health Care Code Info.
O 1

✱

HI11		C022
Health Care Code Info.
O 1

✱

HI12		C022
Health Care Code Info.
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HI01

C022

Health Care Code Information

M 1

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

REQUIRED

HI01-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI01-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI01-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI01-04

1251

Date Time Period

1/35

NOT USED

HI01-05

782

Monetary Amount

1/18

NOT USED

HI01-06

380

Quantity

1/15

NOT USED

HI01-07

799

Version Identifier

1/30

NOT USED

HI01-08

1271

Industry Code

1/30

NOT USED

HI01-09

1271

Industry Code

1/30

NOT USED

HI01-10

1271

Industry Code

1/30

SITUATIONAL

HI02

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI02-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI02-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI02-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI02-04

1251

Date Time Period

1/35

NOT USED

HI02-05

782

Monetary Amount

1/18

NOT USED

HI02-06

380

Quantity

1/15

NOT USED

HI02-07

799

Version Identifier

1/30

NOT USED

HI02-08

1271

Industry Code

1/30

NOT USED

HI02-09

1271

Industry Code

1/30

NOT USED

HI02-10

1271

Industry Code

1/30

SITUATIONAL

HI03

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI03-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI03-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI03-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI03-04

1251

Date Time Period

1/35

NOT USED

HI03-05

782

Monetary Amount

1/18

NOT USED

HI03-06

380

Quantity

1/15

NOT USED

HI03-07

799

Version Identifier

1/30

NOT USED

HI03-08

1271

Industry Code

1/30

NOT USED

HI03-09

1271

Industry Code

1/30

NOT USED

HI03-10

1271

Industry Code

1/30

SITUATIONAL

HI04

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI04-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI04-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI04-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI04-04

1251

Date Time Period

1/35

NOT USED

HI04-05

782

Monetary Amount

1/18

NOT USED

HI04-06

380

Quantity

1/15

NOT USED

HI04-07

799

Version Identifier

1/30

NOT USED

HI04-08

1271

Industry Code

1/30

NOT USED

HI04-09

1271

Industry Code

1/30

NOT USED

HI04-10

1271

Industry Code

1/30

SITUATIONAL

HI05

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI05-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI05-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI05-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI05-04

1251

Date Time Period

1/35

NOT USED

HI05-05

782

Monetary Amount

1/18

NOT USED

HI05-06

380

Quantity

1/15

NOT USED

HI05-07

799

Version Identifier

1/30

NOT USED

HI05-08

1271

Industry Code

1/30

NOT USED

HI05-09

1271

Industry Code

1/30

NOT USED

HI05-10

1271

Industry Code

1/30

SITUATIONAL

HI06

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI06-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI06-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI06-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI06-04

1251

Date Time Period

1/35

NOT USED

HI06-05

782

Monetary Amount

1/18

NOT USED

HI06-06

380

Quantity

1/15

NOT USED

HI06-07

799

Version Identifier

1/30

NOT USED

HI06-08

1271

Industry Code

1/30

NOT USED

HI06-09

1271

Industry Code

1/30

NOT USED

HI06-10

1271

Industry Code

1/30

SITUATIONAL

HI07

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI07-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI07-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI07-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI07-04

1251

Date Time Period

1/35

NOT USED

HI07-05

782

Monetary Amount

1/18

NOT USED

HI07-06

380

Quantity

1/15

NOT USED

HI07-07

799

Version Identifier

1/30

NOT USED

HI07-08

1271

Industry Code

1/30

NOT USED

HI07-09

1271

Industry Code

1/30

NOT USED

HI07-10

1271

Industry Code

1/30

SITUATIONAL

HI08

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI08-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI08-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI08-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI08-04

1251

Date Time Period

1/35

NOT USED

HI08-05

782

Monetary Amount

1/18

NOT USED

HI08-06

380

Quantity

1/15

NOT USED

HI08-07

799

Version Identifier

1/30

NOT USED

HI08-08

1271

Industry Code

1/30

NOT USED

HI08-09

1271

Industry Code

1/30

NOT USED

HI08-10

1271

Industry Code

1/30

SITUATIONAL

HI09

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI09-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI09-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI09-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI09-04

1251

Date Time Period

1/35

NOT USED

HI09-05

782

Monetary Amount

1/18

NOT USED

HI09-06

380

Quantity

1/15

NOT USED

HI09-07

799

Version Identifier

1/30

NOT USED

HI09-08

1271

Industry Code

1/30

NOT USED

HI09-09

1271

Industry Code

1/30

NOT USED

HI09-10

1271

Industry Code

1/30

SITUATIONAL

HI10

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI10-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI10-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI10-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI10-04

1251

Date Time Period

1/35

NOT USED

HI10-05

782

Monetary Amount

1/18

NOT USED

HI10-06

380

Quantity

1/15

NOT USED

HI10-07

799

Version Identifier

1/30

NOT USED

HI10-08

1271

Industry Code

1/30

NOT USED

HI10-09

1271

Industry Code

1/30

NOT USED

HI10-10

1271

Industry Code

1/30

SITUATIONAL

HI11

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI11-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI11-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI11-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI11-04

1251

Date Time Period

1/35

NOT USED

HI11-05

782

Monetary Amount

1/18

NOT USED

HI11-06

380

Quantity

1/15

NOT USED

HI11-07

799

Version Identifier

1/30

NOT USED

HI11-08

1271

Industry Code

1/30

NOT USED

HI11-09

1271

Industry Code

1/30

NOT USED

HI11-10

1271

Industry Code

1/30

SITUATIONAL

HI12

C022

Health Care Code Information

O 1

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

SITUATIONAL RULE: Required when valued on the Notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

HI12-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI12-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI12-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI12-04

1251

Date Time Period

1/35

NOT USED

HI12-05

782

Monetary Amount

1/18

NOT USED

HI12-06

380

Quantity

1/15

NOT USED

HI12-07

799

Version Identifier

1/30

NOT USED

HI12-08

1271

Industry Code

1/30

NOT USED

HI12-09

1271

Industry Code

1/30

NOT USED

HI12-10

1271

Industry Code

1/30

SEGMENT DETAIL

SV1 - PROFESSIONAL SERVICE

X12 Name:

Professional Service

X12 Purpose:

To specify the service line item detail for a health care professional

X12 Syntax:

1.	P0304 If either SV103 or SV104 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use this segment to indicate the professional service data that prohibits the notification receiver from accepting this notification.

2.	In cases where a drug is reported, the DRA segment of Service Level Loop ID-2000F can be utilized in place of this segment to further specify drug reporting.

TR3 Example:

SV1✱HC:99211:25✱12.25✱UN✱1✱✱✱✱✱✱✱N~


DIAGRAM

SV1

✱

SV101		C003
Comp. Med. Proced. ID
M 1

✱

SV102		782
Monetary Amount
O 1	R	1/18

✱

SV103		355
Unit/Basis Meas Code
X 1	ID	2/2

✱

SV104		380
Quantity
X 1	R	1/15

✱

SV105		1331
~~Facility~~ ~~Code~~
O 1	AN	1/3

✱

SV106		1271
~~Industry~~ ~~Code~~
O 1	AN	1/30

✱

SV107		1328
~~Diagnosis~~ ~~Code Pointr~~
O 12	N0	1/2

✱

SV108		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV109		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV110		1340
~~Multiple~~ ~~Proc Code~~
O 1	ID	1/2

✱

SV111		1073
Yes/No Cond Resp Code
O 1	ID	1/1

✱

SV112		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV113		1364
~~Review~~ ~~Code~~
O 1	ID	1/2

✱

SV114		1341
~~Natl/Local~~ ~~Rev Value~~
O 1	AN	1/2

✱

SV115		1327
~~Copay~~ ~~Status Code~~
O 1	ID	1/1

✱

SV116		1334
~~Healthcare~~ ~~Short Code~~
O 1	ID	1/1

✱

SV117		127
~~Reference~~ ~~Ident~~
O 1	AN	1/80

✱

SV118		116
~~Postal~~ ~~Code~~
O 1	ID	3/15

✱

SV119		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV120		1337
Level of Care Code
O 1	ID	1/1

✱

SV121		1360
~~Provider~~ ~~Agree Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SV101

C003

Composite Medical Procedure Identifier

M 1

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

REQUIRED

SV101-01

235

Product/Service ID Qualifier

2/2

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE 130: Healthcare Common Procedure Coding System

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

Mutually Defined

REQUIRED

SV101-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

SITUATIONAL

SV101-03

1339

Procedure Modifier

2/2

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

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV101-04

1339

Procedure Modifier

2/2

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

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV101-05

1339

Procedure Modifier

2/2

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

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV101-06

1339

Procedure Modifier

2/2

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

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

NOT USED

SV101-07

352

Description

1/80

SITUATIONAL

SV101-08

234

Product/Service ID

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

SITUATIONAL

SV101-09

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV101-10

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV101-11

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV101-12

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV102

782

Monetary Amount

O 1

1/18

1/10

Monetary amount

SEMANTIC: SV102 is the submitted service line item amount.

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

SITUATIONAL

SV103

355

Unit or Basis for Measurement Code

X 1

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Minutes

Unit

SITUATIONAL

SV104

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

NOT USED

SV105

1331

Facility Code Value

O 1

1/3

NOT USED

SV106

1271

Industry Code

O 1

1/30

NOT USED

SV107

1328

Diagnosis Code Pointer

O 12

1/2

NOT USED

SV108

782

Monetary Amount

O 1

1/18

NOT USED

SV109

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV110

1340

Multiple Procedure Code

O 1

1/2

SITUATIONAL

SV111

1073

Yes/No Condition or Response Code

O 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: EPSDT Indicator

CODE

DEFINITION

Yes

NOT USED

SV112

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV113

1364

Review Code

O 1

1/2

NOT USED

SV114

1341

National or Local Assigned Review Value

O 1

1/2

NOT USED

SV115

1327

Copay Status Code

O 1

1/1

NOT USED

SV116

1334

Health Care Professional Shortage Area Code

O 1

1/1

NOT USED

SV117

127

Reference Identification

O 1

1/80

NOT USED

SV118

116

Postal Code

O 1

3/15

NOT USED

SV119

782

Monetary Amount

O 1

1/18

SITUATIONAL

SV120

1337

Level of Care Code

O 1

1/1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

NOT USED

SV121

1360

Provider Agreement Code

O 1

1/1

SEGMENT DETAIL

SV2 - INSTITUTIONAL SERVICE

X12 Name:

Institutional Service

X12 Purpose:

To specify the service line item detail for a health care institution

X12 Syntax:

1.	R0102 At least one of SV201 or SV202 is required.
2.	P0405 If either SV204 or SV205 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	In cases where a drug is reported, the DRA segment of Service Level Loop ID-2000F can be utilized in place of this segment to further specify drug reporting.

TR3 Example:

SV2✱120✱✱1500✱DA✱5✱300~

TR3 Example:

SV2✱300✱HC:80019✱73.42✱UN✱1~


DIAGRAM

SV2

✱

SV201		234
Product/ Service ID
X 1	AN	1/80

✱

SV202		C003
Comp. Med. Proced. ID
X 1

✱

SV203		782
Monetary Amount
O 1	R	1/18

✱

SV204		355
Unit/Basis Meas Code
X 1	ID	2/2

✱

SV205		380
Quantity
X 1	R	1/15

✱

SV206		1371
Unit Rate
O 1	R	1/10

✱

SV207		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV208		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV209		1345
~~Nurse Home~~ ~~Status Code~~
O 1	ID	1/1

✱

SV210		1337
Level of Care Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

SITUATIONAL

SV201

234

Product/Service ID

X 1

1/80

Identifying number for a product or service

SEGMENT SYNTAX: R0102

SEMANTIC: SV201 is the revenue code.

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Revenue Code

See Code Source 132: National Uniform Billing Committee (NUBC) Codes.

SITUATIONAL

SV202

C003

Composite Medical Procedure Identifier

X 1

To identify a medical procedure by its standardized codes and applicable modifiers

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

SV202-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

Mutually Defined

REQUIRED

SV202-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

SITUATIONAL

SV202-03

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV202-04

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV202-05

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV202-06

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

NOT USED

SV202-07

352

Description

1/80

SITUATIONAL

SV202-08

234

Product/Service ID

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

SITUATIONAL

SV202-09

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV202-10

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV202-11

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV202-12

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

SITUATIONAL

SV203

782

Monetary Amount

O 1

1/18

1/10

Monetary amount

SEMANTIC: SV203 is the submitted service line item amount.

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

SITUATIONAL

SV204

355

Unit or Basis for Measurement Code

X 1

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Unit

SITUATIONAL

SV205

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

SITUATIONAL

SV206

1371

Unit Rate

O 1

1/10

The rate per unit of associate revenue for hospital accommodation

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Rate

NOT USED

SV207

782

Monetary Amount

O 1

1/18

NOT USED

SV208

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV209

1345

Nursing Home Residential Status Code

O 1

1/1

SITUATIONAL

SV210

1337

Level of Care Code

O 1

1/1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

SEGMENT DETAIL

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Example:

SV3✱AD:D2150✱80~


DIAGRAM

SV3

✱

SV301		C003
Comp. Med. Proced. ID
M 1

✱

SV302		782
Monetary Amount
O 1	R	1/18

✱

SV303		1331
~~Facility~~ ~~Code~~
O 1	AN	1/3

✱

SV304		C006
Oral Cavity Designat.
O 1

✱

SV305		1358
Prosthesis/ Inlay Code
O 1	ID	1/1

✱

SV306		380
Quantity
O 1	R	1/15

✱

SV307		352
~~Description~~
O 1	AN	1/80

✱

SV308		1327
~~Copay~~ ~~Status Code~~
O 1	ID	1/1

✱

SV309		1360
~~Provider~~ ~~Agree Code~~
O 1	ID	1/1

✱

SV310		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV311		1328
Diagnosis Code Pointr
O 12	N0	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SV301

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

REQUIRED

SV301-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

REQUIRED

SV301-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

SITUATIONAL

SV301-03

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV301-04

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV301-05

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV301-06

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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'.

NOT USED

SV301-07

352

Description

1/80

SITUATIONAL

SV301-08

234

Product/Service ID

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

SITUATIONAL

SV301-09

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV301-10

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV301-11

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV301-12

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when returning data that was not valid at this level. 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

SV302

782

Monetary Amount

O 1

1/18

1/10

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

NOT USED

SV303

1331

Facility Code Value

O 1

1/3

SITUATIONAL

SV304

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

SV304-01

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-02

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-03

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-04

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV304-05

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-01 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

SITUATIONAL

SV305

1358

Prosthesis, Crown or Inlay Code

O 1

1/1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

SITUATIONAL

SV306

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Number of procedures

NOT USED

SV307

352

Description

O 1

1/80

NOT USED

SV308

1327

Copay Status Code

O 1

1/1

NOT USED

SV309

1360

Provider Agreement Code

O 1

1/1

NOT USED

SV310

1073

Yes/No Condition or Response Code

O 1

1/1

SITUATIONAL

SV311

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: Need Situational Rule for this SV3 data element.

SEGMENT DETAIL

TOO - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

1.	P0102 If either TOO01 or TOO02 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~


DIAGRAM

TOO

✱

TOO01		1270
Code List Qual Code
X 1	ID	1/3

✱

TOO02		1271
Industry Code
X 1	AN	1/30

✱

TOO03		C005
Tooth Surface
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TOO01

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

TOO02

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

Code source 135: American Dental Association Codes

SITUATIONAL

TOO03

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

REQUIRED

TOO03-01

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

SITUATIONAL

TOO03-02

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

SITUATIONAL

TOO03-03

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

SITUATIONAL

TOO03-04

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

SITUATIONAL

TOO03-05

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

Use code values from TOO03-01.

SEGMENT DETAIL

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

1.	P0405 If either DN204 or DN205 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Example:

DN2✱5✱E✱✱✱✱JP~


DIAGRAM

DN2

✱

DN201		127
Reference Ident
M 1	AN	1/80

✱

DN202		1368
Tooth Status Code
O 1	ID	1/2

✱

DN203		380
~~Quantity~~
O 1	R	1/15

✱

DN204		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

DN205		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

DN206		1270
Code List Qual Code
M 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DN201

127

Reference Identification

M 1

1/80

1/50

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

DN202

1368

Tooth Status Code

O 1

1/2

Code specifying the status of the tooth

NOT USED

DN203

380

Quantity

O 1

1/15

NOT USED

DN204

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

DN205

1251

Date Time Period

X 1

1/35

REQUIRED

DN206

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

SEGMENT DETAIL

DRA - DRUG AUTHORIZATION

X12 Name:

Drug Authorization

X12 Purpose:

To specify a drug for which authorization is being requested

X12 Syntax:

1.	P0405 If either DRA04 or DRA05 is present, then the other is required.
2.	P080910 If either DRA08, DRA09 or DRA10 are present, then the others are required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the request is for a compound drug, repeat the segment for each ingredient in the compound.

TR3 Example:


DIAGRAM

DRA

✱

DRA01		352
Description
M 2	AN	1/80

✱

DRA02		1322
Certificate Type Code
O 1	ID	1/1

✱

DRA03		C003
Comp. Med. Proced. ID
O 2

✱

DRA04		355
Unit/Basis Meas Code
X 1	ID	2/2

✱

DRA05		380
Quantity
X 1	R	1/15

✱

DRA06		933
Free-Form Message Txt
O 1	AN	1/264

✱

DRA07		1073
Yes/No Cond Resp Code
O 1	ID	1/1

✱

DRA08		1073
Yes/No Cond Resp Code
X 1	ID	1/1

✱

DRA09		374
Date/Time Qualifier
X 1	ID	3/3

✱

DRA10		373
Date
X 1	DT	8/8

✱

DRA11		933
Free-Form Message Txt
O 999	AN	1/264

✱

DRA12		380
Quantity
O 1	R	1/15

✱

DRA13		C060
Question and Answer
O 999

✱

DRA14		1330
Dosage Form Code
O 1	ID	2/2

✱

DRA15		933
~~Free-Form~~ ~~Message Txt~~
O 999	AN	1/264

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DRA01

352

Description

M 2

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: DRA01 is the drug name. Position of data in the repeating data element conveys no significance.

INDUSTRY NAME: Drug Name

REQUIRED

DRA02

1322

Certification Type Code

O 1

1/1

Code indicating the type of certification

SEMANTIC: DRA02 is the drug therapy type.

INDUSTRY NAME: Drug Therapy Type

CODE

DEFINITION

Extension

Use when this is the extension of the first use of this drug or its therapeutic equivalent as a supplemental therapy for treatment of this condition.

Initial

Use when this is the first use of this drug or its therapeutic equivalent for treatment of this condition.

Renewal

Use when this is for continuation of the use of this drug or its therapeutic equivalent for treatment of this condition.

Revised

Use when this is the first use of this drug or its therapeutic equivalent to replace a previous unsuccessful or non-optimal therapy for treatment of this condition.

SITUATIONAL

DRA03

C003

Composite Medical Procedure Identifier

O 2

To identify a medical procedure by its standardized codes and applicable modifiers

SEMANTIC: DRA03 Position of data in the repeating data element conveys no significance.

SITUATIONAL RULE: Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

REQUIRED

DRA03-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

REQUIRED

DRA03-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: National Drug Code or Device Identifier of the Unique Device Identifier

NOT USED

DRA03-03

1339

Procedure Modifier

2/2

NOT USED

DRA03-04

1339

Procedure Modifier

2/2

NOT USED

DRA03-05

1339

Procedure Modifier

2/2

NOT USED

DRA03-06

1339

Procedure Modifier

2/2

NOT USED

DRA03-07

352

Description

1/80

NOT USED

DRA03-08

234

Product/Service ID

1/80

NOT USED

DRA03-09

1339

Procedure Modifier

2/2

NOT USED

DRA03-10

1339

Procedure Modifier

2/2

NOT USED

DRA03-11

1339

Procedure Modifier

2/2

NOT USED

DRA03-12

1339

Procedure Modifier

2/2

REQUIRED

DRA04

355

Unit or Basis for Measurement Code

X 1

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

CODE

DEFINITION

International Unit

Gram

Milligram

Milliliter

Unit

REQUIRED

DRA05

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

SEMANTIC: DRA05 is the quantity being requested.

INDUSTRY NAME: National Drug Unit Count

REQUIRED

DRA06

933

Free-form Message Text

O 1

1/264

Free-form message text

SEMANTIC: DRA06 is the Sig (The Sig is a Latin term used in the pharmacy industry that represents theinstructions/directions that are printed on the drug label.)

INDUSTRY NAME: Sig

If the Sig is not known at the the time of the request, send unknown in this data element.

REQUIRED

DRA07

1073

Yes/No Condition or Response Code

O 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: DRA07 is the self administer indicator. A "Y" value indicates that the drug can be administered by the patient. An "N" value indicates that the drug can not be administered by the patient.

INDUSTRY NAME: Self Administered Drug Indicator

CODE

DEFINITION

Yes

REQUIRED

DRA08

1073

Yes/No Condition or Response Code

X 1

1/1

Code indicating a Yes or No condition or response

SEGMENT SYNTAX: P080910

SEMANTIC: DRA08 is the end stage renal disease (ESRD) indicator. A "Y" value indicates that the patient has ESRD. An "N" value indicates that the patient does not have ESRD.

INDUSTRY NAME: ESRD Indicator

CODE

DEFINITION

Yes

SITUATIONAL

DRA09

374

Date/Time Qualifier

X 1

3/3

Code specifying type of date or time, or both date and time

SEGMENT SYNTAX: P080910

SITUATIONAL RULE: Required when the patient has ESRD certification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

458

Certification

SITUATIONAL

DRA10

373

Date

X 1

8/8

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: P080910

SEMANTIC: DRA10 is the ESRD certification date.

SITUATIONAL RULE: Required when DRA09 is used. If not required by this implementation guide do not send.

INDUSTRY NAME: ESRD Certification Date

SITUATIONAL

DRA11

933

Free-form Message Text

O 999

1/264

Free-form message text

SEMANTIC: DRA11 is for questions that are related to the authorization of the drug. Position of data in the repeating data element conveys no significance.

SITUATIONAL RULE: Required when UMO policy has defined additional information necessary for the completion of the authorization. If not required by this implementation guide, do not send.

INDUSTRY NAME: Drug Authorization Question/Answer

Use this data element to convey the UMO question and the answer.

SITUATIONAL

DRA12

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: DRA12 is the number of refills requested.

SITUATIONAL RULE: Required when refills are ordered. If not required by this implementation guide, do not send.

SITUATIONAL

DRA13

C060

Question and Answer

O 999

Used to supply the answers to pre-defined questions

SEMANTIC: DRA13 Position of data in the repeating data element conveys no significance.