277 Transaction Set Listing

008020X331 Health Care Claim Pending Status Information
Usage
Repeats

ISA - INTERCHANGE CONTROL HEADER

X12 Name:
Interchange Control Header
X12 Purpose:
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
  1. All positions within each of the data elements must be filled.
  2. For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
  3. The first element separator defines the element separator to be used through the entire interchange.
  4. Spaces in the example interchanges are represented by "." for clarity.
  5. The ISA segment terminator defines the segment terminator used throughout the entire interchange.
TR3 Example:
ISA✱00✱..........✱01✱SECRET....✱ZZ✱SENDERS.ID.....✱ZZ✱RECEIVERS.ID...✱030101✱1253✱^✱00802✱000000905✱0✱T✱:~
ISA
✱
1
I01
Author Info
Qualifier
M 1
ID
2
✱
2
I02
Author
Information
M 1
AN
10
✱
3
I03
Security
Info Qual
M 1
ID
2
✱
4
I04
Security
Information
M 1
AN
10
✱
5
I05
Interchange
ID Qual
M 1
ID
2
✱
6
I06
Interchange
Sender ID
M 1
AN
15
✱
7
I05
Interchange
ID Qual
M 1
ID
2
✱
8
I07
Interchange
Receiver ID
M 1
AN
15
✱
9
I08
Interchange
Date
M 1
DT
6
✱
10
I09
Interchange
Time
M 1
TM
4
✱
11
I65
Repetition
Separator
M 1
✱
12
I11
Inter Ctrl
Version Num
M 1
ID
5
✱
13
I12
Inter Ctrl
Number
M 1
N
9
✱
14
I13
Ack
Requested
M 1
ID
1
✱
15
I14
Usage
Indicator
M 1
ID
1
✱
16
I15
Component
Elem Sep
M 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
I01
Authorization Information Qualifier
M 1
ID
2
Code identifying the type of information in the Authorization Information
CODE
DEFINITION
00
No Authorization Information Present (No Meaningful Information in I02)
03
Additional Data Identification
Required
2
I02
Authorization Information
M 1
AN
10
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
This element is fixed in length with identical minimum and maximum lengths. Spaces are inserted to meet the minimum length in an AN data element. With the associated code 00 in ISA01 or ISA03, an all space value indicates no information.
Required
3
I03
Security Information Qualifier
M 1
ID
2
Code identifying the type of information in the Security Information
CODE
DEFINITION
00
No Security Information Present (No Meaningful Information in I04)
01
Password
Required
4
I04
Security Information
M 1
AN
10
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
This element is fixed in length with identical minimum and maximum lengths. Spaces are inserted to meet the minimum length in an AN data element. With the associated code 00 in ISA01 or ISA03, an all space value indicates no information.
Required
5
I05
Interchange ID Qualifier
M 1
ID
2
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
This ID qualifies the Sender in ISA06.
CODE
DEFINITION
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
CODE SOURCE: 121: Health Industry Number
27
Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
28
Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
29
Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
Required
6
I06
Interchange Sender ID
M 1
AN
15
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Required
7
I05
Interchange ID Qualifier
M 1
ID
2
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
This ID qualifies the Receiver in ISA08.
CODE
DEFINITION
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
CODE SOURCE: 121: Health Industry Number
27
Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
28
Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
29
Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
Required
8
I07
Interchange Receiver ID
M 1
AN
15
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Required
9
I08
Interchange Date
M 1
DT
6
Date of the interchange
The date format is YYMMDD.
Required
10
I09
Interchange Time
M 1
TM
4
Time of the interchange
The time format is HHMM.
Required
11
I65
Repetition Separator
M 1
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
Required
12
I11
Interchange Control Version Number Code
M 1
ID
5
Code specifying the version number of the interchange control segments, the version of the data elements within the control segments, and the code values within those data elements.
INDUSTRY NAME: Interchange Control Version Number
CODE
DEFINITION
00802
00802 Standards Approved for Publication by ASC X12 Procedures Review Board through December 2020
Required
13
I12
Interchange Control Number
M 1
N
9
A control number assigned by the interchange sender
  1. The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
  2. Must be a positive unsigned number and must be identical to the value in IEA02.
Required
14
I13
Acknowledgment Requested Code
M 1
ID
1
Code indicating sender's request for an interchange acknowledgment
INDUSTRY NAME: Acknowledgment Requested
X12.5 - Interchange Control Structure provides the purpose of the TA1 segment. The X12 Acknowledgment Reference Model provides considerable information about the TA1 segment.
CODE
DEFINITION
0
No Interchange Acknowledgment Requested
Use when the interchange contains ONLY acknowledgment Functional Groups (e.g. 999 or 824) or a TA1.
1
Interchange Acknowledgment Requested (TA1)
Use when batch process requires the return of a TA1 for the interchange.
2
Interchange Acknowledgment Requested only when Interchange is "Rejected Because Of Errors"
Use when the transaction is for real-time processing.
3
Interchange Acknowledgment Requested only when Interchange is "Rejected Because Of Errors" or "Accepted but Errors are Noted"
Use when batch processing requires the return of a TA1 for the interchange only when errors are noted.
Required
15
I14
Interchange Usage Indicator Code
M 1
ID
1
Code indicating whether data enclosed by this interchange envelope is test, production or information
INDUSTRY NAME: Interchange Usage Indicator
CODE
DEFINITION
I
Information
Use when the interchange contains ONLY a TA1.
P
Production Data
T
Test Data
Required
16
I15
Component Element Separator
M 1
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

GS*HN - FUNCTIONAL GROUP HEADER

X12 Name:
Functional Group Header
X12 Purpose:
To indicate the beginning of a functional group and to provide control information
X12 Comments:
A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
GS✱XX✱SENDER CODE✱RECEIVER CODE✱19991231✱0802✱1✱X✱008020X331~
GS
✱
1
479
Functional
ID Code
M 1
ID
2
✱
2
142
Application
Send's Code
M 1
AN
2/15
✱
3
124
Application
Rec's Code
M 1
AN
2/15
✱
4
373
Date
M 1
DT
8
✱
5
337
Time
M 1
TM
4/8
✱
6
28
Group Ctrl
Number
M 1
N
1/9
✱
7
455
Responsible
Agency Code
M 1
ID
1/2
✱
8
480
Ver/Release
ID Code
M 1
AN
1/12
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
479
Functional Identifier Code
M 1
ID
2
Code identifying a group of application related transaction sets
This is the 2-character Functional Identifier Code assigned to each transaction set by X12. The specific code for a transaction set defined by this implementation guide is presented in Section 1.2, Version Information.
CODE
DEFINITION
HN
Health Care Information Status Notification (277)
Required
2
142
Application Sender's Code
M 1
AN
2/15
Code identifying party sending transmission; codes agreed to by trading partners
Use this code to identify the unit sending the information.
Required
3
124
Application Receiver's Code
M 1
AN
2/15
Code identifying party receiving transmission; codes agreed to by trading partners
Use this code to identify the unit receiving the information.
Required
4
373
Date
M 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: GS04 is the group date.
Use this date for the functional group creation date.
Required
5
337
Time
M 1
TM
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: GS05 is the group time.
Use this time for the creation time. The recommended format is HHMM.
Required
6
28
Group Control Number
M 1
N
1/9
Assigned number originated and maintained by the sender
SEMANTIC: The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.
For implementations compliant with this guide, GS06 must be unique within a single transmission (that is, within a single ISA to IEA enveloping structure). The authors recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender.
Required
7
455
Responsible Agency Code
M 1
ID
1/2
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
CODE
DEFINITION
X
Accredited Standards Committee X12
Required
8
480
Version / Release / Industry Identifier Code
M 1
AN
1/12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
INDUSTRY NAME: Version, Release, or Industry Identifier Code
This is the unique Version/Release/Industry Identifier Code assigned to an implementation by X12N. The specific code for a transaction set defined by this implementation guide is presented in Section 1.2, Version Information.
CODE SOURCE 881: Version / Release / Industry Identifier Code
CODE
DEFINITION
008020X331
Health Care Claim Pending Status Information

ST*277 - TRANSACTION SET HEADER

X12 Name:
Transaction Set Header
X12 Purpose:
To indicate the start of a transaction set and to assign a control number
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
ST✱277✱0002✱008020X331~
ST
✱
1
143
TS ID
Code
M 1
ID
3
✱
2
329
TS Control
Number
M 1
AN
4/9
✱
3
1705
Imple Conv
Reference
O 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
143
Transaction Set Identifier Code
M 1
ID
3
Code identifying a Transaction Set
SEMANTIC: The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
CODE
DEFINITION
277
Health Care Information Status Notification
Required
2
329
Transaction Set Control Number
M 1
AN
4/9
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
The Transaction Set Control Numbers in ST02 and SE02 must be identical and must be a numeric value. The number (i.e. numeric value) is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the numeric value 0001 and increment from there. The Transaction Set Control Number also aids in error resolution research.
Required
3
1705
Implementation Convention Reference
O 1
AN
1/35
Reference assigned to identify Implementation Convention
SEMANTIC: The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
INDUSTRY NAME: Version, Release, or Industry Identifier
  1. This element must be populated with the implementation guide Version/Release/Industry Identifier Code named in Section 1.2.
  2. This element contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
CODE
DEFINITION
008020X331
Health Care Claim Pending Status Information

BHT*0085 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:
Beginning of Hierarchical Transaction
X12 Purpose:
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
BHT✱0085✱08✱277PEND123✱20220201✱1635✱NO~
BHT
✱
1
1005
Hierarch
Struct Code
M 1
ID
4
✱
2
353
TS Purpose
Code
M 1
ID
2
✱
3
127
Reference
Ident
O 1
AN
1/80
✱
4
373
Date
O 1
DT
8
✱
5
337
Time
O 1
TM
4/8
✱
6
640
Transaction
Type Code
O 1
ID
2
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1005
Hierarchical Structure Code
M 1
ID
4
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
2
353
Transaction Set Purpose Code
M 1
ID
2
Code identifying purpose of transaction set
CODE
DEFINITION
08
Status
Required
3
127
Reference Identification
O 1
AN
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.
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
4
373
Date
O 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: BHT04 is the date the transaction was created within the business application system.
INDUSTRY NAME: Transaction Set Creation Date
Required
5
337
Time
O 1
TM
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: BHT05 is the time the transaction was created within the business application system.
INDUSTRY NAME: Transaction Set Creation Time
Required
6
640
Transaction Type Code
O 1
ID
2
Code specifying the type of transaction
CODE
DEFINITION
NO
Notice

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:
  1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
  2. The HL segment defines a top-down/left-right ordered structure.
Loop:
Loop 2000A - INFORMATION SOURCE LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
This entity is the payer who has the current status information for the specified claims.
TR3 Example:
HL✱1✱✱20✱1~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
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
2
734
Hierarchical Parent ID Number
O 1
AN
1/12
Required
3
735
Hierarchical Level Code
M 1
ID
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
20
Information Source
Required
4
736
Hierarchical Child Code
O 1
ID
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
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:
Individual or Organizational Name
X12 Purpose:
To supply the full name of an individual or organizational entity
X12 Syntax:
  1. P0809
    If either NM108 or NM109 is present, then the other is required.
  2. C1110
    If NM111 is present, then NM110 is required.
  3. C1203
    If NM112 is present, then NM103 is required.
Loop:
Loop 2100A - PAYER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱PR✱2✱ABC INSURANCE CO✱✱✱✱✱XV✱11122333~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/80
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/80
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
PR
Payer
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Payer Name
Not Used
4
1036
Name First
O 1
AN
1/35
Not Used
5
1037
Name Middle
O 1
AN
1/25
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
PI
Payor Identification
Use when reporting the payer identification number established through trading partner agreement.
XV
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
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Payer Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80

HL - INFORMATION RECEIVER LEVEL

X12 Name:
Hierarchical Level
X12 Purpose:
To identify dependencies among and the content of hierarchically related groups of data segments
X12 Comments:
  1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
  2. The HL segment defines a top-down/left-right ordered structure.
Loop:
Loop 2000B - INFORMATION RECEIVER LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
HL✱2✱1✱21✱1~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
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.
Required
2
734
Hierarchical Parent ID Number
O 1
AN
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
3
735
Hierarchical Level Code
M 1
ID
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
21
Information Receiver
Required
4
736
Hierarchical Child Code
O 1
ID
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
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:
Individual or Organizational Name
X12 Purpose:
To supply the full name of an individual or organizational entity
X12 Syntax:
  1. P0809
    If either NM108 or NM109 is present, then the other is required.
  2. C1110
    If NM111 is present, then NM110 is required.
  3. C1203
    If NM112 is present, then NM103 is required.
Loop:
Loop 2100B - INFORMATION RECEIVER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱41✱2✱ABC SUBMITTER✱✱✱✱✱46✱999999999~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/80
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/80
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
41
Submitter
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Information Receiver Last or Organization Name
Situational
4
1036
Name First
O 1
AN
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
5
1037
Name Middle
O 1
AN
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
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
46
Electronic Transmitter Identification Number (ETIN)
Required
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Information Receiver Identification Number
The ETIN is established through Trading Partner agreement.
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80

HL - SERVICE PROVIDER LEVEL

X12 Name:
Hierarchical Level
X12 Purpose:
To identify dependencies among and the content of hierarchically related groups of data segments
X12 Comments:
  1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
  2. The HL segment defines a top-down/left-right ordered structure.
Loop:
Loop 2000C - SERVICE PROVIDER LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
HL✱3✱2✱19✱1~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
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.
Required
2
734
Hierarchical Parent ID Number
O 1
AN
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
3
735
Hierarchical Level Code
M 1
ID
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
19
Provider of Service
Required
4
736
Hierarchical Child Code
O 1
ID
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
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*1P - PROVIDER NAME

X12 Name:
Individual or Organizational Name
X12 Purpose:
To supply the full name of an individual or organizational entity
X12 Syntax:
  1. P0809
    If either NM108 or NM109 is present, then the other is required.
  2. C1110
    If NM111 is present, then NM110 is required.
  3. C1203
    If NM112 is present, then NM103 is required.
Loop:
Loop 2100C - PROVIDER NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
The provider identified facilitates identification of the claim within a payer's system.
TR3 Example:
NM1✱1P✱2✱HOME MEDICAL✱✱✱✱✱XX✱1666666666~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/80
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/80
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
1P
Provider
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Provider Last or Organization Name
Situational
4
1036
Name First
O 1
AN
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
5
1037
Name Middle
O 1
AN
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
6
1038
Name Prefix
O 1
AN
1/10
Situational
7
1039
Name Suffix
O 1
AN
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
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
FI
Federal Taxpayer's Identification Number
SV
Service Provider Number
XX
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
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Provider Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80

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:
  1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
  2. The HL segment defines a top-down/left-right ordered structure.
Loop:
Loop 2000D - PATIENT LEVEL
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
HL✱4✱3✱PT~
HL
✱
1
628
Hierarch
ID Number
M 1
AN
1/12
✱
2
734
Hierarch
Parent ID
O 1
AN
1/12
✱
3
735
Hierarch
Level Code
M 1
ID
1/2
✱
4
736
Hierarch
Child Code
O 1
ID
1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
628
Hierarchical ID Number
M 1
AN
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.
Required
2
734
Hierarchical Parent ID Number
O 1
AN
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
3
735
Hierarchical Level Code
M 1
ID
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
PT
Patient
Not Used
4
736
Hierarchical Child Code
O 1
ID
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:
  1. P0809
    If either NM108 or NM109 is present, then the other is required.
  2. C1110
    If NM111 is present, then NM110 is required.
  3. C1203
    If NM112 is present, then NM103 is required.
Loop:
Loop 2100D - PATIENT NAME
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
NM1✱QC✱1✱SMITH✱JOHN✱Q✱✱IV✱MI✱99887777~
NM1
✱
1
98
Entity ID
Code
M 1
ID
2/3
✱
2
1065
Entity Type
Qualifier
M 1
ID
1
✱
3
1035
Name Last/
Org Name
X 1
AN
1/80
✱
4
1036
Name
First
O 1
AN
1/35
✱
5
1037
Name
Middle
O 1
AN
1/25
✱
6
1038
Name
Prefix
O 1
AN
1/10
✱
7
1039
Name
Suffix
O 1
AN
1/10
✱
8
66
ID Code
Qualifier
X 1
ID
1/2
✱
9
67
ID
Code
X 1
AN
2/80
✱
10
706
Entity
Relat Code
X 1
ID
2
✱
11
98
Entity ID
Code
O 1
ID
2/3
✱
12
1035
Name Last/
Org Name
O 1
AN
1/80
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
QC
Patient
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Patient Last Name
Situational
4
1036
Name First
O 1
AN
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: Patient First Name
Situational
5
1037
Name Middle
O 1
AN
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: Patient Middle Name or Initial
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Situational
7
1039
Name Suffix
O 1
AN
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: Patient Name Suffix
Required
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
CODE
DEFINITION
II
Standard Unique Health Identifier for each Individual in the United States
Use when reporting the HIPAA Individual Patient Identifier.
MI
Member Identification Number
Required
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
INDUSTRY NAME: Patient Identification Number
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80

TRN*1 - PAYER CLAIM CONTROL NUMBER

X12 Name:
Trace
X12 Purpose:
To uniquely identify a transaction to an application
Loop:
Loop 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
This is the payer's claim control number.
TR3 Example:
TRN✱1✱0612991010987~
TRN
✱
1
481
Trace Type
Code
M 1
ID
1/2
✱
2
127
Reference
Ident
M 1
AN
1/80
✱
3
509
Originating
Company ID
O 1
AN
10
✱
4
127
Reference
Ident
O 1
AN
1/80
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
481
Trace Type Code
M 1
ID
1/2
Code identifying which transaction is being referenced
CODE
DEFINITION
1
Current Transaction Trace Numbers
Required
2
127
Reference Identification
M 1
AN
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: 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
3
509
Originating Company Identifier
O 1
AN
10
Not Used
4
127
Reference Identification
O 1
AN
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
>1
TR3 Notes:
See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
TR3 Example:
STC✱P1:56✱20110201✱✱50~
STC
✱
1
C043
Health Care
Stat Claim
M 1
✱
2
373
Date
O 1
DT
8
✱
3
306
Action
Code
O 1
ID
1/2
✱
4
782
Monetary
Amount
O 1
R
1/18
✱
5
782
Monetary
Amount
O 1
R
1/18
✱
6
373
Date
O 1
DT
8
✱
7
591
Payment
Method Code
O 1
ID
3
✱
8
373
Date
O 1
DT
8
✱
9
429
Check
Number
O 1
AN
1/16
✱
10
C043
Health Care
Stat Claim
O 1
✱
11
C043
Health Care
Stat Claim
O 1
✱
12
933
Free-Form
Message Txt
O 1
AN
1/264
✱
13
1383
Claim Submt
Reason Code
O 1
ID
2
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
C043
Health Care Claim Status
M 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. 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.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
Required
1-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. For this business function, use Pending "P" type Category Codes.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
1-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Status Code
  1. The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
  2. The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC01-04 must have the value 'RX'.
Situational
1-3
98
Entity Identifier Code
O 1
ID
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
03
Dependent
1P
Provider
1U
Long Term Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
2B
Third-Party Administrator
36
Employer
3F
Rehabilitation Facility
3T
Alcoholism and Other Chemical Dependency Facility
40
Receiver
41
Submitter
45
Drop-off Location
4Z
Hospice
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
82
Rendering Provider
85
Billing Provider
87
Pay-to Provider
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
DQ
Supervising Physician
FA
Facility
GB
Other Insured
GK
Previous Insured
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IL
Insured or Subscriber
MSC
Mammography Screening Center
O4
Factor
Use when identifying a Pay to Factoring Agent.
OD
Doctor of Optometry
OOP
Other Operating Physician
P2
Primary Insured or Subscriber
P3
Primary Care Provider
PR
Payer
PRP
Primary Payer
PTP
Pay-to Plan Name
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QE
Policyholder
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QY
Medical Doctor
S4
Skilled Nursing Facility
SEP
Secondary Payer
TQ
Third Party Reviewing Organization (TPO)
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
X3
Utilization Management Organization
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.
Situational
1-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC01-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.
CODE
DEFINITION
RX
National Council for Prescription Drug Programs Reject Codes
CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes
Required
2
373
Date
O 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: STC02 is the effective date of the status information.
INDUSTRY NAME: Status Information Effective Date
This is the date the claim was placed in this status by the Information Source's adjudication process.
Not Used
3
306
Action Code
O 1
ID
1/2
Required
4
782
Monetary Amount
O 1
R
1/18
Monetary amount
SEMANTIC: STC04 is the total charge amount.
INDUSTRY NAME: Total Claim Charge Amount
  1. The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
  2. 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
5
782
Monetary Amount
O 1
R
1/18
Not Used
6
373
Date
O 1
DT
8
Not Used
7
591
Payment Method Code
O 1
ID
3
Not Used
8
373
Date
O 1
DT
8
Not Used
9
429
Check Number
O 1
AN
1/16
Situational
10
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. 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.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.
Required
10-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. See STC01-01 for valid values.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
10-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Status Code
  1. The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
  2. The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC10-04 must have the value 'RX'.
Situational
10-3
98
Entity Identifier Code
O 1
ID
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.
See STC01-03 for valid values.
CODE
DEFINITION
03
Dependent
1P
Provider
1U
Long Term Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
2B
Third-Party Administrator
36
Employer
3F
Rehabilitation Facility
3T
Alcoholism and Other Chemical Dependency Facility
40
Receiver
41
Submitter
45
Drop-off Location
4Z
Hospice
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
82
Rendering Provider
85
Billing Provider
87
Pay-to Provider
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
DQ
Supervising Physician
FA
Facility
GB
Other Insured
GK
Previous Insured
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IL
Insured or Subscriber
MSC
Mammography Screening Center
O4
Factor
Use when identifying a Pay to Factoring Agent.
OD
Doctor of Optometry
OOP
Other Operating Physician
P2
Primary Insured or Subscriber
P3
Primary Care Provider
PR
Payer
PRP
Primary Payer
PTP
Pay-to Plan Name
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QE
Policyholder
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QY
Medical Doctor
S4
Skilled Nursing Facility
SEP
Secondary Payer
TQ
Third Party Reviewing Organization (TPO)
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
X3
Utilization Management Organization
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.
Situational
10-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC01-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.
CODE
DEFINITION
RX
National Council for Prescription Drug Programs Reject Codes
CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes
Situational
11
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. 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.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.
Required
11-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. See STC01-01 for valid values.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
11-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Status Code
  1. The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
  2. The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC11-04 must have the value 'RX'.
Situational
11-3
98
Entity Identifier Code
O 1
ID
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.
See STC01-03 for valid values.
CODE
DEFINITION
03
Dependent
1P
Provider
1U
Long Term Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
2B
Third-Party Administrator
36
Employer
3F
Rehabilitation Facility
3T
Alcoholism and Other Chemical Dependency Facility
40
Receiver
41
Submitter
45
Drop-off Location
4Z
Hospice
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
82
Rendering Provider
85
Billing Provider
87
Pay-to Provider
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
DQ
Supervising Physician
FA
Facility
GB
Other Insured
GK
Previous Insured
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IL
Insured or Subscriber
MSC
Mammography Screening Center
O4
Factor
Use when identifying a Pay to Factoring Agent.
OD
Doctor of Optometry
OOP
Other Operating Physician
P2
Primary Insured or Subscriber
P3
Primary Care Provider
PR
Payer
PRP
Primary Payer
PTP
Pay-to Plan Name
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QE
Policyholder
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QY
Medical Doctor
S4
Skilled Nursing Facility
SEP
Secondary Payer
TQ
Third Party Reviewing Organization (TPO)
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
X3
Utilization Management Organization
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.
Situational
11-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC11-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.
CODE
DEFINITION
RX
National Council for Prescription Drug Programs Reject Codes
CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes
Not Used
12
933
Free-form Message Text
O 1
AN
1/264
Situational
13
1383
Claim Submission Reason Code
O 1
ID
2
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
08
Pre-Determination
Use when the claim is for a medical related predetermination (Professional or Institutional)
PB
Predetermination of Dental Benefits

REF*X1 - PROVIDER'S ASSIGNED CLAIM IDENTIFIER

X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
Loop:
Loop 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Provider's Assigned Claim Identifier was submitted on the claim. If not required by this implementation guide, do not send.
TR3 Example:
REF✱X1✱PT12345~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
X1
Provider Claim Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Provider's Assigned Claim Identifier
  1. Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
  2. For example, this is the value from CLM01 of an 837.
  3. 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
3
352
Description
X 1
AN
1/80
Not Used
4
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
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
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
BLT
Billing Type
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
  1. 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
  2. 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
3
352
Description
X 1
AN
1/80
Not Used
4
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Pharmacy Prescription Number was submitted on the claim and the number applies to the entire claim. If not required by this implementation guide, do not send.
TR3 Example:
REF✱XZ✱1234567~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
XZ
Pharmacy Prescription Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Pharmacy Prescription Number
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a transmission intermediary (clearinghouse or other) needs to attach their own unique tracking number. If not required by this implementation guide, do not send.
TR3 Notes:
Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, recipients are not required to return this number. Trading partners may voluntarily agree to this interaction if they wish.
TR3 Example:
REF✱D9✱TJ98UU321~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
D9
Claim Number
Required
2
127
Reference Identification
X 1
AN
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
3
352
Description
X 1
AN
1/80
Not Used
4
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a Property & Casualty Claim Number has been established by the Property & Casualty payer. If not required by this implementation guide, do not send.
TR3 Example:
REF✱Y4✱4445555~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
Y4
Agency Claim Number
Required
2
127
Reference Identification
X 1
AN
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
3
352
Description
X 1
AN
1/80
Not Used
4
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 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
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
✱
1
374
Date/Time
Qualifier
M 1
ID
3
✱
2
1250
Date Time
Format Qual
M 1
ID
2/3
✱
3
1251
Date Time
Period
M 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
472
Service
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Claim Service Period

DTP*050 - CLAIM RECEIVED DATE

X12 Name:
Date or Time or Period
X12 Purpose:
To specify any or all of a date, a time, or a time period
Loop:
Loop 2200D - PAYER CLAIM CONTROL NUMBER
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
This is the date the claim was received by the payer.
TR3 Example:
DTP✱050✱D8✱20221030~
DTP
✱
1
374
Date/Time
Qualifier
M 1
ID
3
✱
2
1250
Date Time
Format Qual
M 1
ID
2/3
✱
3
1251
Date Time
Period
M 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
050
Received
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Claim Received Date

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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when the reason for the pended claim is at the service line. If not required by this implementation guide, do not send.
TR3 Notes:
  1. 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.
  2. Only those service lines that caused the pended status are to be reported.
TR3 Example:
SVC✱HC:99214✱50✱✱✱✱✱1~ orSVC✱NU:0710✱100✱✱✱✱✱1~
SVC
✱
1
C003
Comp. Med.
Proced. ID
M 1
✱
2
782
Monetary
Amount
O 1
R
1/18
✱
3
782
Monetary
Amount
O 1
R
1/18
✱
4
234
Product/
Service ID
O 1
AN
1/80
✱
5
380
Quantity
O 1
R
1/15
✱
6
C003
Comp. Med.
Proced. ID
O 1
✱
7
380
Quantity
O 1
R
1/15
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
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:
  1. C003-01 qualifies C003-02 and C003-08.
  2. If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
  3. C003-03 modifies the value in C003-02 and C003-08.
  4. C003-04 modifies the value in C003-02 and C003-08.
  5. C003-05 modifies the value in C003-02 and C003-08.
  6. C003-06 modifies the value in C003-02 and C003-08.
  7. C003-07 is the description of the procedure identified in C003-02.
  8. C003-08 represents the ending value in the range in which the code occurs.
  9. C003-09 modifies the value in C003-02 and C003-08.
  10. C003-10 modifies the value in C003-02 and C003-08.
  11. C003-11 modifies the value in C003-02 and C003-08.
  12. C003-12 modifies the value in C003-02 and C003-08.
Required
1-1
235
Product/Service ID Qualifier
M 1
ID
2
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
INDUSTRY NAME: Product or Service ID Qualifier
CODE
DEFINITION
AD
American Dental Association Codes
CODE SOURCE: 135: American Dental Association
ER
Jurisdiction Specific Procedure and Supply Codes
Use when applicable for Property & Casualty claims
CODE SOURCE: 576: Workers Compensation Specific Procedure and Supply Codes
HC
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
HP
Health Insurance Prospective Payment System (HIPPS) Rate Code
CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code
N4
National Drug Code in 5-4-2 Format
CODE SOURCE: 240: National Drug Code by Format
NU
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
AN
1/80
Identifying number for a product or service
INDUSTRY NAME: Product or Service ID
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.
Situational
1-3
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-4
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-5
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-6
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Not Used
1-7
352
Description
O 1
AN
1/80
Not Used
1-8
234
Product/Service ID
O 1
AN
1/80
Situational
1-9
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-10
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-11
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Situational
1-12
1339
Procedure Modifier
O 1
AN
2
This identifies special circumstances related to the performance of the service, as defined by trading partners
SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-02. If not required by this implementation guide, do not send.
Required
2
782
Monetary Amount
O 1
R
1/18
Monetary amount
SEMANTIC: SVC02 is the submitted service charge.
  1. This is the line item total on the current claim service status.
  2. Zero is an acceptable amount.
  3. 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
3
782
Monetary Amount
O 1
R
1/18
Situational
4
234
Product/Service ID
O 1
AN
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: Product or Service ID
Not Used
5
380
Quantity
O 1
R
1/15
Not Used
6
C003
Composite Medical Procedure Identifier
O 1
Required
7
380
Quantity
O 1
R
1/15
Numeric value of quantity
SEMANTIC: SVC07 is the original submitted units of service.
INDUSTRY NAME: Units of Service Count
A zero or negative value is not allowed.

STC - SERVICE LINE STATUS INFORMATION

X12 Name:
Status Information
X12 Purpose:
To report the status, required action, and paid information of a claim or service line
Loop:
Loop 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
>1
TR3 Notes:
See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
TR3 Example:
STC✱P3:297✱20110201✱✱50✱✱✱✱✱✱P3:331~
STC
✱
1
C043
Health Care
Stat Claim
M 1
✱
2
373
Date
O 1
DT
8
✱
3
306
Action
Code
O 1
ID
1/2
✱
4
782
Monetary
Amount
O 1
R
1/18
✱
5
782
Monetary
Amount
O 1
R
1/18
✱
6
373
Date
O 1
DT
8
✱
7
591
Payment
Method Code
O 1
ID
3
✱
8
373
Date
O 1
DT
8
✱
9
429
Check
Number
O 1
AN
1/16
✱
10
C043
Health Care
Stat Claim
O 1
✱
11
C043
Health Care
Stat Claim
O 1
✱
12
933
Free-Form
Message Txt
O 1
AN
1/264
✱
13
1383
Claim Submt
Reason Code
O 1
ID
2
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
C043
Health Care Claim Status
M 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. 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.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
Required
1-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. For this business function, use Pending "P" type Category Codes.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
1-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Status Code
  1. The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
  2. The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC01-04 must have the value 'RX'.
Situational
1-3
98
Entity Identifier Code
O 1
ID
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
03
Dependent
1P
Provider
1U
Long Term Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
2B
Third-Party Administrator
36
Employer
3F
Rehabilitation Facility
3T
Alcoholism and Other Chemical Dependency Facility
40
Receiver
41
Submitter
45
Drop-off Location
4Z
Hospice
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
82
Rendering Provider
85
Billing Provider
87
Pay-to Provider
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
DQ
Supervising Physician
FA
Facility
GB
Other Insured
GK
Previous Insured
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IL
Insured or Subscriber
MSC
Mammography Screening Center
O4
Factor
Use when identifying a Pay to Factoring Agent.
OD
Doctor of Optometry
OOP
Other Operating Physician
P2
Primary Insured or Subscriber
P3
Primary Care Provider
PR
Payer
PRP
Primary Payer
PTP
Pay-to Plan Name
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QE
Policyholder
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QY
Medical Doctor
S4
Skilled Nursing Facility
SEP
Secondary Payer
TQ
Third Party Reviewing Organization (TPO)
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
X3
Utilization Management Organization
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.
Situational
1-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC01-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.
CODE
DEFINITION
RX
National Council for Prescription Drug Programs Reject Codes
CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes
Required
2
373
Date
O 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: STC02 is the effective date of the status information.
INDUSTRY NAME: Status Information Effective Date
This is the date the service was placed in this status by the Information Source's adjudication process.
Not Used
3
306
Action Code
O 1
ID
1/2
Not Used
4
782
Monetary Amount
O 1
R
1/18
Not Used
5
782
Monetary Amount
O 1
R
1/18
Not Used
6
373
Date
O 1
DT
8
Not Used
7
591
Payment Method Code
O 1
ID
3
Not Used
8
373
Date
O 1
DT
8
Not Used
9
429
Check Number
O 1
AN
1/16
Situational
10
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. 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.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.
Required
10-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. See STC01-01 for valid values.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
10-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Status Code
  1. The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
  2. The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC10-04 must have the value 'RX'.
Situational
10-3
98
Entity Identifier Code
O 1
ID
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.
See STC01-03 for valid values.
CODE
DEFINITION
03
Dependent
1P
Provider
1U
Long Term Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
2B
Third-Party Administrator
36
Employer
3F
Rehabilitation Facility
3T
Alcoholism and Other Chemical Dependency Facility
40
Receiver
41
Submitter
45
Drop-off Location
4Z
Hospice
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
82
Rendering Provider
85
Billing Provider
87
Pay-to Provider
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
DQ
Supervising Physician
FA
Facility
GB
Other Insured
GK
Previous Insured
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IL
Insured or Subscriber
MSC
Mammography Screening Center
O4
Factor
Use when identifying a Pay to Factoring Agent.
OD
Doctor of Optometry
OOP
Other Operating Physician
P2
Primary Insured or Subscriber
P3
Primary Care Provider
PR
Payer
PRP
Primary Payer
PTP
Pay-to Plan Name
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QE
Policyholder
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QY
Medical Doctor
S4
Skilled Nursing Facility
SEP
Secondary Payer
TQ
Third Party Reviewing Organization (TPO)
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
X3
Utilization Management Organization
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.
Situational
10-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC01-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.
CODE
DEFINITION
RX
National Council for Prescription Drug Programs Reject Codes
CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes
Situational
11
C043
Health Care Claim Status
O 1
Used to convey status of the entire claim or a specific service line
X12 COMPOSITE SEMANTIC NOTES:
  1. C043-01 (Claim Status Category Codes, Code Source 507) is used to specify the logical groupings of codes used in C043-02.
  2. 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.
  3. C043-03 identifies the entity associated with the Health Care Claim Status Code.
  4. C043-04 is used to identify the Code Source referenced in C043-02.
SITUATIONAL RULE: Required when additional status information is needed. If not required by this implementation guide, do not send.
Required
11-1
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Health Care Claim Status Category Code
  1. See STC01-01 for valid values.
  2. CODE SOURCE 507: Health Care Claim Status Category Code
Required
11-2
1271
Industry Code
M 1
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY NAME: Status Code
  1. The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject Code (Code Source 530).
  2. The National Council for Prescription Drug Programs Reject Codes may be used for status related to pharmacy claims. When these codes are used, STC11-04 must have the value 'RX'.
Situational
11-3
98
Entity Identifier Code
O 1
ID
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.
See STC01-03 for valid values.
CODE
DEFINITION
03
Dependent
1P
Provider
1U
Long Term Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
2B
Third-Party Administrator
36
Employer
3F
Rehabilitation Facility
3T
Alcoholism and Other Chemical Dependency Facility
40
Receiver
41
Submitter
45
Drop-off Location
4Z
Hospice
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
82
Rendering Provider
85
Billing Provider
87
Pay-to Provider
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
DQ
Supervising Physician
FA
Facility
GB
Other Insured
GK
Previous Insured
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IL
Insured or Subscriber
MSC
Mammography Screening Center
O4
Factor
Use when identifying a Pay to Factoring Agent.
OD
Doctor of Optometry
OOP
Other Operating Physician
P2
Primary Insured or Subscriber
P3
Primary Care Provider
PR
Payer
PRP
Primary Payer
PTP
Pay-to Plan Name
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QE
Policyholder
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QY
Medical Doctor
S4
Skilled Nursing Facility
SEP
Secondary Payer
TQ
Third Party Reviewing Organization (TPO)
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
X3
Utilization Management Organization
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
Use when established by trading partner agreement, only when one of the other specific entity codes listed does not apply.
Situational
11-4
1270
Code List Qualifier Code
O 1
ID
1/3
Code identifying a specific industry code list
SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject Code in STC11-02 for status related to a pharmacy claim. If not required by this implementation guide, do not send.
CODE
DEFINITION
RX
National Council for Prescription Drug Programs Reject Codes
CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes
Not Used
12
933
Free-form Message Text
O 1
AN
1/264
Situational
13
1383
Claim Submission Reason Code
O 1
ID
2
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
08
Pre-Determination
Use when the service line is for a medical related predetermination (Professional or Institutional)
PB
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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
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
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
6R
Provider Control Number
Required
2
127
Reference Identification
X 1
AN
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
3
352
Description
X 1
AN
1/80
Not Used
4
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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the Pharmacy Prescription Number was submitted for this service. If not required by this implementation guide, do not send.
TR3 Example:
REF✱XZ✱1234567~
REF
✱
1
128
Reference
Ident Qual
M 1
ID
2/3
✱
2
127
Reference
Ident
X 1
AN
1/80
✱
3
352
Description
X 1
AN
1/80
✱
4
C040
Reference
Identifier
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
XZ
Pharmacy Prescription Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Pharmacy Prescription Number
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
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
✱
1
374
Date/Time
Qualifier
M 1
ID
3
✱
2
1250
Date Time
Format Qual
M 1
ID
2/3
✱
3
1251
Date Time
Period
M 1
AN
1/35
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
472
Service
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
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 2220D - SERVICE LINE INFORMATION
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
32
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
✱
1
1270
Code List
Qual Code
X 1
ID
1/3
✱
2
1271
Industry
Code
X 1
AN
1/30
✱
3
C005
Tooth
Surface
O 1
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1270
Code List Qualifier Code
X 1
ID
1/3
Code identifying a specific industry code list
SEGMENT SYNTAX: P0102
CODE
DEFINITION
JO
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
JP
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
2
1271
Industry Code
X 1
AN
1/30
Code indicating a code from a specific industry code list
SEGMENT SYNTAX: P0102
INDUSTRY NAME: Tooth Code
Situational
3
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
ID
1/2
Code identifying the area of the tooth that was treated
CODE
DEFINITION
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-2
1369
Tooth Surface Code
O 1
ID
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
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-3
1369
Tooth Surface Code
O 1
ID
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
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-4
1369
Tooth Surface Code
O 1
ID
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
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal
Situational
3-5
1369
Tooth Surface Code
O 1
ID
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
B
Buccal
D
Distal
F
Facial
I
Incisal
L
Lingual
M
Mesial
O
Occlusal

SE - TRANSACTION SET TRAILER

X12 Name:
Transaction Set Trailer
X12 Purpose:
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
X12 Comments:
SE is the last segment of each transaction set.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
SE✱1230✱0002~
SE
✱
1
96
Number of
Inc Segs
M 1
N
1/10
✱
2
329
TS Control
Number
M 1
AN
4/9
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
96
Number of Included Segments
M 1
N
1/10
Total number of segments included in a transaction set including ST and SE segments
INDUSTRY NAME: Transaction Segment Count
Required
2
329
Transaction Set Control Number
M 1
AN
4/9
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
The Transaction Set Control Number in ST02 and SE02 must be identical.

GE - FUNCTIONAL GROUP TRAILER

X12 Name:
Functional Group Trailer
X12 Purpose:
To indicate the end of a functional group and to provide control information
X12 Comments:
The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
GE✱1✱1~
GE
✱
1
97
Number of
TS Included
M 1
N
1/6
✱
2
28
Group Ctrl
Number
M 1
N
1/9
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
97
Number of Transaction Sets Included
M 1
N
1/6
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Required
2
28
Group Control Number
M 1
N
1/9
Assigned number originated and maintained by the sender
SEMANTIC: The data interchange control number GE02 in this trailer must be identical to the same data element in the associated functional group header, GS06.

IEA - INTERCHANGE CONTROL TRAILER

X12 Name:
Interchange Control Trailer
X12 Purpose:
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
IEA✱1✱000000905~
IEA
✱
1
I16
Num of Incl
Funct Group
M 1
N
1/5
✱
2
I12
Inter Ctrl
Number
M 1
N
9
~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
I16
Number of Included Functional Groups
M 1
N
1/5
A count of the number of functional groups included in an interchange
Required
2
I12
Interchange Control Number
M 1
N
9
A control number assigned by the interchange sender
The Value in IEA02 must be identical to the value in ISA13.
logo

277 Health Care Claim Pending Status Information (008020X331)

JANUARY 2022

Copyright © 2008-22, X12 Incorporated, Format © 2008-22 Washington Publishing Company. Exclusively published by the Washington Publishing Company. No part of this publication may be distributed, posted, reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written permission of the copyright owner.

All rights reserved.

Abstract

The Health Care Claim Pending Status Information Implementation Guide describes the use of the X12 Health Care Information Status Notification (277) transaction set to provide claim status information on claims pending in the payer's adjudication system without requiring health care provider solicitation.

Preface

X12 standards are developed to identify the broadest data requirements for a transaction set. Type 3 Technical Reports (TR3), also known as implementation guides, define the explicit data requirements for a specific business purpose. Trading partners who implement according to the instructions in this TR3 can exchange data consistently with multiple trading partners.

As X12 does not define transport requirements, trading partners define their specific transport requirements separately.

1.1 Implementation Purpose and Scope

For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

The purpose of this implementation guide is to provide standardized data requirements and content for all users of X12, Health Care Information Status Notification (277). This guide will focus on usage of the 277 by a health care payer to provide claim status information on claims pending in the payer's adjudication system without requiring health care provider solicitation. This guide provides a detailed explanation of the transaction set by defining uniform data content and identifying valid code tables and specifying values applicable for the business focus of the Health Care Claim Pending Status Information 277. The intention of the developers of the 277 is represented in the guide.

Health Care Providers receiving the 277 include, but are not limited to, hospitals, nursing homes, laboratories, physicians, medical groups, pharmacies, and suppliers. Organizations sending the 277 include, but are not limited to, insurance companies, third-party administrators, state and federal agencies and their contractors.

Other business partners affiliated with the 277 include, but are not limited to, billing services, clearinghouses and value-added networks.

1.2 Version Information

This implementation guide is based on the October 2020 X12 standards, referred to as Version 8, Release 2 (008020).

The unique Version/Release/Industry Identifier Code for transaction sets that are defined by this implementation guide is 008020X331.

The two-character Functional Identifier Code for the transaction set included in this implementation guide:

  • HN   Health Care Information Status Notification (277)

The Version/Release/Industry Identifier Code and the applicable Functional Identifier Code must be transmitted in the Functional Group Header (GS segment) that begins a functional group of these transaction sets. For more information, see the descriptions of GS01 and GS08 in Appendix C EDI Control Directory.

1.3.1 Batch and Real-Time Usage

There are multiple methods available for sending and receiving business transactions electronically. Two common modes for EDI transactions are batch and real-time.

Batch - In a batch mode the sender does not remain connected while the receiver processes the transactions. Processing is usually completed according to a set schedule. If there is an associated business response transaction (such as a 271 Response to a 270 Request for Eligibility), the receiver creates the response transaction and stores it for future delivery or transmits the response transaction back to the sender of the original transaction. The sender of the original transmission reconnects at a later time and picks up the response transaction. Note: The sender of the original transmission may not always be the entity that picks up the response transaction at a later time (e.g. Provider submitting through a clearinghouse.)

Real-Time - In real-time mode the sender remains connected while the receiver processes the transactions and returns a response transaction to the sender. This implementation guide does not set specific response time parameters for implementers.

This implementation guide was based on requirements for batch mode. Willing trading partners may use batch or real-time mode.

1.3.2 Other Usage Limitations

There are other usage limitations.

1.3.2.1 Claim Status Category Codes

Claim status is limited to use of the Pending Claims Status Category Codes (P codes) in this implementation.

1.3.2.2 277 Business Functions

Additional 277 business functions, beyond a pending claim list, are not supported in this implementation. See Section 1.4.5 - 277 Transaction Usages, for additional information on the other 277 business functions.

1.4 Business Usage

The X12 Health Care Claim Pending Status Information (277) implementation guide addresses the usage for providing a list of claims that are pending final adjudication in a payer's claim processing system. The listing would include claims that have been accepted into the payer's processing system, but have not been finalized, paid, or denied. The listing may also provide information for claims which have been suspended for additional information or review. However the Health Care Claim Pending Status Information transaction is not used to make the actual request for information. See Section 1.4.5 - 277 Transaction Usages, for the appropriate business function transaction.

The Health Care Claim Pending Status Information transaction is initiated by the payer to the provider. This transaction's intent is to supply the provider with claim status without the provider initiating a specific request for the information. Whether the transaction is sent and when (weekly, monthly, etc.) is determined by trading partners. It is recommended it be sent at the same time as the Health Care Claim Payment/Advice (835), although that capability may vary by trading partner.

Finalized payment or denial information is not included in the transaction. The payer uses the Health Care Claim Payment/Advice (835) transaction to advise the provider on claims that have been finalized, paid or denied, by the adjudication system. When the payer generates the 277 in addition to the 835, a more complete claim accounting is provided. Usage of the Health Care Claim Pending Status Information transaction may minimize the need for the Health Care Claim Status Request and Response transaction (276/277).

Figure 1.1 - Information Flow of Health Care Claim Pending Status Information

Information Flow of Health Care Claim Pending Status Information

1.4.1 Health Care Transaction Flow

Each X12 implementation guide explains how to use X12 transaction sets to meet a single defined business purpose. The diagrams found at https://www.x12.org/flow depict the business functions supported by the X12 health care implementation guides.

1.4.2 Transaction Participants

The hierarchical level structure is used to identify and relate the participants involved in the transaction. The relationships between the hierarchical levels are described by the hierarchical level code data elements, also known as HL01 and HL02. The data element HL03 identifies the participants within the transaction. The participants described are as follows:

When HL03 = 20, the hierarchical level contains the Information Source. This entity is the decision maker in the business transaction. For this business use, this entity is the payer who has the current status information for the identified claims.

When HL03 = 21, the hierarchical level contains the Information Receiver. This entity is receiving the claim status information from the Information Source. For this business use, this entity can be a provider, a provider group, a claims clearinghouse, a service bureau, an agency, an employer, etc. This entity will be identified via their electronic ID.

When HL03 = 19, the hierarchical level contains the Provider of Service. This entity delivered the health care service. Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider).

When HL03 = PT, the hierarchical level contains the Patient information. This entity is the recipient of the health care service rendered.

The Information Receiver and the Service Provider hierarchical levels have a unique relationship. Information Receiver refers to the entity that processes the detailed information contained within the transaction set. In some cases, the Information Receiver is an entity acting on behalf of the Service Provider. When this occurs, the entity is described when HL03 = 21, and the Provider of Service is described when HL03 = 19. In other instances, the Information Receiver is also the Service Provider. When this occurs, the same entity is described at two hierarchical levels - when HL03 = 21 and when HL03 = 19.

The coding examples are presented sequentially as found within an actual transaction set. However, for reading ease each segment begins on a new line.

The following example demonstrates the coding of the segments and data elements within the Information Source hierarchical level:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~

The following is a coding example of the Information Receiver hierarchical level:

HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~

The following is a coding example of the Service Provider hierarchical level:

HL*3*2*19*1~
NM1*1P*2*HOME MEDICAL*****XX*1666666666~

The following is a coding example of the Patient Hierarchical level:

HL*4*3*PT~
NM1*QC*1*MANN*JOHN****MI*345678901~

1.4.3 Claim and Service Information

The specific claim and service details are not given a hierarchical level. Claim and service information are positioned in the Patient hierarchical level. The specific claim(s) for which status is being provided is described in Loop 2200D, while the service details follow the claim data in Loop 2220D.

A payer must report status information at the claim level, and when applicable at the service line level using the Status Information (STC) segment. The STC segment reports the status and the effective date of the status. Since the claims reported in this implementation are pending in a payers adjudication system, no payment amounts, paid dates, or check issue dates are included.

1.4.3.1 The Claim

When conveying claim status, the Information Source must provide key data to the Information Receiver in order to identify the claim to which the status applies. The key identifier used by the Information Receiver for identifying the claim within their system is the Provider's Assigned Claim Identifier. This identifier when submitted on the claim is returned in the Provider's Assigned Claim Identifier REF Segment in the 2200D loop of the 277 transaction.

The Information Source also supplies the Payer Claim Control Number which is the key identifier for the payer's system. The payer's identifier is provided in the Payer Claim Control Number TRN Segment in the 2200D Loop. This identifier may be used by the Information Receiver to subsequently inquire about claim status, if necessary.

In addition to the reference and trace numbers, the payer transmits information such as the patient name and identifiers, service dates, service codes and claim and service charges, as applicable. This information serves as secondary verification to the reported reference numbers.

Claim Received Date - Payers are required to provide the date the claim was received by the payer. This date will assist providers with reviewing the list of pending payer claims. Providers may use the date to calculate, sort, etc. claims by Claim Received Date to identify a claim's age within the payer's processing system.

1.4.3.2 The Service

When a service line is the reason a claim is pended, Loop 2220D is used. The service information follows the Loop 2200D claim data. The SVC segment is used to report the actual service (procedure) data for the pending service line.

1.4.4 Status Information (STC) Segment Usage

The primary vehicle for the claim status information in the 277 Transaction is the Status Information (STC) Segment. The level of information returned in the STC Segment may vary from payer to payer. Payers are urged to provide a greater level of detail information to the Information Receiver so that the data exchange is beneficial to both entities. Payers who meet the minimum required basics, defined in Section 1.4.4.1 - STC Composite and Code Use Rules, may not satisfy the receiver's need for complete and detailed status which could result in the generation of subsequent inquiries to the payer. See Section 1.4.4.1 - STC Composite and Code Use Rules, for additional information.

The STC segment contains three iterations of the Health Care Claim Status composite data element (C043) within STC01, STC10 and STC11. Multiple STC segments may be sent when needed to fully explain the claim status.

The Health Care Claim Status composite (C043) consists of four elements:

  • The first element in the C043 composite (C043-01) is the Health Care Claim Status Category Code (Code Source 507). The Category Code indicates the payer's current system status of the claim. This implementation guide requires the use of Pending Category Codes ('P' Codes).
  • The second element in the C043 composite (C043-02) is either the Health Care Claim Status Code (Code Source 508) or the National Council for Prescription Drug Programs Reject/Payment Codes (Code Source 530). These codes provide more specific information about the claim or line item.
  • The third element in the C043 composite (C043-03) is the Entity Identifier Code (X12 data element 98). The Entity Identifier code is used to clarify the entity when referred to in the status message (C043-02). The code list identifies an organizational entity, a physical location, property, or an individual. A list of appropriate code values for data element 98 appears within the STC segments in Section 2.4.
  • The fourth element in the C043 composite (C043-04) is the Code List Qualifier Code (X12 data element 1270). This element is Situational and only used when identifying the second element of the composite (C043-02) as a National Council for Prescription Drug Programs Reject/Payment Code. When this element is used, it will contain code value 'RX' - National Council for Prescription Drug Programs Reject/Payment Codes.

A committee of healthcare industry representatives from payer, provider and vendor organizations maintain the Health Care Claim Status Category Codes and Health Care Claim Status Codes (Code Sources 507 and 508). They are updated after each X12 Standing Meeting. Version specific code additions or deactivations are noted on the code lists.

The primary distribution source is the Washington Publishing Company website (www.wpc-edi.com). This website offers an online conferencing facility that allows interested parties to submit requests for new codes, changes to existing codes, or simply view comments on pending requests.

The National Council for Prescription Drug Programs (NCPDP) Reject/Payment Codes list is maintained by the National Council for Prescription Drug Programs. For information on the NCPDP Reject/Payment Codes (Code Source 530) refer to Appendix A, External Code Sources.

1.4.4.1 STC Composite and Code Use Rules

The following rules apply to use of the composites and codes within the STC segment:

  • STC01 is required.
  • STC10 and STC11 are situational and provide additional status (second and third, respectively). Use of these data elements is encouraged to support the reporting of more detail and a complete message in order to minimize subsequent inquiries.
  • An Entity Code must be identified when the Health Care Claim Status Code message refers to an Entity. For example the Entity Code '85 - Billing Provider' could be used when Status Code '24 - Entity not approved as an electronic submitter' is used. The Information Source may use an Entity Code to provide a more complete message, even though 'Entity' is not referred to in the status code message.

1.4.5 277 Transaction Usages

The Health Care Information Status Notification (277) transaction set has multiple implementation conventions to meet various business needs of the health care industry. The transaction set can be used to provide healthcare claim information in the following business scenarios:

  • X12 Health Care Claim Pending Status Information (277), which is used as a listing of pending claims in a payer's system. This function is supported in this implementation guide.
  • X12 Health Care Claim Acknowledgement (277), which is a business application response to the X12 837 claim/encounter transactions. This function is not supported in this implementation guide.
  • X12 Health Care Claim Request for Additional information (277), which is a payer's request for additional information to support a health care claim. This function is not supported in this implementation guide.
  • X12 Health Care Claim Status Request and Response (276/277), where the 277 is a response to a request for claim status information. This function is not supported in this implementation guide.

Figure 1.2 - General X12 Health Care Claim Information Flow illustrates the flow of information related to several usages of the 277. The multiple uses of the 277 claim status are differentiated by values in the ST and BHT Segments of Table 1 data. Element BHT06, in addition to the GS08 value, is used to distinguish between these varied business functions. The various 277 - BHT06 code values are:

  • NO - Notice (Health Care Claim Pending Status Information)
  • TH - Receipt Acknowledgement Advice (Health Care Claim Acknowledgement)
  • RQ - Request (Health Care Claim Request for Additional information)
  • DG - Response (Health Care Claim Status Request and Response)

Figure 1.2 - General X12 Health Care Claim Information Flow

General X12 Health Care Claim Information Flow

1.5 Business Terminology

To ensure consistent use of terms, definitions, and acronyms across X12 products, X12 maintains the Wordbook, a comprehensive corporate glossary. The included terms are either proprietary to X12, cite definitions published by another authority, or represent common terms and definitions that are relevant to X12's work. The terms and definitions defined in the Wordbook are used in X12 work products when applicable, without modification or revision. The Wordbook can be referenced online at wordbook.x12.org.

1.6 Transaction Acknowledgments

The purpose of transaction acknowledgments is to report to the sender whether the transaction being acknowledged was accepted or rejected.

The X12 Technical Report Type 2, Acknowledgment Reference Model provides guidance on several control structures and transaction set standards intended to augment EDI auditing and control systems.

1.7 Related Transactions

There are one or more transactions related to the transactions described in this implementation guide.

1.7.1 The Claim (837)

Submitting a claim using the 837 transaction is the first step in the claim adjudication process. The data elements found on the original claim have their source from the provider's billing system. When the payer generates the Health Care Claim Pending Status Information transaction, data from the original claim is returned to the Information Receiver on the 277 to facilitate locating the claim within their system.

1.8 Trading Partner Agreements

Trading partner agreements are used to establish and document the relationship between trading partners. A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide.

1.9 Transaction Compliance

There are three types of compliance that may be relevant to a transmitted transaction.

Compliance with implementation guide requirements

Compliance with state and federal regulation

Compliance with trading partner contractual agreements

1.9.1 Transaction Compliance with Implementation Guide Requirements

A transaction complies with X12 implementation guide requirements if the transaction satisfies all format and content rules and constraints specified in the applicable X12 standards and the implementation guide (also known as a TR3) itself.

Should additional clarification of an X12 implementation guide requirement be desired, two options are available.

X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that are not TR3-compliant based on its own business process.

A receiver may specify its business rules in a trading partner agreement or companion document. As stated in §1.8, these documents do not override TR3 requirements, nor change how transaction compliance with this TR3 is determined.

1.9.2 Transaction Compliance with State and Federal Regulations

This implementation guide has been developed for use as an insurance industry implementation guide. At the time of publication it has not been adopted as a state or federal standard. Should this implementation guide be adopted as a standard, the adopting authority will establish compliance dates for its use by impacted entities.

X12 is not the authority for determining compliance with regulatory requirements that might further constrain implementation guide requirements. Questions of compliance for regulatory requirements should be directed to the governing authority.

X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with applicable regulatory requirements as specified by the applicable regulation(s) or governing authority.

1.9.3 Transaction Compliance with Contractual Requirements

X12 is not the authority for determining compliance with contractual requirements that might further constrain implementation guide requirements. Questions of compliance for contractual requirements should be directed to the contracting entity.

X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with contractual requirements as specified by the applicable contract or contracting entity.

1.10 Data Overview

This section introduces the structures of the 277. Familiarity with X12 nomenclature, segments, data elements, hierarchical levels, and looping structure is recommended. For a review, see Appendix B, X12 Control and Guidance and Appendix C, EDI Control Directory.

1.10.1 Overall Data Architecture

Two formats, or views, are used to present the transaction set: the implementation view and the standard view. The intent of the implementation view is to clarify the purpose and use of the segments by restricting the view to display only those segments used with their assigned health care names. The implementation view for the 277 is presented in Section 2.3.1, Implementation. The standard view for the 277 displays all segments available within the transaction set with their assigned X12 names. This view is presented in Section 2.3.2, X12 Standard.

The transaction set is divided into two levels, or tables, Table 1 and Table 2.

Table 1
Table 1 is named the Header Level and contains the transaction control information. The ST segment identifies the start of a transaction and the specific transaction set. The BHT identifies the transactions business purpose and the hierarchical structure used in Table 2.

Table 2
Table 2 is named the Detail Level because it contains the detail information for the business function of the transactions. This table uses the hierarchical level structure. Each hierarchical level (HL) is a series of loops, which are identified by numbers. The hierarchical level that identifies the patient is Loop ID-2000D. The patient name is contained in Loop ID-2100D. Specific claim details begin with Loop ID-2200D.

The following are HL segment coding examples and the data element significance within the HL segments:

HL*1**20*1~ Information Source Level
HL*2*1*21*1~ Information Receiver Level
HL*3*2*19*1~ Service Provider Level
HL*4*3*PT~ Patient Level
  • HLs are sequentially numbered. The sequential number is found in HL01, which is the first data element in the HL segment.
  • The second element, HL02, indicates the sequential number of the parent hierarchical level to which this hierarchical level is subordinate. The absence of a data value in HL02, indicates it is the highest hierarchical level. In this example, the Information Source is the highest parent. The Information Receiver level is subordinate to the Information Source hierarchical level numbered 1 (HL01 = 1). The Provider Service Level is subordinate to the Information Receiver hierarchical level numbered 2 (HL01 = 2), etc.
  • The data value in data element HL03 describes the hierarchical level entity. For example, when HL03 = 20, the hierarchical level is the Information Source. When HL03 = PT, the hierarchical level is the Patient.
  • Data element HL04 indicates whether or not child (subordinate) hierarchical levels exist. A value of "1" indicates subordinate hierarchical levels exist. A value of "0" or the absence of a data value indicates that no subordinate hierarchical levels exist.

2. Transaction Set

NOTE
See X12 documents X12.5, X12.6, and X12.59 to review transaction set structure, including descriptions of segments, levels, and loops.

2.1 Presentation Examples

The X12 standards are generic. For example, multiple trading communities use the same PER segment to specify administrative communication contacts. Each community decides which elements to use and which code values in those elements are applicable.

This implementation guide uses a format that depicts both the generalized standard and the insurance industry-specific implementation. In this implementation guide, IMPLEMENTATION specifies the requirements for this implementation. X12 STANDARD is included as a reference only.

The transaction set presentation is comprised of two main sections with subsections within the main sections:

Transaction Set Listing

There are two sub-sections under this general title. The first sub-section concerns this implementation of a generic X12 transaction set. The second sub-section concerns the generic X12 standard itself.

This section lists the levels, loops, and segments contained in this implementation. It also serves as an index to the segment detail.

This section is included as a reference.

Segment Detail

There are three sub-sections under this general title. This section repeats once for each segment used in this implementation providing segment specific detail and X12 standard detail.

This section is included as a reference.

This section is included as a reference. It provides a pictorial view of the standard and shows which elements are used in this implementation.

This section specifies the implementation details of each data element.

These illustrations (Figures 2.1 through 2.5) are examples and are not extracted from the Section 2 detail in this implementation guide. Annotated illustrations, presented below in the same order they appear in this implementation guide, describe the format of the transaction set that follows.

Figure 2.1 - Transaction Set Key - Implementation

Transaction Set Key - Implementation

Figure 2.2 - Transaction Set Key - Standard

Transaction Set Key - Standard

Figure 2.3 - Segment Key - Implementation

Segment Key - Implementation

Figure 2.4 - Segment Key - Diagram

Segment Key - Diagram

Figure 2.5 - Segment Key - Element Summary

Segment Key - Element Summary

2.2.1 Industry Usage

Industry Usage describes when loops, segments, and elements are to be sent when complying with this implementation guide. The three choices for Usage are required, not used, and situational. To avoid confusion, these are named differently than the X12 standard Condition Designators (mandatory, optional, and relational).

Required  

This loop/segment/element must always be sent.

Required segments in Situational loops only occur when the loop is used.

Required elements in Situational segments only occur when the segment is used.

Required component elements in Situational composite elements only occur when the composite element is used.

Not Used  

This element must never be sent.

Situational  

Use of this loop/segment/element varies, depending on data content and business context as described in the defining rule. The defining rule is documented in a Situational Rule attached to the item.

There are two forms of Situational Rules.

"Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver."

The data qualified by such a situational rule cannot be required, requested or rejected by the receiver when the condition is not applicable. Transmission of this data is solely at the sender's discretion when the stated condition does not apply.

"Required when <explicit condition statement>. If not required by this implementation guide, do not send."

The data qualified by such a situational rule must not be sent except as described in the explicit condition statement.

2.2.1.1 Determining Transaction Compliance with Industry Usage Requirements

A transmitted transaction complies with the governing implementation guide when it satisfies the requirements as defined within the implementation guide. Specifically, the presence or absence of an item (loop, segment, or element) complies with the industry usage specified by this implementation guide according to the following table.

Industry Usage

Business
Condition
is

Item
is

Transaction
Complies with
Implementation
Guide?

Required

N/A

Sent

Yes

Not Sent

No

Not Used

N/A

Sent

No

Not Sent

Yes

Situational (Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.)

True

Sent

Yes

Not Sent

No

Not True

Sent

Yes

Not Sent

Yes

Situational (Required when <explicit condition statement>. If not required by this implementation guide, do not send.)

True

Sent

Yes

Not Sent

No

Not True

Sent

No

Not Sent

Yes

2.2.2 Loops

Loop requirements depend on the context or location of the loop within the transaction. See Appendix B for more information on loops.

  • A nested loop can be used only when the associated higher level loop is used.
  • The usage of a loop is the same as the usage of its beginning segment.
    • If a loop's beginning segment is Required, the loop is Required and must occur at least once unless it is nested in a loop that is not being used.
    • If a loop's beginning segment is Situational, the loop is Situational.
  • Subsequent segments within a loop can be sent only when the beginning segment is used.
  • Required segments in Situational loops occur only when the loop is used.

3. Examples

Business scenario examples for use of this transaction can be found on the X12 Examples website at http://examples.x12.org. The X12 Examples website provides convenient access to examples of X12 transaction transmissions, including the data stream and a description of the associated scenario.

 

Appendix A. External Code Sources

Prior to this publication, X12 TR3s contained a subset of the overall Code Source Directory, formerly known as Appendix A of X12.3. External code lists are not part of the X12 standard and are provided for information purposes only. The full listing is available in Glass, X12's On-Line viewer.

Read more about Glass here: https://glasshelp.x12.org/.

Where an external code source is referenced in this publication, the implementer is required to use only the codes from that list. Codes must be reported as listed in the code source (e.g. with leading zeroes). Implementers must follow the instructions for code use that are supplied by the code set owner.

 

B.1.1 X12 Referenced and Related Standards

This technical report is based on the X12 EDI standard which comprises a series of interdependent publications. Implementers are advised to consult these publications when using this technical report.

The following standards are required to interpret, understand, and use this technical report:

  • X12.5 - Interchange Control Structure
  • X12.6 - Application Control Structure

The following guideline is useful to interpret, understand, and use this technical report:

  • Compliance in X12

The following reference model is useful to interpret, understand, and use this technical report:

  • Acknowledgment Reference Model

All of the documents above are available online using links to X12's Online Viewer.

 

B.1.1.1 Transmission Control Schematic

Refer to X12.5 - Interchange Control Structures, Section 3.5 - Order of Control Segments, and Chapter 5 Interchange Segment Specifications.

Similar transaction sets, called "functional groups," can be sent together within a transmission. Each functional group is prefaced by a group start segment; and a functional group is terminated by a group end segment. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer. Figure B.1 - Transmission Control Schematic, illustrates this interchange control.

Figure B.1 - Transmission Control Schematic

Transmission Control Schematic

 

B.1.1.2 Constraints applicable to the suite of TR3s

Refer to X12.6 - Application Control Structure, Section 3.2.8 - Minimums/Maximums.

Data element minimum and maximum lengths are set by the X12 standard. This implementation guide may further restrict minimum and maximum lengths within the bounds set by the standard. Such restrictions may occur implicitly by virtue of the allowed qualifier for the data element, or they may be stated explicitly in a note attached to the element or in the general limitations below.

 

B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification

The current X12 standard allows a maximum length greater than 50 characters for data element 127. For implementations governed by this implementation guide, unless another value is specified in an attached note, the maximum length of each occurrence of this data element is constrained to 50 characters.

 

B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount

For implementations governed by this implementation guide, unless another value is specified for an instance of Data Element 782 within Section 2 (Transaction Set), each occurrence of Data Element 782 (Monetary Amount) will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). Note that the decimal point and leading sign, if sent, are not part of the character count.

EXAMPLE

  • The following transmitted value represents the largest positive dollar amount that can be sent: 99999999.99
  • The following transmitted value is the longest string of characters that can be sent representing whole dollars. 99999999
  • The following transmitted value is the longest string of characters that can be sent representing negative dollars and cents. -99999999.99
  • The following transmitted value is the longest string of characters that can be sent representing negative whole dollars. -99999999
 

B.1.1.3 Decimal

While the X12 standard supports usage of exponential notation, this guide prohibits that usage.

Appendix D. Change Summary

This Implementation Guide (008020X331) defines the X12 requirements for the Health Care Claim Pending Status Information. It is based on version/release/subrelease 008020 of the X12 standards.