276/277 Health Care Claim Status Request and Response (008020X329)

Loop 2000A - INFORMATION SOURCE 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

0010

Information Source, Information Receiver, Provider of Service, Subscriber, Dependent

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Request

Required

127

Reference Identification

O 1

1/80

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

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

INDUSTRY NAME: Originator Application Transaction Identifier

This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse.
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 the request is for status on a predetermination of benefits. If not required by this implementation guide, do not send.

CODE

DEFINITION

Predetermination - Medical

Use when the transaction is for a medical related predetermination (Professional or Institutional).

Predetermination - Dental

HL - INFORMATION SOURCE 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 entity is the payer who has the current status information for the specified claims.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

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

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

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

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Payer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Use when reporting the payer identification number established through trading partner agreement.

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)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

HL - INFORMATION 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 entity expects a response from the Information Source. See Section 1.4.2 Transaction Participants for more information on the Information 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

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*41 - INFORMATION 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 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2000C - SERVICE PROVIDER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

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 identifier in NM109 is not sufficient for identification. If not required by this implementation guide, may be provided at 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 the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Receiver Identification Number

The ETIN is established through Trading Partner agreement.

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 - SERVICE PROVIDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity delivered the health care service. See Section 1.4.2 Transaction Participants for more information on the Provider.

TR3 Example:

HL✱3✱2✱19✱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

Provider of Service

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*1P - 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 2100C - PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider). The provider identified facilitates identification of the claim within a payer's system.

TR3 Example:

NM1✱1P✱2✱HOME MEDICAL✱✱✱✱✱XX✱1666666666~

NM1

✱

✱

Loop 2000D - 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

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: Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 and the person has a name suffix that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Name Suffix

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

Service Provider Number

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)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: 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

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:

When the patient is the subscriber or a dependent with a unique identification number, the claim status request information is reflected in the 2200D Loop under the Subscriber HL, 2000D Loop (HL03 = 22). The Dependent HL, 2000E Loop is not used. See Section 1.4.2.1 for more information on defining the patient.
When requesting and responding to claim status for both a subscriber and dependent(s) of that subscriber without a unique ID, the Subscriber HL Loop 2000D must be followed by the subscriber's claim status data, Loop 2200D. In this instance, HL04=0 would be used. The Subscriber HL Loop 2000D must be repeated prior to one or more of the Dependent HL Loop 2000E and their corresponding claim status data, Loop 2200E. In this instance, Loop 2000D HL04=1 would be used. See Section 1.4.3.3 for an example of this structure.

TR3 Example:

HL✱4✱3✱22✱0~ or HL✱4✱3✱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

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

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.

X12 Set Notes:

NOTE: The DMG segment may only appear at the Subscriber (HL03=22) or Dependent (HL03=23) level.

Loop:

Loop 2000D - SUBSCRIBER LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 2000D HL04 = 0. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

Loop 2100D - SUBSCRIBER NAME

✱

✱

✱

✱

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 available from the Information Receiver. 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

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 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

Use when reporting a non-person entity in an employer-subscriber situation, such as Workers' Compensation or any other Property & Casualty claims.

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 and the person has a name suffix that is known. 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

Employer's Identification Number

Use when reporting the Employer's Identification Number for Workers' Compensation or any other Property & Casualty claims.

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*1 - CLAIM STATUS TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the 2000D HL04 = 0. If not required by this implementation guide, do not send.

TR3 Notes:

This segment conveys a unique trace or reference number for each 2200D loop. This number will be returned in the 277 response.
When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.

TR3 Example:

TRN✱1✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Current Transaction Trace Number

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

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.8 for Payer Claim Control Number Search and Response requirements.

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE 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 the Information Receiver wants to further define data related to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Use of this data as search criteria may vary by information source.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

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: Bill Type Identifier

Concatenate the 837I CLM05-01 (Facility Type Code) and CLM05-03 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6P - GROUP 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 the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6P✱GRP123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group 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: Group 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*X1 - PROVIDER'S ASSIGNED CLAIM IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver wants to further define data related to a specific claim. If not required by this implementation guide may be provided by the sender but cannot be required by the receiver.

TR3 Notes:

Use of this data as search criteria may vary by information source.

TR3 Example:

REF✱X1✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider 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: Provider's Assigned Claim 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.
For example, this is the value from CLM01 of an 837.
The maximum number of characters to be supported for this qualifier is 35. Characters beyond the maximum are not required to be stored or returned by the receiving system.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION 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 the Information Receiver wants to further define data related to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Use of this data as search criteria may vary by information source.

TR3 Example:

REF✱XZ✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription 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: Pharmacy Prescription Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a transmission intermediary (clearinghouse or other) needs to attach their own unique tracking number. If not required by this implementation guide, do not send.

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Clearinghouse Trace Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY & CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Property and Casualty number has been established and the number has been previously communicated to the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

AMT*T3 - TOTAL CLAIM CHARGE AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver wants to further define data related to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
Use of this data as search criteria may vary by information source.

TR3 Example:

AMT✱T3✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Total Submitted Charges

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Claim Charge Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.
The Total Claim Charge Amount must be greater than or equal to zero.

Not Used

478

Credit/Debit Flag Code

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 the claim is not a predetermination and service level dates (Loop-ID 2210) are not reported on all service lines. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

For 837 Institutional claims, it is the statement period in Loop-ID 2300 (DTP01=434). For 837 Professional claims this information is derived from the earliest service level dates in Loop-ID 2400 (DTP01=472) to the latest service level date. For 837 Dental claims it is the service date at the claim level in Loop-ID 2300 (DTP01=472) or when not reported at Loop-ID 2300, it is derived from the earliest service level date in Loop-ID 2400 (DTP01=472) to the latest service level date.

TR3 Example:

DTP✱472✱RD8✱20220314-20220325~

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

Use when the "From and To" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "From and To" dates are the same.

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: Claim Service Period

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

To supply payment and control information to a provider for a particular service

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when requesting status for Service Lines. If not required by this implementation guide, do not send.

TR3 Notes:

For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-02 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-02.

TR3 Example:

SVC✱HC:C8900:AA✱800✱✱0111✱✱✱12~orSVC✱NU:0710✱50✱✱✱✱✱1~

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

SEMANTIC: SVC01 is the medical procedure upon which adjudication is based.

COMMENT: For Medicare Part A claims, SVC01 would be the Healthcare Common Procedure Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

X12 COMPOSITE SEMANTIC NOTES:

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.

SVC01-02 will contain the procedure code of the adjudicated claim. If the adjudicated code is not known then SVC01-02 will contain the original submitted procedure code.

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

Jurisdiction Specific Procedure and Supply Codes

Use when applicable for Property & Casualty claims

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

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

Health Insurance Prospective Payment System (HIPPS) Rate Code

CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

Use when reporting a NUBC Revenue Code

CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-01 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

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 modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/80

Situational

1-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This amount is the original submitted charge.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

782

Monetary Amount

O 1

1/18

Situational

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.

SITUATIONAL RULE: Required on institutional claims to report a NUBC revenue code when a HCPCS or HIPPS code is reported in the SVC01-02. If not required by this implementation guide, do not send.

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

A zero or negative value is not allowed.

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver wants to further define data related to this specific service. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

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 a service level date was submitted on the claim for this service. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

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

Use when the "From and To" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "From and To" dates are the same.

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

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:

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

Loop:

Loop 2000E - DEPENDENT LEVEL

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when tooth information is needed to further define the service. 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

International Standard Designation System for Teeth and Areas of the Oral Cavity

Use when reporting areas of the oral cavity; do not use to report individual teeth.

CODE SOURCE: 135: American Dental Association

Universal National Tooth Designation System

Use when reporting individual teeth; do not use when reporting areas of the oral cavity.

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: Oral Cavity Area/Tooth Code

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

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 Loop 2000D HL04 = 1. If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is the dependent, the claim status request information is reflected in the 2200E Loop under the Dependent HL, 2000E Loop (HL03 = 23). See Section 1.4.2.1 for more information on defining the patient.

TR3 Example:

HL✱5✱4✱23~

✱

✱

✱

✱

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

Not Used

736

Hierarchical Child Code

O 1

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.

X12 Set Notes:

NOTE: The DMG segment may only appear at the Subscriber (HL03=22) or Dependent (HL03=23) level.

Loop:

Loop 2000E - DEPENDENT LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

Loop 2100E - DEPENDENT NAME

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Patient Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when available from the Information Receiver. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Gender Code

CODE

DEFINITION

Female

Male

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

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 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Name Suffix

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*1 - CLAIM STATUS TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys a unique trace or reference for each 2200E Loop. This number will be returned in the 277 response.

TR3 Example:

TRN✱1✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Current Transaction Trace Number

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

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.8 for Payer Claim Control Number Search and Response requirements.

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver wants to further define data related to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Use of this data as search criteria may vary by information source.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

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: Bill Type Identifier

Concatenate the 837I CLM05-01 (Facility Type Code) and CLM05-03 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6P - GROUP 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 patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6P✱GRP123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group 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: Group 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*X1 - PROVIDER'S ASSIGNED CLAIM IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Use of this data as search criteria may vary by information source.

TR3 Example:

REF✱X1✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider 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: Provider's Assigned Claim 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.
For example, this is the value from CLM01 of an 837.
The maximum number of characters to be supported for this qualifier is 35. Characters beyond the maximum are not required to be stored or returned by the receiving system.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION 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 Information Receiver wants to further define data related to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Use of this data as search criteria may vary by information source.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription 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: Pharmacy Prescription Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a transmission intermediary (clearinghouse or other) needs to attach their own unique tracking number. If not required by this implementation guide, do not send.

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Clearinghouse Trace Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY & CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Property and Casualty number has been established and the number has been previously communicated to the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

AMT*T3 - TOTAL CLAIM CHARGE AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver wants to further define data related to a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
Use of this data as search criteria may vary by information source.

TR3 Example:

AMT✱T3✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Total Submitted Charges

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Claim Charge Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.
The Total Claim Charge Amount must be greater than or equal to zero.

Not Used

478

Credit/Debit Flag Code

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:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

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

Use when the "From and To" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "From and To" dates are the same.

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: Claim Service Period

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

To supply payment and control information to a provider for a particular service

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when requesting status for Service Lines. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

SVC✱HC:C8900:AA✱800✱✱0111✱✱✱12~orSVC✱NU:0710✱50✱✱✱✱✱1~

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

SEMANTIC: SVC01 is the medical procedure upon which adjudication is based.

COMMENT: For Medicare Part A claims, SVC01 would be the Healthcare Common Procedure Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

X12 COMPOSITE SEMANTIC NOTES:

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.

SVC01-02 will contain the procedure code of the adjudicated claim. If the adjudicated code is not known then SVC01-02 will contain the original submitted procedure code.

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

Jurisdiction Specific Procedure and Supply Codes

Use when applicable for Property & Casualty claims

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

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

Health Insurance Prospective Payment System (HIPPS) Rate Code

CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

Use when reporting a NUBC Revenue Code

CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-01 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

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 modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/80

Situational

1-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This amount is the original submitted charge.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

782

Monetary Amount

O 1

1/18

Situational

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.

SITUATIONAL RULE: Required on institutional claims to report a NUBC revenue code when a HCPCS or HIPPS code is reported in the SVC01-02. If not required by this implementation guide, do not send.

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

A zero or negative value is not allowed.

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver wants to further define data related to this specific service. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

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 a service level date was submitted on the claim for this service. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

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

Use when the "From and To" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "From and To" dates are the same.

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

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:

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 tooth information is needed to further define the service. 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

International Standard Designation System for Teeth and Areas of the Oral Cavity

Use when reporting areas of the oral cavity; do not use to report individual teeth.

CODE SOURCE: 135: American Dental Association

Universal National Tooth Designation System

Use when reporting individual teeth; do not use when reporting areas of the oral cavity.

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: Oral Cavity Area/Tooth Code

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

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.

277 Response Transaction Set Listing

008020X329 Health Care Claim Status Request and Response

Usage

Repeats

ISA INTERCHANGE CONTROL HEADER

Required

1
GS*HR FUNCTIONAL GROUP HEADER

Required

1
ST*277 TRANSACTION SET HEADER

Required

1
BHT*0010 BEGINNING OF HIERARCHICAL TRANSACTION

Required

1
Loop 2000A - INFORMATION SOURCE LEVEL

Required

1
- HL INFORMATION SOURCE LEVEL
  
  Required
  
  1
- Loop 2100A - PAYER NAME
  
  Required
  
  1
  - NM1*PR PAYER NAME
    
    Required
    
    1
  - PER*IC PAYER CONTACT INFORMATION
    
    Situational
    
    1
- Loop 2200A - INFORMATION SOURCE APPLICATION TRACE IDENTIFIER
  
  Situational
  
  1
  - TRN*1 INFORMATION SOURCE APPLICATION TRACE IDENTIFIER
    
    Required
    
    1
Loop 2000B - INFORMATION RECEIVER LEVEL

Required

1
- HL INFORMATION RECEIVER LEVEL
  
  Required
  
  1
- Loop 2100B - INFORMATION RECEIVER NAME
  
  Required
  
  1
  - NM1*41 INFORMATION RECEIVER NAME
    
    Required
    
    1
- Loop 2200B - INFORMATION RECEIVER TRACE IDENTIFIER
  
  Situational
  
  1
  - TRN*2 INFORMATION RECEIVER TRACE IDENTIFIER
    
    Required
    
    1
  - STC INFORMATION RECEIVER STATUS INFORMATION
    
    Required
    
    >1
Loop 2000C - SERVICE PROVIDER LEVEL

Situational

>1
- HL SERVICE PROVIDER LEVEL
  
  Required
  
  1
- Loop 2100C - PROVIDER NAME
  
  Required
  
  1
  - NM1*1P PROVIDER NAME
    
    Required
    
    1
Loop 2000D - SUBSCRIBER LEVEL

Situational

>1
- HL SUBSCRIBER LEVEL
  
  Required
  
  1
- Loop 2100D - SUBSCRIBER NAME
  
  Required
  
  1
  - NM1*IL SUBSCRIBER NAME
    
    Required
    
    1
- Loop 2200D - CLAIM STATUS TRACE NUMBER
  
  Situational
  
  >1
  - TRN*2 CLAIM STATUS TRACE NUMBER
    
    Required
    
    1
  - STC CLAIM LEVEL STATUS INFORMATION
    
    Required
    
    >1
  - REF*1K PAYER CLAIM CONTROL NUMBER
    
    Situational
    
    1
  - REF*BLT INSTITUTIONAL BILL TYPE IDENTIFICATION
    
    Situational
    
    1
  - REF*X1 PROVIDER'S ASSIGNED CLAIM IDENTIFIER
    
    Situational
    
    1
  - REF*XZ PHARMACY PRESCRIPTION NUMBER
    
    Situational
    
    1
  - REF*VV VOUCHER IDENTIFIER
    
    Situational
    
    1
  - REF*D9 CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES
    
    Situational
    
    1
  - REF*Y4 PROPERTY & CASUALTY CLAIM NUMBER
    
    Situational
    
    1
  - DTP*472 SERVICE DATE
    
    Situational
    
    1
  - DTP*050 CLAIM RECEIVED DATE
    
    Situational
    
    1
  - Loop 2210D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
    
    Situational
    
    1
    - PWK*V4 TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
      
      Required
      
      1
    - PER*IC TRANSFER TO ENTITY CONTACT INFORMATION
      
      Required
      
      1
    - N1 TRANSFER TO ENTITY NAME
      
      Required
      
      1
    - N3 TRANSFER TO ENTITY ADDRESS
      
      Situational
      
      1
    - N4 TRANSFER TO ENTITY CITY, STATE, ZIP CODE
      
      Situational
      
      1
  - Loop 2220D - SERVICE LINE INFORMATION
    
    Situational
    
    >1
    - SVC SERVICE LINE INFORMATION
      
      Required
      
      1
    - STC SERVICE LINE STATUS INFORMATION
      
      Required
      
      >1
    - REF*6R LINE ITEM CONTROL NUMBER
      
      Situational
      
      1
    - DTP*472 SERVICE DATE
      
      Situational
      
      1
    - TOO TOOTH INFORMATION
      
      Situational
      
      32
    - Loop 2225D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
      
      Situational
      
      1
      - PWK*V4 TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
        
        Required
        
        1
      - PER*IC TRANSFER TO ENTITY CONTACT INFORMATION
        
        Required
        
        1
      - N1 TRANSFER TO ENTITY NAME
        
        Required
        
        1
      - N3 TRANSFER TO ENTITY ADDRESS
        
        Situational
        
        1
      - N4 TRANSFER TO ENTITY CITY, STATE, ZIP CODE
        
        Situational
        
        1
Loop 2000E - DEPENDENT LEVEL

Situational

>1
- HL DEPENDENT LEVEL
  
  Required
  
  1
- Loop 2100E - DEPENDENT NAME
  
  Required
  
  1
  - NM1*QC DEPENDENT NAME
    
    Required
    
    1
- Loop 2200E - CLAIM STATUS TRACE NUMBER
  
  Required
  
  >1
  - TRN*2 CLAIM STATUS TRACE NUMBER
    
    Required
    
    1
  - STC CLAIM LEVEL STATUS INFORMATION
    
    Required
    
    >1
  - REF*1K PAYER CLAIM CONTROL NUMBER
    
    Situational
    
    1
  - REF*BLT INSTITUTIONAL BILL TYPE IDENTIFICATION
    
    Situational
    
    1
  - REF*X1 PROVIDER'S ASSIGNED CLAIM IDENTIFIER
    
    Situational
    
    1
  - REF*XZ PHARMACY PRESCRIPTION NUMBER
    
    Situational
    
    1
  - REF*VV VOUCHER IDENTIFIER
    
    Situational
    
    1
  - REF*D9 CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES
    
    Situational
    
    1
  - REF*Y4 PROPERTY & CASUALTY CLAIM NUMBER
    
    Situational
    
    1
  - DTP*472 SERVICE DATE
    
    Situational
    
    1
  - DTP*050 CLAIM RECEIVED DATE
    
    Situational
    
    1
  - Loop 2210E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
    
    Situational
    
    1
    - PWK*V4 TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
      
      Required
      
      1
    - PER*IC TRANSFER TO ENTITY CONTACT INFORMATION
      
      Required
      
      1
    - N1 TRANSFER TO ENTITY INFORMATION
      
      Required
      
      1
    - N3 TRANSFER TO ENTITY ADDRESS
      
      Situational
      
      1
    - N4 TRANSFER TO ENTITY CITY, STATE, ZIP CODE
      
      Situational
      
      1
  - Loop 2220E - SERVICE LINE INFORMATION
    
    Situational
    
    >1
    - SVC SERVICE LINE INFORMATION
      
      Required
      
      1
    - STC SERVICE LINE STATUS INFORMATION
      
      Required
      
      >1
    - REF*6R LINE ITEM CONTROL NUMBER
      
      Situational
      
      1
    - DTP*472 SERVICE DATE
      
      Situational
      
      1
    - TOO TOOTH INFORMATION
      
      Situational
      
      32
    - Loop 2225E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
      
      Situational
      
      1
      - PWK*V4 TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION
        
        Required
        
        1
      - PER*IC TRANSFER TO ENTITY CONTACT INFORMATION
        
        Required
        
        1
      - N1 TRANSFER TO ENTITY NAME
        
        Required
        
        1
      - N3 TRANSFER TO ENTITY ADDRESS
        
        Situational
        
        1
      - N4 TRANSFER TO ENTITY CITY, STATE, ZIP CODE
        
        Situational
        
        1
SE TRANSACTION SET TRAILER

Required

1
GE FUNCTIONAL GROUP TRAILER

Required

1
IEA INTERCHANGE CONTROL TRAILER

Required

1

ISA - INTERCHANGE CONTROL HEADER

X12 Name:

Interchange Control Header

X12 Purpose:

To start and identify an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
The first element separator defines the element separator to be used through the entire interchange.
Spaces in the example interchanges are represented by "." for clarity.
The ISA segment terminator defines the segment terminator used throughout the entire interchange.
All positions within each of the data elements must be filled.

TR3 Example:

ISA✱00✱..........✱01✱SECRET....✱ZZ✱SENDERS.ID.....✱ZZ✱RECEIVERS.ID...✱030101✱1253✱^✱00802✱000000905✱0✱T✱:~

ISA

✱

I01

Author Info
Qualifier

✱

✱

✱

✱

✱

Interchange
Sender ID

✱

✱

Interchange
Receiver ID

✱

✱

✱

✱

Inter Ctrl
Version Num

✱

✱

✱

✱

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

CODE SOURCE: 121: Health Industry Number

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

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

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

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

CODE SOURCE: 121: Health Industry Number

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

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

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

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Required

I11

Interchange Control Version Number Code

M 1

Code specifying the version number of the interchange control segments, the version of the data elements within the control segments, and the code values within those data elements.

INDUSTRY NAME: Interchange Control Version Number

CODE

DEFINITION

00802

00802 Standards Approved for Publication by ASC X12 Procedures Review Board through December 2020

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

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

Required

I13

Acknowledgment Requested Code

M 1

Code indicating sender's request for an interchange acknowledgment

INDUSTRY NAME: Acknowledgment Requested

X12.5 - Interchange Control Structure provides the purpose of the TA1 segment. The X12 Acknowledgment Reference Model provides considerable information about the TA1 segment.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Use when the interchange contains ONLY acknowledgment Functional Groups (e.g. 999 or 824) or a TA1.

Interchange Acknowledgment Requested (TA1)

Use when batch process requires the return of a TA1 for the interchange.

Interchange Acknowledgment Requested only when Interchange is "Rejected Because Of Errors"

Use when the transaction is for real-time processing.

Interchange Acknowledgment Requested only when Interchange is "Rejected Because Of Errors" or "Accepted but Errors are Noted"

Use when batch processing requires the return of a TA1 for the interchange only when errors are noted.

Required

I14

Interchange Usage Indicator Code

M 1

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

INDUSTRY NAME: Interchange Usage Indicator

CODE

DEFINITION

Information

Use when the interchange contains ONLY a TA1.

Production Data

Test Data

Required

I15

Component Element Separator

M 1

GS*HR - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

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

X12 Comments:

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱XX✱SENDER CODE✱RECEIVER CODE✱19991231✱0802✱1✱X✱008020X329~

✱

✱

Application
Send's Code

M 1

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

CODE

DEFINITION

Health Care Claim Status Request (276)HN Health Care Information Status Notification (277)

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

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.

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

INDUSTRY NAME: Version, Release, or Industry Identifier Code

CODE SOURCE 881: Version / Release / Industry Identifier Code

CODE

DEFINITION

008020X329

Health Care Claim Status Request and Response

ST*277 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱277✱0002✱008020X329~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code identifying a Transaction Set

CODE

DEFINITION

277

Health Care Information Status Notification

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

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

INDUSTRY NAME: Version, Release, or Industry Identifier

This element must be populated with the implementation guide Version/Release/Industry Identifier Code named in Section 1.2.
This element 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

008020X329

Health Care Claim Status Request and Response

BHT*0010 - 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✱0010✱08✱ABC276XXX✱20220921✱0430✱DG~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 2000A - INFORMATION SOURCE 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

CODE

DEFINITION

0010

Information Source, Information Receiver, Provider of Service, Subscriber, Dependent

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Status

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

SITUATIONAL RULE: Required when the transaction is used in real-time or when rejecting 276 Claim Status Requests (batch) for errors at the Information Source or the Information Receiver level. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Originator Application Transaction Identifier

This identifier is the identifier received in the BHT03 of the corresponding 276 transaction.
This information may be sent at the creator of the 277's discretion if using the transaction in a Batch mode. Due to the nature of batch transaction processing, the receiver of the 277 transaction (whether it is a clearinghouse or information source) may or may not be able to return the 276 BHT03 value in the 277 BHT03.
This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier is not to be passed through the complete life of the transaction, rather replaced with the identifier received in the 276.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

CODE

DEFINITION

Response

HL - INFORMATION SOURCE 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 entity is the payer who has the current status information for the specified claims.

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

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

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Payer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Use when reporting the payer identification number established through trading partner agreement.

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)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*IC - PAYER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer's contact information is not otherwise specified in a Trading Partner Agreement and the Information Receiver does not know how to contact the payer. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

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✱✱TE✱3135551234~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2200A - INFORMATION SOURCE APPLICATION TRACE IDENTIFIER

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 a specific person or department is the contact for the response. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer Contact Communication Number

When an extension or additional contact number is required, use PER06.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

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: Payer 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 Data Interchange Access Number

Electronic Mail

Telephone Extension

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: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

TRN*1 - INFORMATION SOURCE APPLICATION TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the Information Source wants to assign a unique identifier to the 277 Response for tracking purposes within their system. If not required by this implementation guide, do not send.

TR3 Example:

TRN✱1✱1722634842~

TRN

✱

✱

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Information Source Application Trace Identifier

This is a unique trace number that identifies a specific transaction. This number is assigned by the Information Source.
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

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

HL - INFORMATION 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 entity expects a response from the Information Source. See Section 1.4.2 Transaction Participants for more information on the Information Receiver.

TR3 Example:

HL✱2✱1✱21✱1~ or HL✱2✱1✱21✱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

Information Receiver

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*41 - INFORMATION 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 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the individual or organization requesting to receive the status information.

TR3 Example:

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

NM1

✱

✱

Loop 2200B - INFORMATION RECEIVER TRACE IDENTIFIER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Information Receiver Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Receiver Identification Number

The ETIN is established through Trading Partner agreement.

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

TRN*2 - INFORMATION RECEIVER TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an entire 276 transaction is rejected for errors at the Information Source or Information Receiver level (2000B HL04 = "0"). If not required by this implementation guide, do not send.

TR3 Notes:

If reporting error status at this level, 2000C, 2000D and 2000E Loops are not used.
See Section 1.4.4.2 Status Response Levels for additional information on reporting status at the Information Receiver level.

TR3 Example:

TRN✱2✱ABC276XXX~

TRN

✱

✱

✱

Loop 2200B - INFORMATION RECEIVER TRACE IDENTIFIER

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Claim Transaction Batch Number

This value must be the BHT03 data element value from the 276 Claim Status Request being rejected.
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

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

STC - INFORMATION RECEIVER STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

To report the status, required action, and paid information of a claim or service line

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
If reporting error status at this level, 2000C, 2000D and 2000E Loops are not used.

TR3 Example:

STC✱E0:24:41✱20110830~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2000C - SERVICE PROVIDER LEVEL

Required

C043

Health Care Claim Status

M 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Only the 'D0' Category Code and 'E' Category Codes are allowable at this level.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

SITUATIONAL RULE: Required when an entity must be identified to further clarify the status code in this composite data element. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Submitter

Use when errors apply to the Information Receiver.

Payer

Use when errors apply to the Information Source.

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Required

373

Date

O 1

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

SEMANTIC: STC02 is the effective date of the status information.

INDUSTRY NAME: Status Information Effective Date

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Submitter

Use when errors apply to the Information Receiver.

Payer

Use when errors apply to the Information Source.

Not Used

10-4

1270

Code List Qualifier Code

O 1

1/3

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Submitter

Use when errors apply to the Information Receiver.

Payer

Use when errors apply to the Information Source.

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

Not Used

933

Free-form Message Text

O 1

1/264

Not Used

1383

Claim Submission Reason Code

O 1

HL - SERVICE PROVIDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when status was not reported at the Information Receiver level (2000B HL04=1). If not required by this implementation guide, do not send.

TR3 Notes:

This entity delivered the health care service. See Section 1.4.2 Transaction Participants for more information on the Provider.

TR3 Example:

HL✱3✱2✱19✱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

Provider of Service

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*1P - 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 2100C - PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱1P✱2✱HOME MEDICAL✱✱✱✱✱XX✱1666666666~

NM1

✱

✱

Loop 2000D - 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

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: Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 and the person has a name suffix that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Name Suffix

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

Service Provider Number

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: 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

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:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when status was not reported at the Information Receiver level (2000B HL04=1). If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is the subscriber or a dependent with a unique identification number, the claim status response information is reflected in the 2200D Loop under the Subscriber HL, 2000D Loop (HL03 = 22). The Dependent HL, 2000E Loop is not used. See Section 1.4.2.1 for more information on defining the patient.
When requesting and responding to claim status for both a subscriber and dependent(s) of that subscriber without a unique ID, the Subscriber HL Loop 2000D must be followed by the subscriber's claim status data, Loop 2200D. In this instance, HL04=0 would be used. The Subscriber HL Loop 2000D must be repeated prior to one or more of the Dependent HL Loop 2000E and their corresponding claim status data, Loop 2200E. In this instance, Loop 2000D HL04=1 would be used. See Section 1.4.3.3 for an example of this structure.

TR3 Example:

HL✱4✱3✱22✱0~ or HL✱4✱3✱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

No Subordinate HL Segment in This Hierarchical Structure.

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 2100D - SUBSCRIBER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

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

Use when reporting a non-person entity in an employer-subscriber situation, such as Workers' Compensation or any other Property & Casualty claims.

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the value in NM102 = 1 and the person has a first name that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 and the person has a name suffix that is known. 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

Employer's Identification Number

Use when reporting the Employer's Identification Number for Workers' Compensation or any other Property & Casualty claims.

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*2 - CLAIM STATUS TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the 2000D HL04 = 0. If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.
This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.

TR3 Example:

TRN✱2✱ABC12345~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Referenced Transaction Trace Number

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

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

To report the status, required action, and paid information of a claim or service line

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱A1:20✱20110501✱✱50~ -or-STC✱F1:65✱20110511✱✱50✱40✱20110510✱✱20110510✱445321~ orSTC✱F2:88:IL✱20110501✱✱50✱0✱✱✱✱✱F2:27~ orSTC✱F2:79::RX✱20110501✱✱50✱0~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except 'Request for Additional Information' (R Category Codes) are allowable at this level.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC01-04 must have the value 'RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC01-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Required

373

Date

O 1

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

SEMANTIC: STC02 is the effective date of the status information.

INDUSTRY NAME: Status Information Effective Date

This is the date the claim was placed in this status by the Information Source's adjudication process.

Not Used

306

Action Code

O 1

1/2

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the total charge amount.

SITUATIONAL RULE: Required when the response provides status on a claim found in the Information Source's system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Claim Charge Amount

The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC05 is the amount paid.

SITUATIONAL RULE: Required when the remittance cycle is complete and a remittance advice has been issued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Claim Payment Amount

Zero is an acceptable amount when no payment is being made.
Some payers are able to provide the adjudicated payment amount prior to the remittance being issued.
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

373

Date

O 1

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

SEMANTIC: STC06 is the paid date.

INDUSTRY NAME: Adjudication Finalized Date

This is the date of approval or denial for the claim. This date may or may not be the same as the payment effective date from the remittance advice (STC08). In the 835, the payment effective date is BPR16.
Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.

Not Used

591

Payment Method Code

O 1

Situational

373

Date

O 1

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

SEMANTIC: STC08 is the check issue date.

SITUATIONAL RULE: Required when the remittance cycle is complete and this claim is included on a payment that is reported in an 835 or paper remittance to the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Remittance Date

This is the payment effective date from the remittance advice. In the 835, this is the value in BPR16.
This could include a non-payment remittance advice date if available from the Information Source's system.

Situational

429

Check Number

O 1

1/16

Check identification number

INDUSTRY NAME: Remittance Trace Number

This is the unique identification number assigned to the payment in the remittance advice for tracking purposes. In the 835, this is the value from TRN02.
This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC10-04 must have the value 'RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC11-04 must have the value 'RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC11-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

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

INDUSTRY NAME: Predetermination of Benefits Code

CODE

DEFINITION

Pre-Determination

Use when the claim is for a medical related predetermination (Professional or Institutional)

Predetermination of Dental Benefits

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a claim is located in the Information Source's system or when a payer claim control number was submitted on the 276, but did not result in a found claim for the submitted number. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.8 for Payer Claim Control Number Search and Response requirements.

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE 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 an institutional claim is located in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

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: Bill Type Identifier

Concatenate the 837I CLM05-01 (Facility Type Code) and CLM05-03 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*X1 - PROVIDER'S ASSIGNED CLAIM IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Provider's Assigned Claim Identifier was submitted on the claim(s) found in the Information Source's system or when a Provider's Assigned Claim Identifier was submitted in the 276 transaction and a claim with that value was not found in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Notes:

The information returned in this segment may not match the information submitted in the 276 request when additional responses are returned based on other search criteria.

TR3 Example:

REF✱X1✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider 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: Provider's Assigned Claim 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.
For example, this is the value from CLM01 of an 837.
The maximum number of characters to be supported for this qualifier is 35. Characters beyond the maximum are not required to be stored or returned by the receiving system.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION 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 the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription 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: Pharmacy Prescription 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*VV - VOUCHER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.

TR3 Notes:

Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.

TR3 Example:

REF✱VV✱V123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Voucher

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: Voucher Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when received on the 276 status request. If not required by this implementation guide, do not send.

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Clearinghouse Trace Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY & CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Property & Casualty Claim Number has been established by the Property & Casualty payer for the claim (bill) reported in the Payer Claim Control Number REF Segment. If not required by this implementation guide, do not send.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

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 the claim is not a predetermination and service level dates (Loop-ID 2220) are not reported on all service lines. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

For 837 Institutional claims, it is the statement period in Loop-ID 2300 (DTP01=434). For 837 Professional claims this information is derived from the earliest service level dates in Loop-ID 2400 (DTP01=472) to the latest service level date. For 837 Dental claims it is the service date at the claim level in Loop-ID 2300 (DTP01=472) or when not reported at Loop-ID 2300, it is derived from the earliest service level date in Loop-ID 2400 (DTP01=472) to the latest service level date.
When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

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: Claim Service Period

DTP*050 - CLAIM RECEIVED DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Notes:

This is the date the claim was received by the payer.

TR3 Example:

DTP✱050✱D8✱20221030~

DTP

✱

✱

Loop 2210D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

050

Received

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Received Date

PWK*V4 - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

COMMENT: The 2210 loop may be used when there is a status notification or a request for additional information about a particular claim.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a claim has been permanently transferred to another entity for processing and the Information Source can no longer provide status. If not required by this implementation guide, do not send.

TR3 Notes:

The PWK segment is syntactically required in order to use the Transfer to Entity data in Loop ID 2210D.
This is not for COB reporting or when a service is transferred internally within the payer's system(s).

TR3 Example:

PWK✱V4✱✱✱TT~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

CODE

DEFINITION

Change of Name and/or Address

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Required

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Transfer To

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

PER*IC - TRANSFER TO ENTITY 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 2210D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

PER✱IC✱EDI HELP DESK✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2210D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the contact name is known and is specific to the inquiries of the status of the transferred claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transfer to Entity Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer 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

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when PER08 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

N1 - TRANSFER TO ENTITY NAME

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱PR✱TIMBUCKTU INSURANCE✱FI✱8888888888~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Clearinghouse

Payer

Third Party Repricing Organization (TPO)

Third Party Administrator (TPA)

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Transfer to Entity Name

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Federal Taxpayer's Identification Number

Payor Identification

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

COMMENT: This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when available to identify the transfer to entity. If not required by this implementation guide do not send.

INDUSTRY NAME: Transfer to Entity Identification

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - TRANSFER TO ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop 2210D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source can provide the physical address of the Transfer to Entity. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Transfer to Entity Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Transfer to Entity Address Line

N4 - TRANSFER TO ENTITY 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 2210D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

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: Transfer to 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: Transfer to 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: Transfer to Postal 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: Transfer to Entity Country

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Not Used

1715

Country Subdivision Code

X 1

1/3

Not Used

1702

Postal Code-Formatted

X 1

3/20

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

To supply payment and control information to a provider for a particular service

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when service line level status varies by service line or when a service line status is different than the claim-level status or when the 276 made a service specific 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:

For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-02 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-02.
When a service specific claim status request is received, the claim status response may include additional service lines applicable to the claim.

TR3 Example:

SVC✱HC:99214✱75✱50✱✱✱✱1~ orSVC✱NU:0710✱50✱0✱✱✱✱1~

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

SEMANTIC: SVC01 is the medical procedure upon which adjudication is based.

COMMENT: For Medicare Part A claims, SVC01 would be the Healthcare Common Procedure Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

X12 COMPOSITE SEMANTIC NOTES:

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.

SVC01-02 contains the adjudicated procedure code. This code may be different than the original submitted procedure code based on the payer's claim processing.

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

Jurisdiction Specific Procedure and Supply Codes

Use when applicable for Property & Casualty claims

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

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

Health Insurance Prospective Payment System (HIPPS) Rate Code

CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

Use when reporting a NUBC Revenue Code

CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-01 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

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 modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/80

Situational

1-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This is the line item total on the current claim service status.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC03 is the amount paid this service.

INDUSTRY NAME: Line Item Payment Amount

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

Situational

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.

SITUATIONAL RULE: Required on institutional claims to report a NUBC revenue code when a HCPCS or HIPPS code is reported in the SVC01-02. If not required by this implementation guide, do not send.

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

A zero or negative value is not allowed.

STC - SERVICE LINE STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

To report the status, required action, and paid information of a claim or service line

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱F1:65✱20110501~ orSTC✱A3:110✱20110501✱✱✱✱✱✱✱✱A3:400~ orSTC✱F2:79::RX✱20110501~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except 'Request for Additional Information' (R Category Codes) are allowable at this level.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-04 must have the value 'RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject/Payment Code in STC01-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Required

373

Date

O 1

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

SEMANTIC: STC02 is the effective date of the status information.

INDUSTRY NAME: Status Information Effective Date

This is the date the service was placed in this status by the Information Source's adjudication process.

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Situational

373

Date

O 1

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

SEMANTIC: STC06 is the paid date.

SITUATIONAL RULE: Required when the remittance cycle is complete, this service is included on a payment that is reported in an 835 or paper remittance to the provider AND the payment information for this service is different from the claim level payment information. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Adjudication Finalized Date

This is the date of approval or denial for the service. This date may or may not be the same as the payment effective date from the remittance advice (STC08). In the 835, the payment effective date is BPR16.
Some payers are able to provide the final service adjudicated date prior to the remittance being issued.

Not Used

591

Payment Method Code

O 1

Situational

373

Date

O 1

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

SEMANTIC: STC08 is the check issue date.

INDUSTRY NAME: Remittance Date

This could include a non-payment remittance advice date if available from the Information Source's system.
This is the payment effective date from the remittance advice. In the 835, this is the value in BPR16.

Situational

429

Check Number

O 1

1/16

Check identification number

INDUSTRY NAME: Remittance Trace Number

This is the unique identification number assigned to the payment in the remittance advice for tracking purposes. In the 835, this is the value from TRN02.
This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-04 must have the value 'RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject/Payment Code in STC10-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-04 must have the value 'RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject/Payment Code in STC11-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

SITUATIONAL RULE: Required when the service line was submitted as a predetermination request. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Predetermination of Benefits Code

CODE

DEFINITION

Pre-Determination

Use when the service line is for a medical related predetermination (Professional or Institutional)

Predetermination of Dental Benefits

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Service Line Item Control Number was submitted on the claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

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 a service level date was submitted on the claim for this service. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

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:

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

Loop:

Loop 2225D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when tooth information was submitted on the original claim for this service. 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

International Standard Designation System for Teeth and Areas of the Oral Cavity

Use when reporting areas of the oral cavity; do not use to report individual teeth.

CODE SOURCE: 135: American Dental Association

Universal National Tooth Designation System

Use when reporting individual teeth; do not use when reporting areas of the oral cavity.

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

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

PWK*V4 - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

COMMENT: The 2225 loop may be used when there is a status notification or a request for additional information about a particular service line.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a service has been permanently transferred to another entity for processing and the Information Source can no longer provide status
AND
The entity in this loop is different or not present at the claim level (Loop ID-2210D). If not required by this implementation guide, do not send.

TR3 Notes:

The PWK segment is syntactically required in order to use the Transfer To Entity data in Loop ID 2225D.
This is not for COB reporting or when a service is transferred internally within the payer's system(s).

TR3 Example:

PWK✱V4✱✱✱TT~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

CODE

DEFINITION

Change of Name and/or Address

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Required

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Transfer To

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

PER*IC - TRANSFER TO ENTITY 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 2225D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

PER✱IC✱EDI HELP DESK✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2225D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the contact name is known and is specific to the inquiries of the status of the transferred claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transfer to Entity Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer 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

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when PER08 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

N1 - TRANSFER TO ENTITY NAME

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱PR✱TIMBUCKTU INSURANCE✱FI✱8888888888~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Clearinghouse

Payer

Third Party Repricing Organization (TPO)

Third Party Administrator (TPA)

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Transfer to Entity Name

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Federal Taxpayer's Identification Number

Payor Identification

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when available to identify the transfer to entity. If not required by this implementation guide do not send.

INDUSTRY NAME: Transfer to Entity Identification

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - TRANSFER TO ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop 2225D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Transfer to Entity Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Transfer to Entity Address Line

N4 - TRANSFER TO ENTITY 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 2225D - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2000E - DEPENDENT LEVEL

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: Transfer to 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: Transfer to 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: Transfer to Postal 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: Transfer to Entity Country

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Not Used

1715

Country Subdivision Code

X 1

1/3

Not Used

1702

Postal Code-Formatted

X 1

3/20

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 Loop 2000D HL04 = 1. If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is a dependent, the claim status response information is reflected in the 2200E Loop under the Dependent HL, 2000E Loop (HL03 = 23). See Section 1.4.2.1 for more information on defining the patient.

TR3 Example:

HL✱5✱4✱23~

✱

✱

✱

✱

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

Not Used

736

Hierarchical Child Code

O 1

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 2100E - DEPENDENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the person has a middle name or initial that is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Name Suffix

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*2 - CLAIM STATUS TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.

TR3 Example:

TRN✱2✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Referenced Transaction Trace Number

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

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

To report the status, required action, and paid information of a claim or service line

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱A1:20✱20110501✱✱50~ -or-STC✱F1:65✱20110511✱✱50✱40✱20110510✱✱20110510✱445321~ orSTC✱F2:88:G0✱20110501✱50✱0✱✱✱✱✱F2:27~ orSTC✱F2:79::RX✱20110501✱✱50✱0~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except 'Request for Additional Information' (R Category Codes) are allowable at this level.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC01-04 must have the value 'RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Required

373

Date

O 1

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

SEMANTIC: STC02 is the effective date of the status information.

INDUSTRY NAME: Status Information Effective Date

This is the date the claim was placed in this status by the Information Source's adjudication process.

Not Used

306

Action Code

O 1

1/2

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the total charge amount.

SITUATIONAL RULE: Required when the response provides status on a claim found in the Information Source's system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Claim Charge Amount

The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC05 is the amount paid.

INDUSTRY NAME: Claim Payment Amount

Zero is an acceptable amount when no payment is being made.
Some payers are able to provide the adjudicated payment amount prior to the remittance being issued.
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

373

Date

O 1

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

SEMANTIC: STC06 is the paid date.

INDUSTRY NAME: Adjudication Finalized Date

This is the date of approval or denial for the claim. This date may or may not be the same as the payment effective date from the remittance advice (STC08). In the 835, the payment effective date is BPR16.
Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.

Not Used

591

Payment Method Code

O 1

Situational

373

Date

O 1

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

SEMANTIC: STC08 is the check issue date.

INDUSTRY NAME: Remittance Date

This is the payment effective date from the remittance advice. In the 835, this is the value in BPR16.
This could include a non-payment remittance advice date if available from the Information Source's system.

Situational

429

Check Number

O 1

1/16

Check identification number

INDUSTRY NAME: Remittance Trace Number

This is the unique identification number assigned to the payment in the remittance advice for tracking purposes. In the 835, this is the value from TRN02.
This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC10-04 must have the value 'RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC11-04 must have the value 'RX'.
The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

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

INDUSTRY NAME: Predetermination of Benefits Code

CODE

DEFINITION

Pre-Determination

Use when the claim is for a medical related predetermination (Professional or Institutional)

Predetermination of Dental Benefits

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

See Section 1.4.8 for Payer Claim Control Number Search and Response requirements.

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE 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 an institutional claim is located in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

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: Bill Type Identifier

Concatenate the 837I CLM05-01 (Facility Type Code) and CLM05-03 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*X1 - PROVIDER'S ASSIGNED CLAIM IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

The information returned in this segment may not match the information submitted in the 276 request when additional responses are returned based on other search criteria.

TR3 Example:

REF✱X1✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider 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: Provider's Assigned Claim 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.
For example, this is the value from CLM01 of an 837.
The maximum number of characters to be supported for this qualifier is 35. Characters beyond the maximum are not required to be stored or returned by the receiving system.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription 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: Pharmacy Prescription 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*VV - VOUCHER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.

TR3 Notes:

Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.

TR3 Example:

REF✱VV✱V123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Voucher

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: Voucher Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when received on the 276 status request. If not required by this implementation guide, do not send.

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Clearinghouse Trace Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY & CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

For 837 Institutional claims, it is the statement period in Loop-ID 2300 (DTP01=434). For 837 Professional claims this information is derived from the earliest service level dates in Loop-ID 2400 (DTP01=472) to the latest service level date. For 837 Dental claims it is the service date at the claim level in Loop-ID 2300 (DTP01=472) or when not reported at Loop-ID 2300, it is derived from the earliest service level date in Loop-ID 2400 (DTP01=472) to the latest service level date.
When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

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: Claim Service Period

DTP*050 - CLAIM RECEIVED DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Notes:

This is the date the claim was received by the payer.

TR3 Example:

DTP✱050✱D8✱20221030~

DTP

✱

✱

Loop 2210E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

050

Received

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Received Date

PWK*V4 - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

COMMENT: The 2210 loop may be used when there is a status notification or a request for additional information about a particular claim.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

The PWK segment is syntactically required in order to use the Transfer to Entity data in Loop ID 2210E.
This is not for COB reporting or when a service is transferred internally within the payer's system(s).

TR3 Example:

PWK✱V4✱✱✱TT~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

CODE

DEFINITION

Change of Name and/or Address

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Required

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Transfer To

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

PER*IC - TRANSFER TO ENTITY 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 2210E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

PER✱IC✱EDI HELP DESK✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2210E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the contact name is known and is specific to the inquiries of the status of the transferred claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transfer to Entity Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer 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

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when PER08 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

N1 - TRANSFER TO ENTITY INFORMATION

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱PR✱TIMBUCKTU INSURANCE✱FI✱8888888888~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Clearinghouse

Payer

Third Party Repricing Organization (TPO)

Third Party Administrator (TPA)

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Transfer to Entity Name

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Federal Taxpayer's Identification Number

Payor Identification

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when available to identify the transfer to entity. If not required by this implementation guide do not send.

INDUSTRY NAME: Transfer to Entity Identification

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - TRANSFER TO ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop 2210E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Transfer to Entity Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Transfer to Entity Address Line

N4 - TRANSFER TO ENTITY 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 2210E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

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: Transfer to 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: Transfer to 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: Transfer to Postal 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: Transfer to Entity Country

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Not Used

1715

Country Subdivision Code

X 1

1/3

Not Used

1702

Postal Code-Formatted

X 1

3/20

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

To supply payment and control information to a provider for a particular service

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-02 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-02.
When a service specific claim status request is received, the claim status response may include additional service lines applicable to the claim.

TR3 Example:

SVC✱HC:99214✱75✱50✱✱✱✱1~ orSVC✱NU:0710✱50✱0✱✱✱✱1~

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

SEMANTIC: SVC01 is the medical procedure upon which adjudication is based.

COMMENT: For Medicare Part A claims, SVC01 would be the Healthcare Common Procedure Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

X12 COMPOSITE SEMANTIC NOTES:

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.

SVC01-02 contains the adjudicated procedure code. This code may be different than the original submitted procedure code based on the payer's claim processing.

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

Jurisdiction Specific Procedure and Supply Codes

Use when applicable for Property & Casualty claims

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

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

Health Insurance Prospective Payment System (HIPPS) Rate Code

CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

Use when reporting a NUBC Revenue Code

CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-01 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

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 modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/80

Situational

1-9

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-10

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-11

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Situational

1-12

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This is the line item total on the current claim service status.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC03 is the amount paid this service.

INDUSTRY NAME: Line Item Payment Amount

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

Situational

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.

SITUATIONAL RULE: Required on institutional claims to report a NUBC revenue code when a HCPCS or HIPPS code is reported in the SVC01-02. If not required by this implementation guide, do not send.

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

A zero or negative value is not allowed.

STC - SERVICE LINE STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

To report the status, required action, and paid information of a claim or service line

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱F1:65✱20110501~ orSTC✱A3:110✱20110501✱✱✱✱✱✱✱✱A3:400~ orSTC✱F2:79::RX✱20110501~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except 'Request for Additional Information' (R Category Codes) are allowable at this level.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-04 must have the value 'RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Required

373

Date

O 1

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

SEMANTIC: STC02 is the effective date of the status information.

INDUSTRY NAME: Status Information Effective Date

This is the date the service was placed in this status by the Information Source's adjudication process.

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Situational

373

Date

O 1

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

SEMANTIC: STC06 is the paid date.

INDUSTRY NAME: Adjudication Finalized Date

This is the date of approval or denial for the service. This date may or may not be the same as the payment effective date from the remittance advice (STC08). In the 835, the payment effective date is BPR16.
Some payers are able to provide the final service adjudicated date prior to the remittance being issued.

Not Used

591

Payment Method Code

O 1

Situational

373

Date

O 1

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

SEMANTIC: STC08 is the check issue date.

INDUSTRY NAME: Remittance Date

This could include a non-payment remittance advice date if available from the Information Source's system.
This is the payment effective date from the remittance advice. In the 835, this is the value in BPR16.

Situational

429

Check Number

O 1

1/16

Check identification number

INDUSTRY NAME: Remittance Trace Number

This is the unique identification number assigned to the payment in the remittance advice for tracking purposes. In the 835, this is the value from TRN02.
This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-04 must have the value 'RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Situational

C043

Health Care Claim Status

O 1

Used to convey status of the entire claim or a specific service line

X12 COMPOSITE SEMANTIC NOTES:

C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
C043-02 is used to identify the status of an entire claim or a service line. Code Source 508 is referenced unless qualified by C043-04.
C043-03 identifies the entity associated with the Health Care Claim Status Code.
C043-04 is used to identify the Code Source referenced in C043-02.

SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-01 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-04 must have the value 'RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-03 for valid values.

CODE

DEFINITION

Dependent

Provider

Long Term Care Facility

Psychiatric Health Facility

Laboratory

Third-Party Administrator

Employer

Rehabilitation Facility

Alcoholism and Other Chemical Dependency Facility

Receiver

Submitter

Drop-off Location

Hospice

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Assistant Surgeon

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Previous Insured

Home Health Agency

Independent Physicians Association (IPA)

Insured or Subscriber

MSC

Mammography Screening Center

Factor

Use when identifying a Pay to Factoring Agent.

Doctor of Optometry

OOP

Other Operating Physician

Primary Insured or Subscriber

Primary Care Provider

Payer

PRP

Primary Payer

PTP

Pay-to Plan Name

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Policyholder

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Medical Doctor

Skilled Nursing Facility

SEP

Secondary Payer

Third Party Reviewing Organization (TPO)

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Utilization Management Organization

Durable Medical Equipment Supplier

Mutually Defined

Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

SITUATIONAL RULE: Required when the service line was submitted as a predetermination request. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Predetermination of Benefits Code

CODE

DEFINITION

Pre-Determination

Use when the service line is for a medical related predetermination (Professional or Institutional)

Predetermination of Dental Benefits

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Service Line Item Control Number was submitted on the claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

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 a service level date was submitted on the claim for this service. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱RD8✱20220401-20220402~

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

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

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:

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

Loop:

Loop 2225E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when tooth information was submitted on the original claim for this service. 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

International Standard Designation System for Teeth and Areas of the Oral Cavity

Use when reporting areas of the oral cavity; do not use to report individual teeth.

CODE SOURCE: 135: American Dental Association

Universal National Tooth Designation System

Use when reporting individual teeth; do not use when reporting areas of the oral cavity.

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: Oral Cavity Area/Tooth Code

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

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

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

PWK*V4 - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

COMMENT: The 2225 loop may be used when there is a status notification or a request for additional information about a particular service line.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a service has been permanently transferred to another entity for processing and the Information Source can no longer provide status
AND
The entity in this loop is different or not present at the claim level (Loop ID-2210E). If not required by this implementation guide, do not send.

TR3 Notes:

The PWK segment is syntactically required in order to use the Transfer To Entity data in Loop ID 2225E.
This is not for COB reporting or when a service is transferred internally within the payer's system(s).

TR3 Example:

PWK✱V4✱✱✱TT~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

CODE

DEFINITION

Change of Name and/or Address

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Required

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Transfer To

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

PER*IC - TRANSFER TO ENTITY 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 2225E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

PER✱IC✱EDI HELP DESK✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2225E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the contact name is known and is specific to the inquiries of the status of the transferred claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transfer to Entity Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer 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

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when PER08 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 the payer needs to provide additional information associated with the transfer to entity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

N1 - TRANSFER TO ENTITY NAME

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱PR✱TIMBUCKTU INSURANCE✱FI✱8888888888~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Clearinghouse

Payer

Third Party Repricing Organization (TPO)

Third Party Administrator (TPA)

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Transfer to Entity Name

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Federal Taxpayer's Identification Number

Payor Identification

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when available to identify the transfer to entity. If not required by this implementation guide do not send.

INDUSTRY NAME: Transfer to Entity Identification

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - TRANSFER TO ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop 2225E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Transfer to Entity Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Transfer to Entity Address Line

N4 - TRANSFER TO ENTITY 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 2225E - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱