276/277 Health Care Claim Status Request and Response
(005010X212, 005010X212E1, 005010X212E2, 005010X212E3)

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

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

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

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

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

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

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

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

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

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

CODE

DEFINITION

Production Data

Test Data

Required

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*HR - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

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

X12 Comments:

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:

TR3 Example:

GS✱HI✱SENDER CODE✱RECEIVERCODE✱19991231✱0802✱1✱X✱005010X217~

✱

✱

Application
Send's Code

Loop 2000A - INFORMATION SOURCE LEVEL

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

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

CODE

DEFINITION

Health Care Claim Status Request (276)

Required

142

Application Sender's Code

M 1

2/15

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

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

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

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

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

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

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

SEMANTIC: GS05 is the group time.

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

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

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

Required

455

Responsible Agency Code

M 1

1/2

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

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

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

INDUSTRY NAME: Version, Release, or Industry Identifier Code

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

CODE SOURCE 881:Version / Release / Industry Identifier Code

CODE

DEFINITION

005010X212

Health Care Claim Status Request and Response

ST*276 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱276✱0001✱005010X212~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely 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

276

Health Care Claim Status Request

Required

329

Transaction Set Control Number

M 1

4/9

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

The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

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

INDUSTRY NAME: Version, Release, or Industry Identifier

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

CODE

DEFINITION

005010X212

Health Care Claim Status Request and Response

BHT*0010 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0010✱13✱ABC276XXX✱20050920✱1425~

BHT

✱

✱

✱

✱

✱

✱

Required

1005

Hierarchical Structure Code

M 1

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

CODE

DEFINITION

0010

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

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Request

Required

127

Reference Identification

O 1

1/50

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

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

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

Not Used

640

Transaction Type Code

O 1

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity is the payer who has the current status information for the specified claims.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

HL01 must begin with "1" within each ST/SE envelope 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 defining 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✱✱✱✱✱PI✱12345~

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

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

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Payer identification number established through trading partner agreement.

Centers for Medicare and Medicaid Services PlanID

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

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 2000B - INFORMATION RECEIVER LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity expects a response from the Information Source. See Section 1.4.1 Transaction Participants for more information on the Information Receiver.

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱41✱2✱XYZ SERVICE✱✱✱✱✱46✱A222222221~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the identifier in NM109 is not sufficient to identify the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Information Receiver Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 and the person has a middle name 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

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

O 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

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 2000C - SERVICE PROVIDER LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity delivered the health care service. See Section 1.4.1 Transaction Participants for more information on the Provider.

TR3 Example:

HL✱3✱2✱19✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Provider of Service

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*1P - PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100C - PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider). The provider identified facilitates identification of the claim within a payer's system.
During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop must be sent with the NPI reported in the NM109 and NM108=XX.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the identifier in NM109 is not sufficient to identify the Provider. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

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 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

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Service Provider Number

Centers for Medicare and Medicaid Services National Provider Identifier

Required value when the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes must be used.

CODE SOURCE 537: Centers for Medicare and Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Provider Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop 2000D - SUBSCRIBER LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

When the patient is the subscriber or a dependent with a unique identification number, the claim status request information is reflected in the 2200D Loop under the Subscriber HL, 2000D Loop (HL03 = 22). The Dependent HL, 2000E Loop is not used. See Section 1.4.1.1 for more information on defining the patient.
When requesting and responding to claim status for both a subscriber and a dependent of that subscriber, the Subscriber HL Loop 2000D must be followed by the subscriber's claim status data, Loop 2200D. In this instance, HL04=0 would be used. Then the Subscriber HL Loop 2000D must be repeated prior to the dependent HL Loop 2000E and their corresponding claim status data, Loop 2200E. In this instance, HL04=1 would be used. See Section 1.4.2.3 for an example of this structure.

TR3 Example:

HL✱4✱3✱22✱0~ or HL✱4✱3✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Required when there are no dependent claim status requests for this subscriber.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

Required when there are dependent claim status requests for this subscriber.

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop 2000D - SUBSCRIBER LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19330706✱M~

DMG

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

O 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

O 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Subscriber Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

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

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

O 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100D - SUBSCRIBER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱IL✱1✱SMITH✱ROBERT✱✱✱✱MI✱9876543210~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Use the value "2" in an employer-subscriber situation, such as Worker's Compensation.

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Subscriber Name Suffix

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

This code may be used in conjunction with a workers compensation claim.

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated for use. If not required, use one of the other values.

Member Identification Number

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*1 - CLAIM STATUS TRACKING NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

TRN✱1✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Current Transaction Trace Number

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Bill Type Identifier

Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*LU - APPLICATION OR LOCATION SYSTEM IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the application or location system identifier is known. If not required by this implementation guide, do not send.

TR3 Notes:

This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.

TR3 Example:

REF✱LU✱SYS5963~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Application or Location System Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6P - GROUP NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6P✱GRP123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Group Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Group Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EJ - PATIENT CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.

TR3 Notes:

The maximum number of characters supported for the Patient Control Number is '20'.

TR3 Example:

REF✱EJ✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱D9✱20041513010001~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

AMT*T3 - CLAIM SUBMITTED CHARGES

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.

TR3 Example:

AMT✱T3✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Total Submitted Charges

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Claim Charge Amount

Not Used

478

Credit/Debit Flag Code

O 1

DTP*472 - CLAIM 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 2210D - SERVICE LINE INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for institutional claims or for professional and dental claims when the service date (Loop 2210) is not used. 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 professional claims, this date is derived from the service level dates.

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Service Period

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.

TR3 Example:

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

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

COMMENT: For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural 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.

SVC01-2 will contain the procedure code of the adjudicated claim. If the adjudicated code is not known then SVC01-2 will contain the original submitted procedure code.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.

CODE SOURCE 130: Healthcare Common Procedural Coding System

Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

CODE SOURCE 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities

Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

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

Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the adjudicated or submitted procedure code reported in SVC01-2. 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 adjudicated or submitted procedure code reported in SVC01-2. 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 adjudicated or submitted procedure code reported in SVC01-2. 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 adjudicated or submitted procedure code reported in SVC01-2. 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

1/48

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This amount is the original submitted charge.

Not Used

782

Monetary Amount

O 1

1/18

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

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

SITUATIONAL RULE: Required on institutional claims when an NUBC revenue code needs to be reported in addition to a HCPCS or HIPPS code reported in SVC01-2. If not required by this implementation guide, do not send.

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

REF*FJ - SERVICE LINE ITEM 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 2210D - SERVICE LINE INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.

TR3 Example:

REF✱FJ✱6042201~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Line Item Control Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE LINE 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 2210D - SERVICE LINE INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop 2000E - DEPENDENT LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is a dependent who does not have a unique identification number. If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is the dependent, the claim status request information is reflected in the 2200E Loop under the Dependent HL, 2000E Loop (HL03 = 23). See Section 1.4.1.1 for more information on defining the patient.

TR3 Example:

HL✱5✱4✱23~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

Not Used

736

Hierarchical Child Code

O 1

DMG*D8 - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop 2000E - DEPENDENT LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DMG✱D8✱20010706✱M~

DMG

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

O 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

O 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Patient Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

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

INDUSTRY NAME: Patient Gender Code

CODE

DEFINITION

Female

Male

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

O 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

NM1*QC - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100E - DEPENDENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱QC✱1✱SMITH✱JOSEPH~

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Name Suffix

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*1 - CLAIM STATUS TRACKING NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

TRN✱1✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Current Transaction Trace Number

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

Not Used

352

Description

O 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:

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Bill Type Identifier

Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*LU - APPLICATION OR LOCATION SYSTEM 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 application or location system identifier is known. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

REF✱LU✱SYS5963~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Application or Location System Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6P - GROUP NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6P✱GRP123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Group Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Group Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EJ - PATIENT CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.

TR3 Notes:

The maximum number of characters supported for the Patient Control Number is `20'.

TR3 Example:

REF✱EJ✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER 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 Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.

TR3 Example:

REF✱D9✱20041513010001~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

AMT*T3 - CLAIM SUBMITTED CHARGES

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.

TR3 Notes:

Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.

TR3 Example:

AMT✱T3✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Total Submitted Charges

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Claim Charge Amount

Not Used

478

Credit/Debit Flag Code

O 1

DTP*472 - CLAIM 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 2210E - SERVICE LINE INFORMATION

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

For professional claims, this date is derived from the service level dates.

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Service Period

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

TR3 Example:

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

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

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.

SVC01-2 will contain the procedure code of the adjudicated claim. If the adjudicated code is not known then SVC01-2 will contain the original submitted procedure code.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.

CODE SOURCE 130: Healthcare Common Procedural Coding System

Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

CODE SOURCE 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

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

Advanced Billing Concepts (ABC) Codes

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the adjudicated or submitted procedure code reported in SVC01-2. 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 adjudicated or submitted procedure code reported in SVC01-2. 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 adjudicated or submitted procedure code reported in SVC01-2. 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 adjudicated or submitted procedure code reported in SVC01-2. 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

1/48

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This amount is the original submitted charge.

Not Used

782

Monetary Amount

O 1

1/18

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

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

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

REF*FJ - SERVICE LINE ITEM 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 2210E - SERVICE LINE INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.

TR3 Example:

REF✱FJ✱6042201~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Line Item Control Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE LINE 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 2210E - SERVICE LINE INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

SE - TRANSACTION SET TRAILER

X12 Name:

Transaction Set Trailer

X12 Purpose:

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

X12 Comments:

SE is the last segment of each transaction set.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SE✱34✱0001~

✱

✱

Required

Number of Included Segments

M 1

1/10

Total number of segments included in a transaction set including ST and SE segments

INDUSTRY NAME: Transaction Segment Count

Required

329

Transaction Set Control Number

M 1

4/9

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

Data value in SE02 must be identical to ST02.

GE - FUNCTIONAL GROUP TRAILER

X12 Name:

Functional Group Trailer

X12 Purpose:

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

X12 Comments:

The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GE✱1✱1~

✱

Number of
TS Included

✱

Required

Number of Transaction Sets Included

M 1

1/6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

IEA - INTERCHANGE CONTROL TRAILER

X12 Name:

Interchange Control Trailer

X12 Purpose:

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Example:

IEA✱1✱000000905~

IEA

✱

I16

Num of Incl
Funct Group

✱

Required

I16

Number of Included Functional Groups

M 1

1/5

A count of the number of functional groups included in an interchange

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

277 Response Transaction Set Listing

Usage

Repeats

ISA INTERCHANGE CONTROL HEADER

Required

1
GS*HN FUNCTIONAL GROUP HEADER

Required

1
ST*277 TRANSACTION SET HEADER

Required

1
BHT*0010 BEGINNING OF HIERARCHICAL TRANSACTION

Required

1
Loop 2000A - INFORMATION SOURCE LEVEL

Required

>1
- HL INFORMATION SOURCE LEVEL
  
  Required
  
  1
- Loop 2100A - PAYER NAME
  
  Required
  
  1
  - NM1*PR PAYER NAME
    
    Required
    
    1
  - PER*IC PAYER CONTACT INFORMATION
    
    Situational
    
    1
Loop 2000B - INFORMATION RECEIVER LEVEL

Required

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

Situational

>1
- HL SERVICE PROVIDER LEVEL
  
  Required
  
  1
- Loop 2100C - PROVIDER NAME
  
  Required
  
  2
  - NM1*1P PROVIDER NAME
    
    Required
    
    1
- Loop 2200C - PROVIDER OF SERVICE TRACE IDENTIFIER
  
  Situational
  
  1
  - TRN*1 PROVIDER OF SERVICE TRACE IDENTIFIER
    
    Required
    
    1
  - STC PROVIDER STATUS INFORMATION
    
    Required
    
    >1
Loop 2000D - SUBSCRIBER LEVEL

Situational

>1
- HL SUBSCRIBER LEVEL
  
  Required
  
  1
- Loop 2100D - SUBSCRIBER NAME
  
  Required
  
  1
  - NM1*IL SUBSCRIBER NAME
    
    Required
    
    1
- Loop 2200D - CLAIM STATUS TRACKING NUMBER
  
  Situational
  
  >1
  - TRN*2 CLAIM STATUS TRACKING NUMBER
    
    Required
    
    1
  - STC CLAIM LEVEL STATUS INFORMATION
    
    Required
    
    >1
  - REF*1K PAYER CLAIM CONTROL NUMBER
    
    Situational
    
    1
  - REF*BLT INSTITUTIONAL BILL TYPE IDENTIFICATION
    
    Situational
    
    1
  - REF*EJ PATIENT CONTROL NUMBER
    
    Situational
    
    1
  - REF*XZ PHARMACY PRESCRIPTION NUMBER
    
    Situational
    
    1
  - REF*VV VOUCHER IDENTIFIER
    
    Situational
    
    1
  - REF*D9 CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES
    
    Situational
    
    1
  - DTP*472 CLAIM SERVICE DATE
    
    Situational
    
    1
  - Loop 2220D - SERVICE LINE INFORMATION
    
    Situational
    
    >1
    - SVC SERVICE LINE INFORMATION
      
      Required
      
      1
    - STC SERVICE LINE STATUS INFORMATION
      
      Required
      
      >1
    - REF*FJ SERVICE LINE ITEM IDENTIFICATION
      
      Situational
      
      1
    - DTP*472 SERVICE LINE DATE
      
      Required
      
      1
Loop 2000E - DEPENDENT LEVEL

Situational

>1
- HL DEPENDENT LEVEL
  
  Required
  
  1
- Loop 2100E - DEPENDENT NAME
  
  Required
  
  1
  - NM1*QC DEPENDENT NAME
    
    Required
    
    1
- Loop 2200E - CLAIM STATUS TRACKING NUMBER
  
  Required
  
  >1
  - TRN*2 CLAIM STATUS TRACKING NUMBER
    
    Required
    
    1
  - STC CLAIM LEVEL STATUS INFORMATION
    
    Required
    
    >1
  - REF*1K PAYER CLAIM CONTROL NUMBER
    
    Situational
    
    1
  - REF*BLT INSTITUTIONAL BILL TYPE IDENTIFICATION
    
    Situational
    
    1
  - REF*EJ PATIENT CONTROL NUMBER
    
    Situational
    
    1
  - REF*XZ PHARMACY PRESCRIPTION NUMBER
    
    Situational
    
    1
  - REF*VV VOUCHER IDENTIFIER
    
    Situational
    
    1
  - REF*D9 CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES
    
    Situational
    
    1
  - DTP*472 CLAIM SERVICE DATE
    
    Situational
    
    1
  - Loop 2220E - SERVICE LINE INFORMATION
    
    Situational
    
    >1
    - SVC SERVICE LINE INFORMATION
      
      Required
      
      1
    - STC SERVICE LINE STATUS INFORMATION
      
      Required
      
      >1
    - REF*FJ SERVICE LINE ITEM IDENTIFICATION
      
      Situational
      
      1
    - DTP*472 SERVICE LINE DATE
      
      Required
      
      1
SE TRANSACTION SET TRAILER

Required

1
GE FUNCTIONAL GROUP TRAILER

Required

1
IEA INTERCHANGE CONTROL TRAILER

Required

1

ISA - INTERCHANGE CONTROL HEADER

X12 Name:

Interchange Control Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

ISA✱00✱..........✱01✱SECRET....✱ZZ✱SUBMITTERS.ID..✱ZZ✱RECEIVERS.ID...✱030101✱1253✱^✱00501✱000000905✱1✱T✱:~

ISA

✱

I01

Author Info
Qualifier

✱

✱

✱

✱

✱

Interchange
Sender ID

✱

✱

Interchange
Receiver ID

✱

✱

✱

✱

Inter Ctrl
Version Num

✱

✱

✱

✱

Component
Elem Sepera

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

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

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

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

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

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:

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱HI✱SENDER CODE✱RECEIVERCODE✱19991231✱0802✱1✱X✱005010X217~

✱

✱

Application
Send's Code

Loop 2000A - INFORMATION SOURCE LEVEL

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

CODE

DEFINITION

Health Care Information Status Notification (277)

Required

142

Application Sender's Code

M 1

2/15

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

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

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

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

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

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

SEMANTIC: GS05 is the group time.

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

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

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

Required

455

Responsible Agency Code

M 1

1/2

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

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

INDUSTRY NAME: Version, Release, or Industry Identifier Code

CODE SOURCE 881:Version / Release / Industry Identifier Code

CODE

DEFINITION

005010X212

Health Care Claim Status Request and Response

ST*277 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱277✱0001✱005010X212~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely identifying a Transaction Set

CODE

DEFINITION

277

Health Care Information Status Notification

Required

329

Transaction Set Control Number

M 1

4/9

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

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

INDUSTRY NAME: Version, Release, or Industry Identifier

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

CODE

DEFINITION

005010X212

Health Care Claim Status Request and Response

BHT*0010 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0010✱08✱277XXXX✱20050921✱0430✱DG~

BHT

✱

✱

✱

✱

✱

✱

Required

1005

Hierarchical Structure Code

M 1

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

CODE

DEFINITION

0010

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

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Status

Required

127

Reference Identification

O 1

1/50

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

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

INDUSTRY NAME: Originator Application Transaction Identifier

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

CODE

DEFINITION

Response

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity is the payer who has the current status information for the specified claims.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must begin with "1" within each ST/SE envelope 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱PR✱2✱ABC INSURANCE✱✱✱✱✱PI✱12345~

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

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

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Payer identification number established through trading partner agreement.

Centers for Medicare and Medicaid Services PlanID

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

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*IC - PAYER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. A telephone extension, when applicable is reported in the communication number immediately after the telephone number.

TR3 Example:

PER✱IC✱MEDICAL REVIEW DEPARTMENT✱TE✱3135551234✱EX✱6593✱FX✱3135554321~ORPER✱IC✱✱TE✱3135551234✱FX✱3135554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

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

INDUSTRY NAME: Payer Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer Contact Communication Number

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

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

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 2000B - INFORMATION RECEIVER LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity expects a response from the Information Source. See Section 1.4.1 Transaction Participants for more information on the Information Receiver.

TR3 Example:

HL✱2✱1✱21✱1~ or HL✱2✱1✱21✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Required when rejecting the status request for errors at the Information Source or Information Receiver levels.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

Required when reporting status responses at the lower hierarchial levels (i.e. Provider, Subscriber or Dependent).

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

NM1✱41✱2✱XYZ SERVICE✱✱✱✱✱46✱A222222221~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

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 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

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

O 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

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*2 - INFORMATION RECEIVER TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop 2200B - INFORMATION RECEIVER TRACE IDENTIFIER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when rejecting claim status requests for errors at Information Source or Information Receiver levels. If not required by this implementation guide, do not send.

TR3 Notes:

If reporting error status at this level, 2000C, 2000D and 2000E Loops are not used.

TR3 Example:

TRN✱2✱ABC276XXX~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Claim Transaction Batch Number

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

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

STC - INFORMATION RECEIVER STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop 2200B - INFORMATION RECEIVER TRACE IDENTIFIER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱E0:24:41✱20050830~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

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

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

SITUATIONAL RULE: Required when an entity must be identified to further clarify the code message in STC01-2. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Submitter

Clearinghouse

Payer

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a second status is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

SITUATIONAL RULE: Required when an entity must be identified to further clarify the code message in STC10-2. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

See STC01-3 for valid values.

CODE

DEFINITION

Submitter

Clearinghouse

Payer

Not Used

10-4

1270

Code List Qualifier Code

O 1

1/3

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a third status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

SITUATIONAL RULE: Required when an entity must be identified to further clarify the code message in STC11-2. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

See STC01-3 for valid values.

CODE

DEFINITION

Submitter

Clearinghouse

Payer

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

Not Used

933

Free-form Message Text

O 1

1/264

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 2000C - SERVICE PROVIDER LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when status was not reported at the Information Receiver level. If not required by this implementation guide, do not send.

TR3 Notes:

This entity delivered the health care service. See Section 1.4.1 Transaction Participants for more information on the Provider.

TR3 Example:

HL✱3✱2✱19✱0~ or 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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining 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

No Subordinate HL Segment in This Hierarchical Structure.

Required when rejecting the claim status requests for errors at the provider level. The 2000D and 2000E hierarchical levels (children) associated with this provider are not used.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

Required when reporting status responses at lower hierarchical levels (Subscriber or Dependent).

NM1*1P - PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100C - PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop must be sent with the NPI reported in the NM109 and NM108=XX.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

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 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

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Service Provider Number

Centers for Medicare and Medicaid Services National Provider Identifier

Required value when the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes must be used.

CODE SOURCE 537: Centers for Medicare and Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Provider Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*1 - PROVIDER OF SERVICE TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop 2200C - PROVIDER OF SERVICE TRACE IDENTIFIER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when rejecting the claim status request(s) for errors at the provider level. If not required by this implementation guide, do not send.

TR3 Notes:

If reporting error status at this level, the 2000D and 2000E Loops related to this provider are not used.
The TRN Segment is syntactically required in order to use the Loop 2200C STC. TRN02 can be either a default value of zero (0) or any value the Information Source chooses to assign.

TR3 Example:

TRN✱1✱0~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Provider of Service Information Trace Identifier

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

STC - PROVIDER 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 2200C - PROVIDER OF SERVICE TRACE IDENTIFIER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱E0:24:85✱20050830~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

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

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Provider

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a second status is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid value.

CODE

DEFINITION

Provider

Not Used

10-4

1270

Code List Qualifier Code

O 1

1/3

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a third status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid value.

CODE

DEFINITION

Provider

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

Not Used

933

Free-form Message Text

O 1

1/264

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop 2000D - SUBSCRIBER LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is the subscriber or a dependent with a unique identification number and status was not reported at the Provider level. If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is the subscriber or a dependent with a unique identification number, the claim status response information is reflected in the 2200D Loop under the Subscriber HL, 2000D Loop (HL03 = 22). The Dependent HL, 2000E Loop is not used. See Section 1.4.1.1 for more information on defining the patient.
When requesting and responding to claim status for both a subscriber and a dependent of that subscriber, the Subscriber HL Loop 2000D must be followed by the subscriber's claim status data, Loop 2200D. In this instance, HL04=0 would be used. Then the Subscriber HL Loop 2000D must be repeated prior to the dependent HL Loop 2000E and their corresponding claim status data, Loop 2200E. In this instance, HL04=1 would be used. See Section 1.4.2.3 for an example of this structure.

TR3 Example:

HL✱4✱3✱22✱0~ or HL✱4✱3✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Required when there are no dependent claim status responses for this subscriber.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

Required when there are dependent claim status responses for this subscriber.

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100D - SUBSCRIBER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱IL✱1✱SMITH✱ROBERT✱✱✱✱MI✱9876543210~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Use the value "2" in an employer-subscriber situation, such as Worker's Compensation.

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Subscriber Name Suffix

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

This code may be used in conjunction with a workers compensation claim.

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated for use. If not required, use one of the other values.

Member Identification Number

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*2 - CLAIM STATUS TRACKING NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

TRN✱2✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Referenced Transaction Trace Number

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱A1:21✱20050501✱✱50✱0~ or STC✱F1:65✱20050511✱✱50✱40✱20050510✱✱20050510✱50321~ or STC✱F2:79::RX✱20050501✱✱50✱0~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject/Payment Code in STC01-2 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the amount of original submitted charges.

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

INDUSTRY NAME: Total Claim Charge Amount

The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC05 is the amount paid.

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

INDUSTRY NAME: Claim Payment Amount

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

Situational

373

Date

O 1

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

SEMANTIC: STC06 is the paid date.

INDUSTRY NAME: Adjudication Finalized Date

This is the date of denial or approval for the claim. This date may or may not be the same as the issue date of the check, EFT or non-payment remittance (STC08).
Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.

Not Used

591

Payment Method Code

O 1

Situational

373

Date

O 1

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

SEMANTIC: STC08 is the check issue date.

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

INDUSTRY NAME: Remittance Date

This is the check issue or EFT funds available date.
This could include a non-payment remittance advice date if available from the Information Source's system.

Situational

429

Check Number

O 1

1/16

Check identification number

INDUSTRY NAME: Remittance Trace Number

This is the check or EFT Trace Number.
This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a second claim status is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject/Payment Code in STC10-2 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a third claim status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SITUATIONAL RULE: Required when using a National Council for Prescription Drug Programs Reject/Payment Code in STC11-2 for status related to a pharmacy claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Bill Type Identifier

Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EJ - PATIENT CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Notes:

The maximum number of characters supported for the Patient Control Number is `20'.

TR3 Example:

REF✱EJ✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*VV - VOUCHER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱VV✱V123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Voucher

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Voucher Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱D9✱20041513010001~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - CLAIM 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 for institutional claims or for professional and dental claims when the service line date is not used. 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 professional claims, this date is derived from the service level dates.
When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Service Period

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 reporting status for Service Lines. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

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

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

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.

SVC01-2 contains the adjudicated procedure code. This code may be different than the original submitted procedure code based on the payer's claim processing.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.

CODE SOURCE 130: Healthcare Common Procedural Coding System

Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

CODE SOURCE 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

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

Advanced Billing Concepts (ABC) Codes

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the adjudicated procedure code reported in SVC01-2. 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 adjudicated procedure code reported in SVC01-2. 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 adjudicated procedure code reported in SVC01-2. 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 adjudicated procedure code reported in SVC01-2. 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

1/48

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This is the line item total on the current claim service status.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC03 is the amount paid this service.

INDUSTRY NAME: Line Item Payment Amount

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

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

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

STC - SERVICE LINE STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱F1:65✱20050501~ orSTC✱A3:110✱20050501✱✱✱✱✱✱✱✱A3:400~ or STC✱F2:79::RX✱20050501~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

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 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a second claim status is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a third claim status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

REF*FJ - SERVICE LINE ITEM IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.

TR3 Example:

REF✱FJ✱6042201~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Line Item Control Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE LINE 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 2000E - DEPENDENT LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Line Date

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is a dependent who does not have a unique identification number. If not required by this implementation guide, do not send.

TR3 Notes:

When the patient is a dependent, the claim status response information is reflected in the 2200E Loop under the Dependent HL, 2000E Loop (HL03 = 23). See Section 1.4.1.1 for more information on defining the patient.

TR3 Example:

HL✱5✱4✱23~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. 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 defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

Not Used

736

Hierarchical Child Code

O 1

NM1*QC - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100E - DEPENDENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱QC✱1✱SMITH✱JOSEPH~

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Name Suffix

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*2 - CLAIM STATUS TRACKING NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

TRN✱2✱1722634842~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Referenced Transaction Trace Number

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱A1:21✱20050501✱✱50✱0~ or STC✱F1:65✱20050511✱✱50✱40✱20050510✱✱20050510✱50321~ or STC✱F2:79::RX✱20050501✱✱50✱0~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the amount of original submitted charges.

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

INDUSTRY NAME: Total Claim Charge Amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC05 is the amount paid.

INDUSTRY NAME: Claim Payment Amount

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

Situational

373

Date

O 1

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

SEMANTIC: STC06 is the paid date.

INDUSTRY NAME: Adjudication Finalized Date

This is the date of denial or approval for the claim. This date may or may not be the same as the issue date of the check, EFT or non-payment remittance (STC08).
Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.

Not Used

591

Payment Method Code

O 1

Situational

373

Date

O 1

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

SEMANTIC: STC08 is the check issue date.

INDUSTRY NAME: Remittance Date

This is the check issue or EFT funds available date.
This could include a non-payment remittance advice date if available from the Information Source's system.

Situational

429

Check Number

O 1

1/16

Check identification number

INDUSTRY NAME: Remittance Trace Number

This is the check or EFT Trace Number.
This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a second claim status is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a third claim status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

REF*1K - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

TR3 Example:

REF✱1K✱9918046987~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payor's Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Claim Control Number

Not Used

352

Description

O 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:

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Bill Type Identifier

Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
Code Source 236: Uniform Billing Claim Form Bill Type
Code Source 235: Claim Frequency Type Code

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EJ - PATIENT CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

The maximum number of characters supported for the Patient Control Number is `20'.

TR3 Example:

REF✱EJ✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*VV - VOUCHER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱VV✱V123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Voucher

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Voucher Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱D9✱20041513010001~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - CLAIM SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

For professional claims, this date is derived from the service level dates.
When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.

TR3 Example:

DTP✱472✱RD8✱20050401-20050402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Service Period

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 reporting status for Service Lines. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

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

SVC

✱

✱

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

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.

SVC01-2 contains the adjudicated procedure code. This code may be different than the original submitted procedure code based on the payer's claim processing.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.

CODE SOURCE 130: Healthcare Common Procedural Coding System

Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

CODE SOURCE 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

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

Advanced Billing Concepts (ABC) Codes

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the adjudicated procedure code reported in SVC01-2. 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 adjudicated procedure code reported in SVC01-2. 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 adjudicated procedure code reported in SVC01-2. 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 adjudicated procedure code reported in SVC01-2. 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

1/48

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

This is the line item total on the current claim service status.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC03 is the amount paid this service.

INDUSTRY NAME: Line Item Payment Amount

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

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

INDUSTRY NAME: Revenue Code

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

STC - SERVICE LINE STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

TR3 Example:

STC✱F1:65✱20050501~ orSTC✱A3:110✱20050501✱✱✱✱✱✱✱✱A3:400~ or STC✱F2:79::RX✱20050501~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

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 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a second claim status is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
C043-02 is used to identify the status of an entire claim or a serviceline. 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 a third claim status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

REF*FJ - SERVICE LINE ITEM IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.

TR3 Example:

REF✱FJ✱6042201~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Line Item Control Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE LINE 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: