277 Health Care Claim Acknowledgment (005010X214, 005010X214E1, 005010X214E2)

Loop 2000A - INFORMATION SOURCE LEVEL

Required

1005

Hierarchical Structure Code

M 1

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

CODE

DEFINITION

0085

Information Source, Information Receiver, Provider of Service, Patient

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Status

Required

127

Reference Identification

O 1

1/50

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.

The inventory file number of the transmission assigned by the Information Source's system. This number operates as a transaction (batch) control number.

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

CODE

DEFINITION

Receipt Acknowledgment Advice

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This entity is the decision maker in the business transaction. For this business use, this entity is the payer or clearinghouse receiving the ASC X12 837 transaction.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

HL01 must begin with the value "1" and increment 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 - INFORMATION SOURCE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - INFORMATION SOURCE NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱PR✱2✱ABC INSURANCE✱✱✱✱✱PI✱12345~ ORNM1✱AY✱2✱NATIONAL CLEARINGHOUSE✱✱✱✱✱46✱123456789012~ ORNM1✱AY✱2✱SINGLE BILLING SERVICE✱✱✱✱✱FI✱109876543~

NM1

✱

✱

Loop 2200A - TRANSMISSION RECEIPT CONTROL IDENTIFIER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Clearinghouse

Health care clearinghouse means a public or private entity that does either of the following:

(1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.
(2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity.

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: Information Source Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

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)

This number is used for entities identified in translation software typically called "Trading Partner Profiles". It is used for non-health plan entities.

Federal Taxpayer's Identification Number

Payor Identification

Centers for Medicare and Medicaid Services PlanID

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: Information Source 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 - TRANSMISSION RECEIPT CONTROL IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

TRN✱1✱20060831001~

TRN

✱

✱

✱

Loop 2200A - TRANSMISSION RECEIPT CONTROL IDENTIFIER

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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: Information Source Application Trace Identifier

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

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

DTP*050 - INFORMATION SOURCE RECEIPT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱050✱D8✱20060228~

DTP

✱

✱

Loop 2200A - TRANSMISSION RECEIPT CONTROL IDENTIFIER

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

050

Received

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Information Source Receipt Date

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

DTP*009 - INFORMATION SOURCE PROCESS DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

DTP✱009✱D8✱20060301~

DTP

✱

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

009

Process

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Information Source Process Date

HL - INFORMATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Information Receiver is the entity that expects the response from the Information Source. For this business use, this entity can be a provider, a provider group, a claims clearinghouse, a service bureau, an agency, an employer etc.

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

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.

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

Additional Subordinate HL Data Segment in This Hierarchical Structure.

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

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Information Receiver identified in the NM1 is always the electronic connection to the Information Source EDI environment. The Information Receiver has a trading partner profile set up at the Information Source's site and is generally the entity that submitted the claim transaction(s) for processing.
For situations where a person such as a single practitioner submits claim transactions to a payer, the entity identified in the Provider of Service Loop (HL03 = 19) will be the same entity identified here in the Information Receiver Loop (HL03 = 21). The difference may be that the trading partner profile set up in the EDI environment is a separate identification scheme from the identification number set up for the entity in the adjudication system.
In the situation where there is more than one clearinghouse involved in the transmission of the Health Care Claim Acknowledgement as part of the Trading Partner Agreement, this segment will be used to identify the clearinghouse that is passing the information. This segment will be changed to display the information for the next clearinghouse before they continue passing on the transmission. This process will continue until the transmission reaches the initiator of the claim/encounter.

TR3 Example:

NM1✱41✱2✱ST HOLY HILL HOSPITAL✱✱✱✱✱46✱39999000B~ ORNM1✱41✱1✱SMITH✱ROBERT✱J✱✱✱46✱188888000A~

NM1

✱

✱

Loop 2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

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: 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 is "1". 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 if additional name information is needed to identify the Information Receiver and the value in NM102 is "1". 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 Primary 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 - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

TRN✱2✱20060828001~

TRN

✱

✱

✱

Loop 2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Referenced Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

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 Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment will be used to convey information about an entire unit of work (e.g. single transaction of claims). Information contained at this level will be summary details pertaining to the unit of work being acknowledged. Examples include but are not limited to accepted for processing, trading partner not authorized to submit to the Information Source's system, etc.
See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

STC✱A1:19✱20060301✱WQ✱432.55~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types `A' for batch. For real time acknowledgements category types `A' and `E' may be used except for E0. Use of the category type `E' is limited to indicating the business application system is unavailable.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

SITUATIONAL RULE: Required when an entity must be identified to further clarify the 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

Employer

Receiver

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

Required

306

Action Code

O 1

1/2

Code indicating type of action

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

CODE

DEFINITION

Reject

Required when the entire claim transaction (ST-SE) is rejected due to submitter level errors. No subordinate HL information is reported.

Required when code value "U" is not used. At least one subordinate HL loop must be reported.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the amount of original submitted charges.

INDUSTRY NAME: Total Submitted Charges for Unit Work

This will be the sum of all CLM02 values (claim charge) for the claims being acknowledged. In most instances, this will be the sum of charges submitted from ST to SE of a single 837 transaction set.

In situations where the 837 transaction from the Information Receiver is separated (e.g. due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.

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 additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

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

Employer

Receiver

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 additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

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

Employer

Receiver

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

QTY*90 - TOTAL ACCEPTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The purpose of this segment is to report the total number of claims accepted by the Information Source.

TR3 Example:

QTY✱90✱102~

QTY

✱

✱

✱

Loop 2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Acknowledged Quantity

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Accepted Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

O 1

1/30

QTY*AA - TOTAL REJECTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The purpose of this segment is to report the total number of claims rejected for this Information Receiver (e.g. not accepted) by the Information Source.

TR3 Example:

QTY✱AA✱98~

QTY

✱

✱

✱

Loop 2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Unacknowledged Quantity

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Rejected Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

O 1

1/30

AMT*YU - TOTAL ACCEPTED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims accepted by the Information Source.

TR3 Example:

AMT✱YU✱5053.52~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

In Process

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Accepted Amount

Not Used

478

Credit/Debit Flag Code

O 1

AMT*YY - TOTAL REJECTED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims rejected for this Information Receiver (e.g. not accepted) by the Information Source.

TR3 Example:

AMT✱YY✱99.5~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Returned

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Rejected Amount

Not Used

478

Credit/Debit Flag Code

O 1

HL - BILLING PROVIDER OF SERVICE 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 - BILLING PROVIDER OF SERVICE LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

This loop and all subsequent loops are not used when the Information Receiver STC03 is equal to "U" (REJECT).

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

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.

Used for Provider level rejections only.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*85 - BILLING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100C - BILLING PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment contains information which can be found in the 837 Dental, Institutional, and Professional implementation guides at the 2010AA loop.

TR3 Example:

NM1✱85✱1✱SMITH✱JOHN✱C✱✱✱XX✱1546326780~

NM1

✱

✱

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

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: Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the value in NM102 is "1" and supplied on submitted claim. 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 the value in NM102 is "1" and supplied on submitted claim. 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 the value in NM102 is "1" and supplied on submitted claim. 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

Centers for Medicare and Medicaid Services National Provider Identifier

The "XX" qualifier is required only when the National Provider ID is mandated for use.

After the National Provider ID implementation period, enumerated providers use only the NM108 and NM109 data elements and discontinue the generation of the REF segment in Loop ID 2200C.

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

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Billing 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 INFORMATION TRACE IDENTIFIER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when 2200C Loop is used to provide the status of a specific provider's group of claims in the STC segment or a secondary provider identifier needs to be reported in the Provider Secondary REF segment. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

Because the TRN segment is syntactically required in order to use Loop 2200C, TRN02 can either be a sender assigned value or a default value of zero (0).

TR3 Example:

TRN✱1✱0~

TRN

✱

✱

✱

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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 - BILLING 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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to provide the status of a specific Billing Provider's group of claims. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

STC✱A1:19✱✱WQ✱432.55~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types `A' for batch. For real time acknowledgements category types `A' and `E' may be used except for E0. Use of the category type `E' is limited to indicating the business application system is unavailable.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Employer

Receiver

Submitter

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Clearinghouse

Payer

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Not Used

373

Date

O 1

Required

306

Action Code

O 1

1/2

Code indicating type of action

STC03 at this level is intended to convey the electronic claim status of the Billing Provider Claims. The terms "Accept" and "Reject" refer to the status of claims for the Billing Provider not the billing status.

CODE

DEFINITION

Reject

Use this code to indicate the provider's group of claims has been rejected. If any portion of the provider's group of claims is accepted then the code "WQ" - Accept must be used.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the amount of original submitted charges.

INDUSTRY NAME: Total Submitted Charges for Unit Work

Sum of the Billing Provider claims within the 837 transaction being acknowledged.
In situations where the 837 transaction from the Information Receiver is separated (e.g. due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.

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 additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Employer

Receiver

Submitter

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

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 additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Employer

Receiver

Submitter

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

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

REF - PROVIDER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when no billing/service provider identifier is sent in NM109 of this loop

OR

when an identification number in addition to that provided in NM109 of this loop is necessary for the processor to identify the entity.

If not required by this implementation guide, do not send.

TR3 Example:

REF✱G2✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

Provider Commercial Number

Location Number

Social Security Number

Federal Taxpayer's Identification 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: Billing Provider Additional Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

QTY*QA - TOTAL ACCEPTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

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

Loop:

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting status for a specific provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total number of claims (sum of CLM02) accepted to the adjudication process by the Information Source for the Billing Provider in this acknowledgment.

TR3 Example:

QTY✱QA✱5~

QTY

✱

✱

✱

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Quantity Approved

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Accepted Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

O 1

1/30

QTY*QC - TOTAL REJECTED QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting status for a specific provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total number of claims rejected by the Information Source for the Billing Provider.

TR3 Example:

QTY✱QC✱1~

QTY

✱

✱

✱

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Quantity Disapproved

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Total Rejected Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

O 1

1/30

AMT*YU - TOTAL ACCEPTED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting status for a specific provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) accepted by the Information Source for the Billing Provider in this acknowledgment.

TR3 Example:

AMT✱YU✱1000.5~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

In Process

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Accepted Amount

Not Used

478

Credit/Debit Flag Code

O 1

AMT*YY - TOTAL REJECTED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting status for a specific provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) rejected by the Information Source for the Billing Provider in this acknowledgment.

TR3 Example:

AMT✱YY✱52~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Returned

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Total Rejected Amount

Not Used

478

Credit/Debit Flag Code

O 1

HL - PATIENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop 2000D - PATIENT LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when reporting claim status at the patient level. If not required by this guide, do not send.

TR3 Notes:

This HL level contains information about the Patient identified in the 837 transaction. See Section 1.4.1.1 - Defining the Patient Participant for information on identifying the Patient data from the 837 Transaction.

TR3 Example:

HL✱4✱3✱PT~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

Patient

Not Used

736

Hierarchical Child Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100D - PATIENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when information was submitted on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when information was submitted on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

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

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 MI.

Member Identification Number

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Identification Number

This may be a unique identification number for the patient or it may be the subscriber's identification number. This data element is the value from the NM109 identifying the patient in the submitted claim.

When the payer does not use a unique member identification number for the patient, the subscriber identification number should be used.

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 segment is the patient control number submitted in the CLM01 of the 837.
This number must be returned exactly as submitted in the 837 up to the 20 character limit as defined in the 837 guide.

TR3 Example:

TRN✱2✱SMITHSON20060801~

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: Patient Control 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 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

STC✱A6:125:82✱20060830✱WQ✱432.65~ ORSTC✱A6:131:82✱20060830✱U✱65.32~STC✱A8:187✱20060830✱U✱70✱✱✱✱✱✱A8:453✱A8:454~

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types `A' for batch. For real time acknowledgements category types `A' and `E' may be used except for E0. Use of the category type `E' is limited to indicating the business application system is unavailable.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Provider

Home Health Care

Receiver

Submitter

Attending Physician

Operating Physician

Other Physician

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Subscriber

Insured or Subscriber

Independent Lab

MSC

Mammography Screening Center

Payer

PRP

Primary Payer

Purchase Service Provider

Patient

Responsible Party

SEP

Secondary Payer

Testing Laboratory

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

Required

306

Action Code

O 1

1/2

Code indicating type of action

INDUSTRY NAME: Status Information Action Code

CODE

DEFINITION

Reject

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the amount of original submitted charges.

INDUSTRY NAME: Total Claim Charge Amount

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

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 additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Provider

Home Health Care

Receiver

Submitter

Attending Physician

Operating Physician

Other Physician

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Subscriber

Insured or Subscriber

Independent Lab

MSC

Mammography Screening Center

Payer

PRP

Primary Payer

Purchase Service Provider

Patient

Responsible Party

SEP

Secondary Payer

Testing Laboratory

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

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 additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Provider

Home Health Care

Receiver

Submitter

Attending Physician

Operating Physician

Other Physician

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Subscriber

Insured or Subscriber

Independent Lab

MSC

Mammography Screening Center

Payer

PRP

Primary Payer

Purchase Service Provider

Patient

Responsible Party

SEP

Secondary Payer

Testing Laboratory

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

Situational

933

Free-form Message Text

O 1

1/264

Free-form message text

SEMANTIC: STC12 allows additional free-form status information.

SITUATIONAL RULE: Required when Health Care Claim Status Code 448 is used in STC01-2, STC10-2, or STC11-2. If not required by this implementation guide, do not send.

INDUSTRY NAME: Free Form Message Text

See Section 1.4.2.1 for more information on use of STC12 and Status Code `448'.

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 payer assigns a specific number to the claim for processing and the number is available at the time of this acknowledgment. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

REF✱1K✱012421017500~

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*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Claim Identifier Number for Clearinghouse and Other Transmission Intermediary was sent in the 837. If not required by this implementation guide, do not send.

TR3 Notes:

This number must be returned as received in the 837.

TR3 Example:

REF✱D9✱012421017501~

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

REF*BLT - INSTITUTIONAL BILL TYPE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Use this code only for an Institutional Claim.

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

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

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 respectively.

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - CLAIM LEVEL 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:

Required

Segment Repeat:

TR3 Notes:

For Institutional claims, it is the statement period in loop 2300 (DTP01 - 434). For Professional claims this information is derived from the earliest service level dates in loop 2400 (DTP01-472) to the latest service level date. For Dental claims it is the service date at the claim loop 2300 (DTP01=472).

TR3 Example:

DTP✱472✱RD8✱20180820-20180825~ ORDTP✱472✱D8✱20180823~

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 a service line is being rejected and caused the rejection of a claim. If not required by this implementation guide, do not send.

TR3 Notes:

Not used if the claim is being accepted into the adjudication system.
For Institutional claims, when both an NUBC revenue code and 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✱NU:0710✱15.61~ ORSVC✱HC:99213✱35~

SVC

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

Comp. Med.
Proced. ID

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

COMMENT: For Medicare Part A claims, SVC01 would be the 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.

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Procedure Code

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

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

CODE SOURCE 130: Healthcare Common Procedure 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 Uniform Billing Committee (NUBC) UB92 Codes

This is the NUBC 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 element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-2, then SVC04 is not used.
Value submitted on the original claim.

Situational

1-3

1339

Procedure Modifier

O 1

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

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

Situational

1-4

1339

Procedure Modifier

O 1

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

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

Situational

1-5

1339

Procedure Modifier

O 1

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

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

Situational

1-6

1339

Procedure Modifier

O 1

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

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

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

Zero is an acceptable amount.

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 to report a NUBC revenue code when a HCPCS or HIPPS code is reported in the 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

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

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

INDUSTRY NAME: Original Units of Service Count

STC - SERVICE LINE 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 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

TR3 Example:

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

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

For this business application acknowledgment, use of the Claim Status Category Code is limited to category types `A' for batch. For real time acknowledgements category types `A' and `E' may be used except for E0. Use of the category type `E' is limited to indicating the business application system is unavailable.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Provider

Home Health Care

Receiver

Submitter

Attending Physician

Operating Physician

Other Physician

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Subscriber

Insured or Subscriber

Independent Lab

MSC

Mammography Screening Center

Payer

PRP

Primary Payer

Purchase Service Provider

Patient

Responsible Party

SEP

Secondary Payer

Testing Laboratory

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Not Used

1-4

1270

Code List Qualifier Code

O 1

1/3

Not Used

373

Date

O 1

Required

306

Action Code

O 1

1/2

Code indicating type of action

CODE

DEFINITION

Reject

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 additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Provider

Home Health Care

Receiver

Submitter

Attending Physician

Operating Physician

Other Physician

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Subscriber

Insured or Subscriber

Independent Lab

MSC

Mammography Screening Center

Payer

PRP

Primary Payer

Purchase Service Provider

Patient

Responsible Party

SEP

Secondary Payer

Testing Laboratory

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

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 additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.
CODE SOURCE 507: Health Care Claim Status Category Code

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Code

This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
CODE SOURCE 508: Health Care Claim Status Code

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Provider

Home Health Care

Receiver

Submitter

Attending Physician

Operating Physician

Other Physician

Service Location

Rendering Provider

Billing Provider

Pay-to Provider

Ordering Physician

Referring Provider

Supervising Physician

Facility

Other Insured

Subscriber

Insured or Subscriber

Independent Lab

MSC

Mammography Screening Center

Payer

PRP

Primary Payer

Purchase Service Provider

Patient

Responsible Party

SEP

Secondary Payer

Testing Laboratory

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Not Used

11-4

1270

Code List Qualifier Code

O 1

1/3

Situational

933

Free-form Message Text

O 1

1/264

Free-form message text

SEMANTIC: STC12 allows additional free-form status information.

SITUATIONAL RULE: Required when Health Care Claim Status Code 448 is used in STC01-2, STC10-2, or STC11-2. If not required by this implementation guide, do not send.

INDUSTRY NAME: Free Form Message Text

See Section 1.4.2.1 for more information on use of STC12 and Status Code `448'.

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:

Required

Segment Repeat:

TR3 Notes:

This is the Line Item Control Number exactly as submitted in the 837 transaction for the original claim in Loop ID 2400, REF02 (REF01 = 6R). If a Line Item Control Number is not submitted, this will be the line sequence number Loop ID 2400 LX01.

TR3 Example:

REF✱FJ✱001~

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

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Pharmacy Prescription Number was sent in the 837 at the Service Line. If not required by this implementation guide, do not send.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code 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

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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Date of Service from the original submitted claim for a specific line item is present. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱RD8✱20180820-20180825~ ORDTP✱472✱D8✱20180823~

DTP

✱

✱