277 Health Care Claim Acknowledgment (008020X330)

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

0085

Information Source, Information Receiver, Provider of Service, Patient

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Status

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.

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

CODE

DEFINITION

Receipt Acknowledgment Advice

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 decision maker in the business transaction.

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 - INFORMATION SOURCE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - INFORMATION SOURCE NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2200A - TRANSMISSION RECEIPT CONTROL TRACE IDENTIFIER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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)

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: Information Source Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Federal Taxpayer's Identification Number

Payor Identification

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: Information Source Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*1 - TRANSMISSION RECEIPT CONTROL TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

TRN✱1✱1722634842~

TRN

✱

✱

✱

Loop 2200A - TRANSMISSION RECEIPT CONTROL TRACE IDENTIFIER

✱

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

DTP*050 - INFORMATION SOURCE RECEIPT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱050✱D8✱20221030~

DTP

✱

✱

Loop 2200A - TRANSMISSION RECEIPT CONTROL TRACE IDENTIFIER

✱

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: Information Source Receipt Date

This is the receipt date of the 837 by the entity creating the 277 acknowledgment. This date may or may not be the same date as the Information Source's Process Date.

DTP*009 - INFORMATION SOURCE PROCESS DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Payers and clearinghouses often collect claim transmissions throughout the business day. A process which is usually called "batch" is initiated at least once per business day. Some entities may initiate this process more than one time per day. As claim transmission files are processed, EDI reports and or data files are generated from the entity's computer system(s) and are distributed to the Information Receiver.
The Information Source Process Date applies to the processing of the 837 claim transaction file through a pre-adjudication/electronic data interchange (EDI) system. This date may or may not be the same date as the Information Source Receipt Date.

TR3 Example:

DTP✱009✱D8✱20220301~

DTP

✱

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

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

009

Process

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: Information Source Process Date

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

No Subordinate HL Segment in This Hierarchical Structure.

Use when the Information Receiver STC03=U, reject entire transaction.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

Use when the Information Receiver STC03 = WQ, accept entire transmission.

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:

For situations where a person such as a single practitioner submits claim transactions to a payer, the entity identified in the Provider of Service Loop (HL03 = 19) will be the same entity identified here in the Information Receiver Loop (HL03 = 21). The difference may be that the trading partner profile set up in the EDI environment is a separate identification scheme from the identification number set up for the entity in the adjudication system.
In the situation where there is more than one clearinghouse involved in the transmission of the Health Care Claim Acknowledgement as part of the Trading Partner Agreement, this segment will be used to identify the clearinghouse that is passing the information. This segment will be changed to display the information for the next clearinghouse before they continue passing on the transmission. This process will continue until the transmission reaches the initiator of the claim/encounter.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: 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 Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*2 - INFORMATION RECEIVER TRACE IDENTIFIER

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 contains the value submitted in the BHT03 data element from the 837.

TR3 Example:

TRN✱2✱20060828001~

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: Claim Transaction Batch Number

This element contains the value submitted in the BHT03 data element from the 837.
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:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment will be used to convey information about an entire unit of work (e.g. single transaction of claims). Information contained at this level will be summary details pertaining to the unit of work being acknowledged. Examples include but are not limited to accepted for processing, trading partner not authorized to submit to the Information Source's system, etc.
See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

STC✱A1:19✱20110301✱WQ✱432.55~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

✱

1383

Claim Submt
Reason Code

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types 'A' for batch. For real-time acknowledgements category types 'A' and 'E' may be used except for E0. Use of the category type 'E' is limited to indicating the business application system is unavailable.
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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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

Required

306

Action Code

O 1

1/2

Code indicating type of action

STC03 at this level is intended to convey the electronic transmission status of the ST - SE envelope. The terms "Accept" and "Reject" refer to the electronic transmission status of the 837 transaction not the billing status.

CODE

DEFINITION

Reject

Use when the entire claim transaction (ST-SE) is rejected due to submitter level errors. No subordinate HL information is reported. Rejection at this level means all claims in the corresponding 837 (ST-SE) are rejected.

Use when code value "U" is not used. Acceptance at this level does not mean all claims have been accepted for processing. The 2000D Patient HL and 2200D Claim Status MUST be reported to acknowledge (accept or reject) each claim received in the corresponding 837 (ST-SE).

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the total charge amount.

INDUSTRY NAME: Total Submitted Charges for Unit Work

This will be the sum of all CLM02 values (claim charge) for the claims being acknowledged within an ST to SE of a single 837 transaction set.

In situations where the 837 transaction from the Information Receiver is separated (e.g. due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.
Monetary Amounts returned in this element may exceed 10 characters.

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 clarification to STC01 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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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 clarification to STC01 and STC10 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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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

QTY*90 - TOTAL ACCEPTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total number of claims accepted by the Information Source.
For QTY segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

QTY✱90✱102~

QTY

✱

✱

✱

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Acknowledged Quantity

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Accepted Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

QTY*AA - TOTAL REJECTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total number of claims rejected for this Information Receiver (e.g. not accepted) by the Information Source.
For QTY segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

QTY✱AA✱98~

QTY

✱

✱

✱

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Unacknowledged Quantity

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Rejected Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

AMT*YU - TOTAL ACCEPTED 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 at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims accepted by the Information Source.
For AMT segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

AMT✱YU✱5053.52~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

In Process

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Accepted Amount

See STC01-03 for valid values.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

AMT*YY - TOTAL REJECTED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 2000C - BILLING PROVIDER LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims rejected for this Information Receiver (e.g. not accepted) by the Information Source.
For AMT segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

AMT✱YY✱99.5~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Returned

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Rejected Amount

Monetary Amounts returned in this element may exceed 10 characters.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

HL - BILLING PROVIDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when STC03 at the Information Receiver Level (2200B) is equal to "WQ" (ACCEPTED). If not required by this implementation guide, do not send.

TR3 Notes:

This loop may be used to provide totals and amounts by billing provider or when a secondary provider identifier needs to be reported in the Provider Secondary REF segment.

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*85 - BILLING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100C - BILLING PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment contains the Billing Provider Name submitted in the 2010AA loop of the Health Care Claim (X12 837).

TR3 Example:

NM1✱85✱2✱ABC HOSPITAL✱✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: 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

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: Billing Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*1 - PROVIDER OF SERVICE 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 desires to provide claim totals and amounts by billing provider or report a secondary provider identifier. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Example:

TRN✱1✱0~

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: Provider of Service Information Trace 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.
This value must be zero (0).

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

REF - PROVIDER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a secondary identification number is necessary to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:

The primary identification number must be reported in NM109.

TR3 Example:

REF✱A6✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Location Number

Social Security Number

Federal Taxpayer's Identification Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Additional Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

QTY*QA - TOTAL ACCEPTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting totals for a specific billing provider and at least one claim is accepted. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total number of claims accepted to the adjudication process by the Information Source for the Billing Provider in this acknowledgment.
For QTY segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

QTY✱QA✱5~

QTY

✱

✱

✱

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Quantity Approved

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Accepted Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

QTY*QC - TOTAL REJECTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting totals for a specific billing provider and at least one claim is rejected. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total number of claims rejected by the Information Source for the Billing Provider.
For QTY segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

QTY✱QC✱1~

QTY

✱

✱

✱

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Quantity Disapproved

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Rejected Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

AMT*YU - TOTAL ACCEPTED 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 reporting totals for a specific billing provider and at least one claim is accepted. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) accepted by the Information Source for the Billing Provider in this acknowledgment.
For AMT segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

AMT✱YU✱5053.52~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

In Process

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Accepted Amount

Monetary Amounts returned in this element may exceed 10 characters.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

AMT*YY - TOTAL REJECTED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 2000D - PATIENT LEVEL

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting totals for a specific billing provider and at least one claim is rejected. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) rejected by the Information Source for the Billing Provider in this acknowledgment.
For AMT segment balancing, see Section 1.4.5 (Balancing).

TR3 Example:

AMT✱YY✱99.5~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Returned

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Rejected Amount

Monetary Amounts returned in this element may exceed 10 characters.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

HL - PATIENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when STC03 at the Information Receiver Level (Loop 2200B) is equal to "WQ" (ACCEPTED). If not required by this implementation guide, do not send.

TR3 Notes:

This HL level contains information about the Patient identified in the 837 transaction. See Section 1.4.2.1 - Defining the Patient Participant for information on identifying the Patient data from the 837 Transaction.

TR3 Example:

HL✱4✱3✱PT~

✱

✱

✱

✱

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

Patient

Not Used

736

Hierarchical Child Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100D - PATIENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱QC✱1✱SMITH✱JOHN✱Q✱✱IV✱MI✱99887777~

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 information was submitted on the claim. 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 information was submitted on the claim. 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 information was submitted on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when a Subscriber ID was submitted in the 2010BA NM109 or a Property and Casualty Patient Identifier was submitted in the 2010CA REF02 of the 837. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Identification Number

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

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 segment is the Provider's Assigned Claim Identifier submitted in the CLM01 of the 837.

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: 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.
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

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 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

STC✱A6:125:82✱20110830✱WQ✱432.65~ ORSTC✱A6:131:82✱20110830✱U✱65.32~STC✱A8:187✱20110830✱U✱70✱✱✱✱✱✱A8:453✱A8:454~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

✱

1383

Claim Submt
Reason Code

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types 'A' for batch. For real-time acknowledgements category types 'A' and 'E' may be used except for E0. Use of the category type 'E' is limited to indicating the business application system is unavailable.
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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

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.

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

Required

306

Action Code

O 1

1/2

Code indicating type of action

INDUSTRY NAME: Status Information Action Code

CODE

DEFINITION

Reject

Use when the entire claim is being rejected.

Use when the entire claim is being accepted.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the total charge amount.

INDUSTRY NAME: Total Claim Charge Amount

Zero is an acceptable amount.
Sum of the charges (CLM02) submitted from original claim. If an original claim is split, report the original claim total here. Note that this amount may be reported in two or more claims.
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

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 clarification to STC01 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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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.

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 clarification to STC01 and STC10 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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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.

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

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:

Required when Loop ID 2100A NM101 value is PR and the claim has been accepted for adjudication (Loop ID 2200D STC03=WQ). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

This number will be used to track the adjudication of the claim throughout the adjudication system.

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*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 the Claim Identifier for Transmission Intermediaries was sent in the 837. If not required by this implementation guide, do not send.

TR3 Notes:

This number must be returned as received in the 837.

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*9A - REPRICED CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Loop ID 2100A NM101 value is TU (Third Party Repricing Organization) and the claim was accepted for repricing (Loop ID 2200D STC03=WQ). If not required by this implementation guide, do not send.

TR3 Example:

REF✱9A✱RJ55555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Repriced Claim Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Repriced Claim Reference Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*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 for Institutional claims when the Institutional Type of Bill was received on the claim. 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

See 837 Institutional Implementation Guide for definition of Institutional Bill Type components.

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 respectively.
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 & Casualty Claim Number has been validated by the Property & Casualty payer. 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

REF*WF - EDI 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 an EDI Control Number is assigned to claim data during the front-end process and is used for tracking purposes or problem resolution. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

This number is assigned by the Receiver of the 837 to track individual claim data in the EDI front- end and is not used to track the claim through the adjudication system. Assignment of the EDI Control Number does not indicate the claim has been accepted into an adjudication system for processing.

TR3 Example:

REF✱WF✱ED51234567890123456789012~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Locally Assigned 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

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:

Required when the claim is not a predetermination and service level dates are not reported. 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✱D8✱20220201~ ORDTP✱472✱RD8✱20220201-20220205~

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 - CORRECTED DATE OF ILLNESS/INJURY/ACCIDENT

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the date of accident or date of injury/illness submitted on the Property and Casualty claim does not match the date in the Property and Casualty payer's system and it is necessary for the payer to communicate the mismatch to the submitter. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱431✱D8✱20220108~
DTP✱439✱D8✱20221030~

DTP

✱

✱

Loop 2210DA - 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

431

Onset of Current Symptoms or Illness

439

Accident

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

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:

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

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 2210DA - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

PER✱IC✱EDI HELP DESK✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2210DA - 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 2210DA - 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 2210DA - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

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

PWK*R6 - SUPPLEMENTAL STATUS 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 2210DB - SUPPLEMENTAL STATUS INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a non-standard or free form message is necessary to supplement or enhance the status information reported in the 2200D STC Segment. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must not be used in place of reporting the highest level of specificity or the most accurate status information in the 2200D STC Segment (STC01, STC10 and STC11).
This segment must not be used to repeat or duplicate the verbiage associated with the status information reported in the 2200D STC Segment (STC01, STC10 and STC11).
When claim level information caused the rejection of a claim, it must be reported at the Loop 2200D STC Claim Level Status Information.
See Section 1.4.3.1 - STC Composite and Code Use Rules, for additional information.

TR3 Example:

PWK✱R6✱✱✱✱✱✱ID must begin with an alpha prefix of Y✱✱✱65✱153~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

CODE

DEFINITION

Miscellaneous Information

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Situational

352

Description

O 1

1/80

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

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

SITUATIONAL RULE: Required when a non-standard or free form message is necessary to supplement or enhance the status information reported in the 2200D STC (STC01, STC10 and STC11). If not required by this implementation guide, do not send.

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P1011

CODE

DEFINITION

Health Care Claim Status Code

CODE SOURCE: 508: Health Care Claim Status Code

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P1011

This must be the Status Code (STC01-02, STC10-02 or STC11-02) reported in the 2200D STC Segment related to the enhanced or supplemental message.

PER*IC - SUPPLEMENTAL STATUS 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 2210DB - SUPPLEMENTAL STATUS INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when PWK07 is not reported or it is necessary to report a specific contact number or website related to status or follow-up action on this claim. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱IC✱✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Not Used

Name

O 1

1/60

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

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

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 second communication contact number is needed or when an extension applies to the previous communications contact number. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

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 third communication contact number is needed or when an extension applies to the previous communications contact number. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

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 a claim is rejected (2200D STC03 = U) and the service line caused the claim rejection
Or
When the claim is accepted (2200D STC03 = WQ) and a warning/notification applies to the service line.

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✱NU:0710✱15.61~ ORSVC✱HC:99213✱35~

SVC

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

Comp. Med.
Proced. ID

✱

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.

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: Procedure Code

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 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 element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-02, then SVC04 is not used.
Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

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 if submitted on the original claim service line. If not required by this implementation guide, do not send.

Value submitted on the original claim.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

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

Not Used

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

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

SITUATIONAL RULE: Required if submitted on the original claim service line. If not required by this implementation guide, do not send.

INDUSTRY NAME: Original 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 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

STC✱A1:19✱✱U~STC✱A8:187✱✱U✱✱✱✱✱✱✱A8:453✱A8:454~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

✱

1383

Claim Submt
Reason Code

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types 'A' for batch. For real-time acknowledgements category types 'A' and 'E' may be used except for E0. Use of the category type 'E' is limited to indicating the business application system is unavailable.
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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

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.

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Not Used

373

Date

O 1

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 clarification to STC01 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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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.

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 clarification to STC01 and STC10 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: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.3 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim 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

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.

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

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

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 a Pharmacy Prescription Number was sent in the 837 at the Service Line. 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

This is the Pharmacy Prescription Number submitted in the 2410 REF02 from the 837 claim.
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✱D8✱20220201~ ORDTP✱472✱RD8✱20220201-20220205~

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 2225DA - 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-2210DA). If not required by this implementation guide, do not send.

TR3 Notes:

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

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 2225DA - 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 2225DA - 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: Entity Identifier Code

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 2225DA - 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 2225DA - TRANSFER TO ENTITY SUPPLEMENTAL INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

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

PWK*R6 - SUPPLEMENTAL STATUS 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 2225DB - SUPPLEMENTAL STATUS INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a non-standard or free form message is necessary to supplement or enhance the status information reported in the 2220D STC Segment. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.3.1 - STC Composite and Code Use Rules, for additional information.
This segment must not be used in place of reporting the highest level of specificity or the most accurate status information in the 2220D STC Segment (STC01, STC10 and STC11).
This segment must not be used to repeat or duplicate the verbiage associated with the status information reported in the 2220D STC Segment (STC01, STC10 and STC11).
When service level information caused the rejection, it must be reported at the Loop 2220D STC Service Level Status Information.

TR3 Example:

PWK✱R6✱✱✱✱✱✱ID must begin with an alpha prefix of Y✱✱✱65✱153~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

CODE

DEFINITION

Miscellaneous Information

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Situational

352

Description

O 1

1/80

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

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

SITUATIONAL RULE: Required when a non-standard or free form message is necessary to supplement or enhance the status information reported in the 2220D STC (STC01, STC10 and STC11). If not required by this implementation guide, do not send.

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P1011

CODE

DEFINITION

Health Care Claim Status Code

CODE SOURCE: 508: Health Care Claim Status Code

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P1011

This must be the Status Code (STC01-02, STC10-02 or STC11-02) reported in the 2220D STC Segment related to the enhanced or supplemental message.

PER*IC - SUPPLEMENTAL STATUS 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 2225DB - SUPPLEMENTAL STATUS INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

TR3 Example:

PER✱IC✱✱TE✱8009999999~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱