277 Health Care Claim Request for Additional Information (008020X340)

Loop 2000A - INFORMATION SOURCE LEVEL

Required

1005

Hierarchical Structure Code

M 1

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

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

CODE

DEFINITION

0085

Information Source, Information Receiver, Provider of Service, Patient

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Suspended

Required

127

Reference Identification

O 1

1/80

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

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

INDUSTRY NAME: Originator Application Transaction Identifier

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

CODE

DEFINITION

Request

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The entity requesting this information is the payer.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

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

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

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

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Payer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Use when XV is not used.

Standard Unique Health Plan Identifier (HPID)

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

CODE SOURCE: 540: Health Plan Identifier (HPID)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*IC - PAYER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer has contact data that may provide medical or other policy information that may apply to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
This PER Segment provides general payer customer support information and is not returned in the 275.

TR3 Example:

PER✱IC✱✱UR✱www.anyhealthplan.com/policies.html~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

Loop 2000B - INFORMATION RECEIVER LEVEL

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when it is necessary to identify a contact name or department for questions or general information related to the payer's additional information requests. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Payer Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the payer has a contact communication number that may provide medical or other policy information related to the additional information requests in this transaction. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

HL - INFORMATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Recipient of the request from the Information Source. For this business use, this entity can be a provider, a provider group, a clearinghouse, a service bureau, an agency, etc.

TR3 Example:

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

NM1

✱

✱

Loop 2000C - SERVICE PROVIDER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

This is the submitter of the original claim or the entity designated to receive the request for additional information.

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Information Receiver Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Receiver Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Receiver Identification Number

The ETIN is established through Trading Partner agreement.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

HL - SERVICE PROVIDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱3✱2✱19✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Provider of Service

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*1P - SERVICE PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100C - SERVICE PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2000D - PATIENT LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Provider Name Suffix

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Service Provider Number

Standard Unique Health Identifier for Health Care Providers (NPI)

Use when the provider is in the United States or its territories and is eligible to receive a National Provider Identifier (NPI).
OR
Use when the provider is not in the United States or its territories and has received an NPI.

CODE SOURCE: 537: National Provider Identifier (NPI)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

HL - PATIENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱4✱3✱PT~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Patient

Not Used

736

Hierarchical Child Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100D - PATIENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the First Name is known to the sender. If not required by this implementation guide do not send.

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the Middle Name or Initial is known to the sender. If not required by this implementation guide do not send.

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the Name Suffix is known to the sender. If not required by this implementation guide do not send.

INDUSTRY NAME: Patient Name Suffix

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Use when reporting the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number, i.e. Insured's ID, Subscriber's ID, Medicare Beneficiary Identifier (MBI), etc.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

TRN*1 - PAYER CLAIM CONTROL NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the payer's claim control number.

TR3 Example:

TRN✱1✱0612991010987~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Payer Claim Control Number

This is the Control Number assigned by the payer. This number is used by the Payer to connect the request to the response. This number must be returned in the 275 response in the 2000A TRN02 data element.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/80

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting additional information at the claim level. If not required by this implementation guide, do not send.

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.
The codes in this STC segment must be returned in the 275 Additional Information to Support a Health Care Claim or Encounter response in the 2000A STC.

TR3 Example:

STC✱RO:18682-5::LOI✱20110824~ orSTC✱R4:18660-1::LOI✱20110824✱✱✱✱✱✱✱✱R4:19790-6::LOI~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

✱

1383

Claim Submt
Reason Code

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Use Requests for Additional Information "R" type Category Codes only.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Information Request Code

This is the LOINC® Code that defines the additional information being requested.

Not Used

1-3

Entity Identifier Code

O 1

2/3

Required

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

This value indicates that STC01-02, STC10-02, STC11-02 are Logical Observation Identifier Names and Codes (LOINC®).

CODE

DEFINITION

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Use Requests for Additional Information "R" type Category Codes only.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Information Request Code

This will be the LOINC® Code that further specifies the request for information.

Not Used

10-3

Entity Identifier Code

O 1

2/3

Required

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Use Requests for Additional Information "R" type Category Codes only.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Information Request Code

This will be the LOINC® Code that further specifies the request for information.

Not Used

11-3

Entity Identifier Code

O 1

2/3

Required

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)

Not Used

933

Free-form Message Text

O 1

1/264

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

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

INDUSTRY NAME: Predetermination of Benefits Code

CODE

DEFINITION

Pre-Determination

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

Predetermination of Dental Benefits

REF*X1 - PROVIDER'S ASSIGNED CLAIM IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Provider's Assigned Claim Identifier was submitted on the claim. If not required by this implementation guide, do not send.

TR3 Notes:

For example, this is the value from CLM01 of an 837.

TR3 Example:

REF✱X1✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Provider's Assigned Claim Identifier

The maximum number of characters to be supported for this field is '35'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for Institutional claims when the Institutional Type of Bill was received on the claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

Concatenate the 837I CLM05-01 (Facility Type Code) and CLM05-03 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EA - MEDICAL RECORD IDENTIFICATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Medical Record Identification Number was submitted on the original claim. If not required by this implementation guide, do not send.

TR3 Notes:

The Medical Record Identification Number is reported in the 837, 2300 Loop REF02 (REF01 = EA).

TR3 Example:

REF✱EA✱44444TH56~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Medical Record Identification Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Medical Record Identification Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Clearinghouse Trace Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Y4 - PROPERTY & CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting information related to a Property & Casualty claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*3H - CASE REFERENCE IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a case reference identifier is assigned by the payer and necessary for tracking related attachment requests. If not required by this implementation guide, do not send.

TR3 Notes:

A case reference identifier may be assigned by the payer to link related attachment requests which may involve single or multiple patients and/or providers.

TR3 Example:

REF✱3H✱XRAY123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Case Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Case Reference Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*X9 - ATTACHMENT REQUEST TRACKING IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an attachment request tracking identifier is assigned by the payer to this attachment request and is necessary for tracking purposes. If not required by this implementation guide, do not send.

TR3 Notes:

This identifier is used to track an individual attachment request for a single claim.

TR3 Example:

REF✱X9✱DOC234~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Internal Control Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Attachment Request Tracking Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*Q4 - PRIOR ATTACHMENT REQUEST TRACKING IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a previously issued attachment request tracking identifier has been terminated and replaced with the current attachment request tracking identifier (REF01=X9). If not required by this implementation guide, do not send.

TR3 Example:

REF✱Q4✱DOC123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Prior Identifier Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Attachment Request Tracking Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim is not a predetermination and service level dates are not reported. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

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

TR3 Example:

DTP✱472✱D8✱20220201~ ORDTP✱472✱RD8✱20220201-20220205~

DTP

✱

✱

Date Time
Format Qual

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Service Period

DTP*106 - RESPONSE DUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This date is supplied to indicate the date the requested information is to be returned by the Information Receiver.

Should this date pass without the requested information being supplied by the Information Receiver, the payer may decide to allow the claim to proceed through the adjudication process based upon the information already received.

TR3 Example:

DTP✱106✱D8✱20220228~

DTP

✱

✱

Date Time
Format Qual

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

106

Required By

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Response Due Date

PWK*OZ - CLAIM SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the payer must have the requested information returned to a specific contact person, number or location. If not required by this implementation guide, do not send.

TR3 Notes:

The PWK segment is syntactically required in order to use the Payer Response Contact data in the 2210D Loop.

TR3 Example:

PWK✱OZ~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

INDUSTRY NAME: Report Transmission Code

CODE

DEFINITION

Support Data for Claim

Not Used

756

Report Transmission Code

O 1

1/2

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

PER*RE - PAYER RESPONSE CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
The data in this PER is used by the payer for routing the requested information within their system. This data must be returned by the provider. In the 275 Transaction, this data is returned in the 1000A loop PER Segment, Payer Response Contact Information.

TR3 Example:

PER✱RE✱MEDICAL REVIEW DEPARTMENT✱ED✱MRD123✱FX✱3135554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Receiving Contact

Situational

Name

O 1

1/60

Free-form name

INDUSTRY NAME: Payer Contact Name

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the payer needs to identify a specific communication number associated with the return and routing of data in the 275 transaction or to identify other communication methods for returning the data. If not required by this implementation guide, do not send.

The presence of the communications qualifiers does not imply the method for which data must be returned.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - PAYER RESPONSE CONTACT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer needs to identify a specific mailing location for the return of attachment data in the event the attachment is not sent electronically. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This data is not returned in the 275 transaction.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Response Contact Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Response Contact Additional Address Line

N4 - PAYER RESPONSE CONTACT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

This data is not returned in the 275 transaction.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Response Contact City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

COMMENT: N403 contains the postal code in an unstructured format. N408 contains the postal code in a structured format. When a postal code data field is used, the parties shall agree as to which data element (N403 or N408) shall be used in the transaction set.

SEGMENT SYNTAX: E0308

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

INDUSTRY NAME: Response Contact Country Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

INDUSTRY NAME: Response Contact Country Subdivision Code

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the request for additional information is about a service line. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

SVC✱NU:0710✱15.61~ ORSVC✱HC:99213✱35~

SVC

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

Comp. Med.
Proced. ID

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

Use when applicable for Property & Casualty claims

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

Healthcare Common Procedure Coding System (HCPCS) Codes

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

CODE SOURCE: 130: Healthcare Common Procedure Coding System

Health Insurance Prospective Payment System (HIPPS) Rate Code

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

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

Use when reporting a NUBC Revenue Code

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

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Service Identification Code

If the value in SVC01-01 is "NU", then this element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-02, then SVC04 is not used.

Situational

1-3

1339

Procedure Modifier

O 1

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

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

Situational

1-4

1339

Procedure Modifier

O 1

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

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

Situational

1-5

1339

Procedure Modifier

O 1

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

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

Situational

1-6

1339

Procedure Modifier

O 1

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

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

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/80

Situational

1-9

1339

Procedure Modifier

O 1

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

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

Situational

1-10

1339

Procedure Modifier

O 1

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

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

Situational

1-11

1339

Procedure Modifier

O 1

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

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

Situational

1-12

1339

Procedure Modifier

O 1

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

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

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

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

Not Used

782

Monetary Amount

O 1

1/18

Situational

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

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

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

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Not Used

380

Quantity

O 1

1/15

STC - SERVICE LINE STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.4 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
The codes in this STC segment must be returned in the 275 Additional Information to Support a Health Care Claim or Encounter response in the 2000A STC.

TR3 Example:

STC✱R3:18682-5::LOI✱20110501~ orSTC✱R3:18660-1::LOI✱20110501✱✱✱✱✱✱✱✱R4:18790-6::LOI~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

✱

1383

Claim Submt
Reason Code

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Use Requests for Additional Information "R" type Category Codes only.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Information Request Code

This is the LOINC® Code that defines the additional information being requested.

Not Used

1-3

Entity Identifier Code

O 1

2/3

Required

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Use Requests for Additional Information "R" type Category Codes only.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Information Request Code

This will be the LOINC® Code that further specifies the request for information.

Not Used

10-3

Entity Identifier Code

O 1

2/3

Required

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when additional LOINC® codes are needed to provide greater specificity. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

Use Requests for Additional Information "R" type Category Codes only.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Information Request Code

This will be the LOINC® Code that further specifies the request for information.

Not Used

11-3

Entity Identifier Code

O 1

2/3

Required

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

LOI

Logical Observation Identifier Names and Codes (LOINC) Codes

CODE SOURCE: 663: Logical Observation Identifier Names and Codes (LOINC)

Not Used

933

Free-form Message Text

O 1

1/264

Situational

1383

Claim Submission Reason Code

O 1

Code identifying reason for claim submission

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

INDUSTRY NAME: Service Line Predetermination of Benefits Code

CODE

DEFINITION

Pre-Determination

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

Predetermination of Dental Benefits

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

DTP✱472✱D8✱20220201~ ORDTP✱472✱RD8✱20220201-20220205~

DTP

✱

✱

Date Time
Format Qual

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

TOO - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

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

Loop: