278 Health Care Services Review Notification and Acknowledgment (005010X216, 005010X216E1, 005010X216E2)

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)

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)

CODE SOURCE 121: Health Industry Number

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)

CODE SOURCE 121: Health Industry Number

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*HI - 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✱XX✱SENDER CODE✱RECEIVER CODE✱20071231✱0802✱1✱X✱005010X216~

✱

✱

Application
Send's Code

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 Services Review Information (278)

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

005010X216

Health Care Services Review Notification and Acknowledgment

ST*278 - 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 Notes:

Use this segment to indicate the start of a health care services review notification or information copy transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based notification or information copy.

TR3 Example:

ST✱278✱0001✱005010X216~

✱

✱

✱

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

278

Health Care Services Review Information

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. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.

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: Implementation Guide Version Name

This element must be populated with the guide identifier 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 (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

CODE

DEFINITION

005010X216

Health Care Services Review Notification and Acknowledgment

BHT*0007 - 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✱0007✱14✱199800114000001✱20050101✱1400~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

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

0007

Information Source, Information Receiver, Subscriber, Dependent, Event, Services

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Advance Notification

Use for administrative notification (provider to payer) of admissions, referrals, pre-certifications of future events. For example, use for notification of authorization to admit a patient, notification of authorization to refer a patient, notification of authorization for pre-certification of services.

Information Copy

Use for courtesy copy of notification. For example, use to send copies of health care service review decision outcomes from a delegated entity, PCP, or UMO to the service provider.

Completion Notification

Use CN for administrative notification (provider to payer) of admissions, referrals, pre-certifications associated with completed events. For example, use for Notice of Admission and Notice of Discharge.

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: Submitter Transaction Identifier

If the receiver returns a 278 acknowledgment response, this identifier must be returned in the 278 acknowledgment transaction's BHT03.

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

Situational

640

Transaction Type Code

O 1

Code specifying the type of transaction

SITUATIONAL RULE: Required when a 278 acknowledgment response to this notification is required. If not required by this implementation guide, do not send.

If BHT06 is not valued, the information receiver shall assume that a 278 acknowledgment response is not required or desired.

CODE

DEFINITION

Notice

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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 segment identifies the information source hierarchical level. For a notification transaction, this segment corresponds to the identification of the provider, payer, HMO, delegated entity, or other utilization management organization sending this information.

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.

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 Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The first occurrence of the NM1 loop is required and identifies the notification sender. In most cases, the sender is the same entity as the information source. The information source is the entity that determined the outcome of a health services review or the owner of the information.
The second NM1 loop may be used when the sender is not the same entity as the information source, or if there is a need to identify another requesting entity that was neither the sender or the information source.

TR3 Example:

NM1✱1P✱1✱GARDENER✱JAMES✱✱✱✱24✱000012345~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

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 name information is needed to identify the information source. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the information source is an individual (NM102 = 1), such as a primary care provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source 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 NM104 is present and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source 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

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

Use until the National PlanID is mandated if the UMO is a payer.

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI;
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI;
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it;

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

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: 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

REF - INFORMATION SOURCE SUPPLEMENTAL 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 prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the UMO to identify the provider;
OR
Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an identifier is necessary for the UMO to identify the entity.
If not required by this implementation guide, do not send.

TR3 Notes:

Use the NM1 segment for the primary identifier.

TR3 Example:

REF✱1G✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider UPIN Number

Facility ID Number

Employer's Identification Number

Not used if NM108 = 24.

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Not used if NM108 = 34.

Carrier Assigned Reference Number

Use if the sender or information source is a provider to indicate the identifier assigned to the provider by the receiver identified in Loop 2000B.

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: Information Source Supplemental Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - INFORMATION SOURCE ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when necessary to identify the information source by location. If not required, by this implementation guide, do not send.

TR3 Notes:

Used to identify a specific location when the information source has multiple locations and his authority varies based on location.

TR3 Example:

N3✱43 SUNRISE BLVD✱SUITE 234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Information Source Address Line

Use this element for the first line of the information source address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Information Source Address Line

N4 - INFORMATION SOURCE CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when necessary to identify the information source by location. If not required, by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Information Source City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Information Source State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

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

INDUSTRY NAME: Information Source Postal Zone or ZIP Code

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

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - INFORMATION SOURCE CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver must direct requests for follow up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

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 telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

TR3 Example:

PER✱IC✱WILBER✱TE✱8189991234✱FX✱8188769304~

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 the response must be directed to a particular contact and the name of the entity to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Name

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued to transmit a contact communication number. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Communication Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

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 the telephone extension or multiple communication numbers are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Communication Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

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 the telephone extension or multiple communication numbers are available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - INFORMATION SOURCE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop 2000B - INFORMATION RECEIVER LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information source is a provider and the provider's role in the care of the patient or the provider's specialty is needed to further identify the provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

PRV02 qualifies PRV03.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Required

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

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: P0203

INDUSTRY NAME: Provider Taxonomy Code

Provider Specialty Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - INFORMATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the health care services review notification 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

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 - 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 2010B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the receiver of information.

TR3 Example:

NM1✱X3✱2✱ABC PAYER✱✱✱✱✱46✱123450000~

NM1

✱

✱

Loop 2000C - SUBSCRIBER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Third-Party Administrator

Facility

Payer

Utilization Management Organization

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 name information is needed to identify the receiver. If not required by this implementation guide, may be provided at the 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 NM103 is present and NM102 = 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 when NM104 is present and the middle name/initial of the person 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

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is present and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver 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

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

Use until the National PlanID is mandated if the information receiver is a payer.

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.

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

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: Information Receiver 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 Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.

TR3 Example:

HL✱3✱2✱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

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

Additional Subordinate HL Data Segment in This Hierarchical Structure.

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 Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name and identification number of the subscriber (who may also be the patient).
The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02)
Refer to Section 1.11.2.1, Identifying the Subscriber/Patient.

TR3 Example:

NM1✱IL✱1✱SMITH✱JOE✱✱✱✱MI✱12345678901~

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

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the receiver to identify the Subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the receiver to identify the Subscriber. 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 name information is needed by the receiver to identify the Subscriber and the middle name/initial of the person 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 the suffix is needed to further identify the patient; e.g. Sr., Jr., or III. 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

Standard Unique Health Identifier for each Individual in the United States

Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms:
Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Primary Identifier

Subscriber Member Number

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

REF - SUBSCRIBER SUPPLEMENTAL 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 when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.

The primary identifier is the Member Identification Number in the NM1 segment.

TR3 Notes:

Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
If the information source values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

Group Number

Patient Account Number

Use this code only if the subscriber is the patient.

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

Health Insurance Claim (HIC) Number

Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there is also a need to pass the subscriber's HIC number. This might occur in a Medicare HMO situation.

Identity Card Number

Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

Social Security Number

Use this code only if the Social Security Number was not used by the payer as its primary method of identifying the subscriber. The social security number may not be used for Medicare.

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: Subscriber Supplemental Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N3✱PO Box 171021~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Use this element for the first line of the Subscriber mailing address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Subscriber Address Line

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Subscriber City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

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

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

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.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the patient or when gender information was used to render a medical decision. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19580322✱M~

DMG

✱

✱

✱

✱

✱

Comp Race
or Ethn Inf

O 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

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 gender (DMG03) was used to determine medical necessity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

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

INS*Y - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the subscriber's role in the military was used to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱AO~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

1/2

✱

584

Employment
Status Code

✱

✱

✱

Loop 2000D - DEPENDENT LEVEL

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

Relationship to Insured Code

CODE

DEFINITION

Self

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Required

584

Employment Status Code

O 1

Code showing the general employment status of an employee/claimant

Use to qualify the patient's relationship to the military.

CODE

DEFINITION

Active Military - Overseas

Active Military - USA

Deceased

Retired Military - USA

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Not Used

1470

Number

O 1

1/9

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:

This hierarchical loop is required when the patient is someone other than the subscriber and the patient does not have a unique (different from the subscriber) member ID. If not required by this implementation guide, do not send.

TR3 Notes:

If the patient has a unique member ID, use Loop 2000C to identify the patient.
Required segments in this loop are required only when this loop is used.

TR3 Example:

HL✱4✱3✱23✱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

Dependent

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*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 Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name of the dependent who is the patient.
The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02)

TR3 Example:

NM1✱QC✱1✱SMITH✱MARY~

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

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the Dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the Dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the Dependent and the middle name/initial of the dependent is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent 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 name information is needed by the UMO to identify the Dependent and the suffix of an individual's name; e.g. Sr., Jr., or III of the dependent is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent 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

REF - DEPENDENT SUPPLEMENTAL 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 when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.

TR3 Notes:

Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
If the information source values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

Social Security Number

The social security number may not be used for Medicare.

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: Dependent Supplemental Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - DEPENDENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N3✱PO Box 171021~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Dependent Address Line

Use this element for the first line of the Dependent address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Dependent Address Line

N4 - DEPENDENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Dependent City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Dependent State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Dependent Postal Zone or ZIP Code

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

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

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.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the patient or when gender information was used to render a medical decision. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19580322✱M~

DMG

✱

✱

✱

✱

✱

Comp Race
or Ethn Inf

O 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

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: Dependent Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when gender (DMG03) was used to determine medical necessity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Gender Code

CODE

DEFINITION

Female

Male

Unknown

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

INS*N - DEPENDENT RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when patient relationship to insured or birth sequence was used to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.

TR3 Notes:

This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name.

TR3 Example:

INS✱N✱19~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

1/2

✱

584

Employment
Status Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

Relationship to Insured Code

CODE

DEFINITION

Spouse

Child

Other Relationship

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Situational

1470

Number

O 1

1/9

A generic number

SEMANTIC: INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).

SITUATIONAL RULE: Required when the dependent is a child from a multiple birth. If not required by this implementation guide, do not send.

INDUSTRY NAME: Birth Sequence Number

HL - PATIENT EVENT 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:

Loop 2000E identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.
Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only.

TR3 Example:

HL✱5✱4✱EV✱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

Event

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.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN*1 - PATIENT EVENT TRACKING NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information source needs to assign a unique trace number at the patient event level. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This enables the requester to
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional patient information related to this patient event request.
If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
Each trace number provided in the TRN segment at this level on the request must be returned by the information receiver in the TRN segment at the corresponding level of the response.

TR3 Example:

TRN✱1✱2001042801✱9012345678✱CARDIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 notification transaction (the information source).

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 Event Trace Number

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid the information source and clearinghouses in identifying their TRN in the 278 acknowledgment.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.

Situational

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: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when a specific division or group of the company identified in the previous data element (TRN03) is needed by the requester to further identify a specific component of the entity. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

AAA - PATIENT EVENT REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a notification of a health care services review that was rejected due to invalid or missing patient event information. If not required by this implementation guide, do not send.

TR3 Notes:

Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request. If not required, may be provided at the sender's discretion.

TR3 Example:

AAA✱N✱✱15~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

SITUATIONAL RULE: Required when AAA01 = "N". If not required, may be provided at the sender's discretion.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.

Input Errors

Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid diagnosis codes and diagnosis dates.

Service Dates Not Within Provider Plan Enrollment

Use for Event Date(s).

Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.

Invalid/Missing Date(s) of Service

Use for invalid/missing event date.

Date of Birth Follows Date(s) of Service

Use for Date(s) of Event.

Date of Death Precedes Date(s) of Service

Use for Date(s) of Event.

Date of Service Not Within Allowable Inquiry Period

Use for Date of Event.

Invalid/Missing Diagnosis Code(s)

Invalid/Missing Onset of Current Condition or Illness Date

Invalid/Missing Accident Date

Invalid/Missing Last Menstrual Period Date

Invalid/Missing Expected Date of Birth

Invalid/Missing Admission Date

Invalid/Missing Discharge Date

Certification Information Missing

Use to indicate missing previous certification number information.

Not Used

889

Follow-up Action Code

O 1

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Required to identify the type of health care services in this notification.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

Certificate
Type Code

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Admission Review

Use this value to identify admission to a facility.

Health Services Review

Use this value to identify services related to an episode of care.

Specialty Care Review

Use this value to identify a referral to a specialty provider.

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

CODE

DEFINITION

Appeal - Immediate

Use this value to identify appeals of review decisions where the service required was emergency or urgent.

Appeal - Standard

Use this value to identify appeals of review decisions where the service required was not emergency or urgent.

Cancel

Extension

Use this value to identify an extension request to a prior approved service.

Notification

Initial

Reconsideration

Renewal

Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

Revised

Use this value to identify a revision of a certification for which services have not been rendered. For example, the information source may be identifying additional procedures or other procedures for the same patient event.

Situational

1365

Service Type Code

O 1

1/2

Code identifying the classification of service

SITUATIONAL RULE: Required when Loop 2000F is not valued. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Second Surgical Opinion

Third Surgical Opinion

Diagnostic Dental

Periodontics

Restorative

Use for restorative dental.

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Chiropractic

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Home Health Care

Home Health Visits

Hospice

Respite Care

Long Term Care

Medically Related Transportation

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Pharmacy

Podiatry

Psychiatric

Psychotherapy

Rehabilitation

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Experimental Drug Therapy

Burn Care

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Cardiac

Gastrointestinal

Endocrine

Neurology

Invasive Procedures

Physician Visit - Office: Sick

Physician Visit - Office: Well

Coronary Care

Case Management

Allergy

Intensive Care

Mental Health

Neonatal Intensive Care

Oncology

Physical Therapy

Pulmonary

Renal

Residential Psychiatric Treatment

Transitional Care

Transitional Nursery Care

Situational

C023

Health Care Service Location Information

O 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

X12 COMPOSITE SEMANTIC NOTES: C023-02 qualifies C023-01 and C023-03.

SITUATIONAL RULE: Required when UM04 is not valued at 2000F. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

Required

4-1

1331

Facility Code Value

M 1

1/2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-2.

Required

4-2

1332

Facility Code Qualifier

O 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE: 237: Place of Service Codes for Professional Claims

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Situational

1338

Level of Service Code

O 1

1/3

Code specifying the level of service rendered

SITUATIONAL RULE: Required when UM02=1 or if the patient event requires a level of service for care other than routine. If not required by this implementation guide, do not send.

CODE

DEFINITION

Emergency

Elective

Urgent

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review information applies to the event level. If not required by this implementation guide, do not send.

TR3 Notes:

The HCR segment at the 2000E event level contains information relevant to the original decision holder for the event. Certification Action, Review Identification, Review Decision Reason Code and Second Surgical Opinion Indicator data from the original decision maker is made available in the HCR segment to the information receiver.

TR3 Example:

HCR✱A1✱20020713~

HCR

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

Certification Action Code

CODE

DEFINITION

Certified in total

Certified - partial

Use to identify that the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

Not Certified

Pended

Modified

Cancelled

Contact Payer

No Action Required

Use only if certification is not required.

Situational

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: HCR02 is the number assigned by the information source to this review outcome.

SITUATIONAL RULE: Required when HCR01 = A1, A2 or A6. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review Identification Number

Situational

1271

Industry Code

O 5

1/30

Code indicating a code from a specific industry code list

SEMANTIC: HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886

SITUATIONAL RULE: Required when HCR01 = A3, or A4. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Review Decision Reason Code

The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.

SITUATIONAL RULE: Required when certification pertains to a surgical procedure and the contract under which the patient is covered has provisions regarding a second surgical opinion. If not required required by this implementation guide, do not send.

INDUSTRY NAME: Second Surgical Opinion Indicator

CODE

DEFINITION

Yes

REF*BB - PREVIOUS REVIEW AUTHORIZATION 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 certification number assigned by the UMO to the original event review outcome was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.

TR3 Notes:

This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.

TR3 Example:

REF✱BB✱123A~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Authorization 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: Previous Review Authorization Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - ADMINISTRATIVE REFERENCE 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 this notification is related to an acknowledgment received from the information receiver in a prior acknowledgment transaction. If not required by this implementation guide, do not send.

TR3 Notes:

This is the administrative number assigned by the Information receiver in an acknowledgment from a prior notification. This is not the trace number assigned by the Information receiver.

TR3 Example:

REF✱NT✱Y456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Administrator's Reference 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: Administrative Reference Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱439✱D8✱20051218~

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

439

Accident

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Accident Date

DTP*484 - LAST MENSTRUAL PERIOD DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the notification is pregnancy related. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱484✱D8✱20051218~

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

484

Last Menstrual Period

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: Last Menstrual Period Date

DTP*ABC - ESTIMATED DATE OF BIRTH

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the notification is related to the estimated date of delivery. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱ABC✱D8✱20050905~

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

ABC

Estimated Date of Birth

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: Estimated Birth Date

DTP*431 - ONSET OF CURRENT SYMPTOMS OR ILLNESS DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱431✱D8✱20051218~

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

431

Onset of Current Symptoms or Illness

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: Onset Date

DTP*AAH - EVENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.

TR3 Notes:

If UM01 = AR use Admit Date.
The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱AAH✱D8✱20050723~

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

AAH

Event

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: Proposed or Actual Event Date

DTP*435 - ADMISSION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱435✱D8✱20050723~

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

435

Admission

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

Use this for the range of dates when admission can occur. Use the HSD segment for the length of stay.

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: Proposed or Actual Admission Date

DTP*096 - DISCHARGE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱096✱D8✱20050724~

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

096

Discharge

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: Proposed or Actual Discharge Date

DTP*102 - CERTIFICATION ISSUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when certification issue date is different than the certification effective date. If not required by this implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱102✱D8✱20050701~

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

102

Issue

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: Certification Issue Date

DTP*036 - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the certification has an expiration date that indicates the date on which the certification will expire. If not required by the implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱036✱D8✱20050731~

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

036

Expiration

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: Certification Expiration Date

DTP*007 - CERTIFICATION EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the certification is limited by effective dates to indicate the date or date range when the certification is effective. If not required by the implementation guide, do not send.

TR3 Notes:

The total number of DPT segments in the 2000E Loop cannot exceed 9.

TR3 Example:

DTP✱007✱RD8✱20050701-20050731~

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

007

Effective

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: Certification Effective Date

HI - PATIENT DIAGNOSIS

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying the diagnosis code at the event level. If not required by this implementation guide, do not send.

TR3 Example:

HI✱BF:41090~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABJ

International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

1-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

O 1

1/30

Not Used

1-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABJ

International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

2-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

O 1

1/30

Not Used

2-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

3-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

O 1

1/30

Not Used

3-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

4-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

O 1

1/30

Not Used

4-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

5-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

O 1

1/30

Not Used

5-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

6-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

O 1

1/30

Not Used

6-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

7-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

O 1

1/30

Not Used

7-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

8-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

O 1

1/30

Not Used

8-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

9-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

9-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

9-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

9-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

9-5

782

Monetary Amount

O 1

1/18

Not Used

9-6

380

Quantity

O 1

1/15

Not Used

9-7

799

Version Identifier

O 1

1/30

Not Used

9-8

1271

Industry Code

O 1

1/30

Not Used

9-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

10-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

10-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

10-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

10-5

782

Monetary Amount

O 1

1/18

Not Used

10-6

380

Quantity

O 1

1/15

Not Used

10-7

799

Version Identifier

O 1

1/30

Not Used

10-8

1271

Industry Code

O 1

1/30

Not Used

10-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

11-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

11-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

11-5

782

Monetary Amount

O 1

1/18

Not Used

11-6

380

Quantity

O 1

1/15

Not Used

11-7

799

Version Identifier

O 1

1/30

Not Used

11-8

1271

Industry Code

O 1

1/30

Not Used

11-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.

Required

12-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Diagnosis Related Group (DRG)

CODE SOURCE: 229: Diagnosis Related Group Number (DRG)

International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

12-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Situational

12-3

1250

Date Time Period Format Qualifier

O 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

Situational

12-4

1251

Date Time Period

O 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the date diagnosed is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Date

Not Used

12-5

782

Monetary Amount

O 1

1/18

Not Used

12-6

380

Quantity

O 1

1/15

Not Used

12-7

799

Version Identifier

O 1

1/30

Not Used

12-8

1271

Industry Code

O 1

1/30

Not Used

12-9

1073

Yes/No Condition or Response Code

O 1

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.

TR3 Notes:

Report delivery patterns for specific services in the Service Level (Loop 2000F).
An explanation of the uses of this segment follows.

HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days".

Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days".

An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".

TR3 Example:

HSD✱VS✱1✱DA✱1✱7✱10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days".)
HSD✱VS✱1✱DA✱✱✱✱W~ (This indicates "1 visit per day whenever necessary".)

HSD

✱

✱

✱

✱

✱

Time Period
Qualifier

✱

✱

Ship/Del or
Calend Code

✱

Situational

673

Quantity Qualifier

O 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD02 is valued to qualify the type of service count for this patient event. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD01 is valued to indicate the service quantity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Service Quantity

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SITUATIONAL RULE: Required when HSD04 is valued to qualify the time frame in which the quantity of services (HSD02) will be rendered. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Months

Week

Situational

1167

Sample Selection Modulus

O 1

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

SITUATIONAL RULE: Required when patient events must be rendered within a specific timeframe. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

O 1

1/2

Code defining periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when patient events must be rendered within a specific timeframe. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Episode

Visit

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when patient events must be rendered within a specific timeframe. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when the patient event must be rendered within a specific calendar delivery pattern. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Sunday, Monday, Thursday, Friday, Saturday

Tuesday through Saturday

Sunday, Wednesday, Thursday, Friday, Saturday

Monday, Wednesday, Thursday, Friday, Saturday

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

1/3 Mon., 1/3 Wed., 1/3 Fri.

Whenever Necessary

Weekend

1/2 By Wed., Bal. By Fri.

None (Also Used to Cancel or Override a Previous Pattern)

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code which specifies the time for routine shipments or deliveries

SITUATIONAL RULE: Required when a specific time delivery pattern for the services in this patient event must be identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

None (Also Used to Cancel or Override a Previous Pattern)

CL1 - INSTITUTIONAL CLAIM CODE

X12 Name:

Claim Codes

X12 Purpose:

To supply information specific to hospital claims

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying certifications for admissions (UM01 = AR) to a facility. If not required by this implementation guide, do not send.

TR3 Example:

CL1✱3✱✱01~

CL1

✱

✱

Admission
Source Code

✱

✱

Nurse Home
Status Code

Situational

1315

Admission Type Code

O 1

Code indicating the priority of this admission

SITUATIONAL RULE: Required when admission type code information is used between the information sender and information receiver. If not required by this implementation guide, do not send.

CODE SOURCE 231: Priority (Type) of Admission or Visit

Situational

1314

Admission Source Code

O 1

Code indicating the source of this admission

SITUATIONAL RULE: Required when admission source code information is used between the information sender and information receiver. If not required by this implementation guide, do not send.

CODE SOURCE 230: Point of Origin for Admission or Visit

Situational

1352

Patient Status Code

O 1

1/2

Code indicating patient status as of the "statement covers through date"

SITUATIONAL RULE: Required when patient status code information is used between the information sender and information receiver. If not required by this implementation guide, do not send.

CODE SOURCE 239: Patient Status Code

Not Used

1345

Nursing Home Residential Status Code

O 1

CR1 - AMBULANCE TRANSPORT INFORMATION

X12 Name:

Ambulance Certification

X12 Purpose:

To supply information related to the ambulance service rendered to a patient

X12 Syntax:

P0102
If either CR101 or CR102 is present, then the other is required.
P0506
If either CR105 or CR106 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.

TR3 Notes:

When the CR1 segment is used, then Loop 2010EB is required.

TR3 Example:

CR1✱✱✱T✱✱DH✱28~

CR1

✱

✱

✱

✱

Ambulance
Reason Code

✱

✱

✱

✱

✱

✱

Not Used

355

Unit or Basis for Measurement Code

O 1

Not Used

Weight

O 1

1/10

Required

1316

Ambulance Transport Code

O 1

Code indicating the type of ambulance transport

CODE

DEFINITION

Initial Trip

Return Trip

Transfer Trip

Round Trip

Not Used

1317

Ambulance Transport Reason Code

O 1

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when distance of transportation is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

Miles

Kilometers

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR106 is the distance traveled during transport.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when distance of transportation is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Transport Distance

Not Used

166

Address Information

O 1

1/55

Not Used

166

Address Information

O 1

1/55

Not Used

352

Description

O 1

1/80

Not Used

352

Description

O 1

1/80

CR2 - SPINAL MANIPULATION SERVICE INFORMATION

X12 Name:

Chiropractic Certification

X12 Purpose:

To supply information related to the chiropractic service rendered to a patient

X12 Syntax:

P0102
If either CR201 or CR202 is present, then the other is required.
C0403
If CR204 is present, then CR203 is required.
P0506
If either CR205 or CR206 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.

TR3 Example:

CR2✱1✱5~

CR2

✱

✱

✱

Subluxation
Level Code

2/3

✱

1367

Subluxation
Level Code

✱

✱

✱

✱

✱

✱

✱

✱

Situational

609

Count

O 1

1/9

Occurrence counter

SEMANTIC: CR201 is the number this treatment is in the series.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.

INDUSTRY NAME: Treatment Series Number

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR202 is the total number of treatments in the series.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.

INDUSTRY NAME: Treatment Count

Situational

1367

Subluxation Level Code

O 1

2/3

Code identifying the specific level of subluxation

COMMENT: When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.

SEGMENT SYNTAX: C0403

SITUATIONAL RULE: Required when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Cervical 1

Cervical 2

Cervical 3

Cervical 4

Cervical 5

Cervical 6

Cervical 7

Coccyx

Ilium

Lumbar 1

Lumbar 2

Lumbar 3

Lumbar 4

Lumbar 5

Occiput

Sacrum

Thoracic 1

T10

Thoracic 10

T11

Thoracic 11

T12

Thoracic 12

Thoracic 2

Thoracic 3

Thoracic 4

Thoracic 5

Thoracic 6

Thoracic 7

Thoracic 8

Thoracic 9

Situational

1367

Subluxation Level Code

O 1

2/3

Code identifying the specific level of subluxation

SEGMENT SYNTAX: C0403

SITUATIONAL RULE: Required when the patient's condition or treatment involves subluxation to express the ending level of subluxation. If not required by this implementation guide, do not send.

CODE

DEFINITION

Cervical 1

Cervical 2

Cervical 3

Cervical 4

Cervical 5

Cervical 6

Cervical 7

Coccyx

Ilium

Lumbar 1

Lumbar 2

Lumbar 3

Lumbar 4

Lumbar 5

Occiput

Sacrum

Thoracic 1

T10

Thoracic 10

T11

Thoracic 11

T12

Thoracic 12

Thoracic 2

Thoracic 3

Thoracic 4

Thoracic 5

Thoracic 6

Thoracic 7

Thoracic 8

Thoracic 9

Not Used

355

Unit or Basis for Measurement Code

O 1

Not Used

380

Quantity

O 1

1/15

Not Used

380

Quantity

O 1

1/15

Not Used

1342

Nature of Condition Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

352

Description

O 1

1/80

Not Used

352

Description

O 1

1/80

Not Used

1073

Yes/No Condition or Response Code

O 1

CR5 - HOME OXYGEN THERAPY INFORMATION

X12 Name:

Oxygen Therapy Certification

X12 Purpose:

To supply information regarding certification of medical necessity for home oxygen therapy

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying initial, extended, or revised certification of home oxygen therapy. If not required by this implementation guide, do not send.

TR3 Notes:

Use the UM segment data element UM02 instead of CR501 to specify the Certification Type Code.
Use the HSD segment instead of CR502 to specify the treatment period.

TR3 Example:

CR5✱✱✱D✱✱✱1✱✱✱✱✱✱✱✱✱✱2✱A~

CR5

✱

1322

Certificate
Type Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Oxygen Test
Cond Code

✱

1350

Oxygen Test
Find Code

✱

1350

Oxygen Test
Find Code

✱

1350

Oxygen Test
Find Code

✱

✱

✱

Not Used

1322

Certification Type Code

O 1

Not Used

380

Quantity

O 1

1/15

Required

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

Situational

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

SITUATIONAL RULE: Required when CR503 is present and more than one type of equipment was identified to administer the oxygen therapy. If not required by this implementation guide, do not send.

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

Not Used

352

Description

O 1

1/80

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR506 is the oxygen flow rate in liters per minute.

INDUSTRY NAME: Oxygen Flow Rate

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR507 is the number of times per day the patient must use oxygen.

SITUATIONAL RULE: Required when daily oxygen use count is relevant to the type of home oxygen therapy identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Daily Oxygen Use Count

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR508 is the number of hours per period of oxygen use.

SITUATIONAL RULE: Required when daily oxygen use count is relevant to the type of home oxygen therapy identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Oxygen Use Period Hour Count

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR509 is the special orders for the respiratory therapist.

SITUATIONAL RULE: Required when necessary to convey special orders for the respiratory therapist. If not required by this implementation guide, do not send.

INDUSTRY NAME: Respiratory Therapist Order Text

Not Used

380

Quantity

O 1

1/15

Not Used

380

Quantity

O 1

1/15

Not Used

1349

Oxygen Test Condition Code

O 1

Not Used

1350

Oxygen Test Findings Code

O 1

Not Used

1350

Oxygen Test Findings Code

O 1

Not Used

1350

Oxygen Test Findings Code

O 1

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.

SITUATIONAL RULE: Required when either CR503, CR504 or CR518 = "D" (Liquid Portable) or "E" (Gaseous Portable). If not required by this implementation guide, do not send.

INDUSTRY NAME: Portable Oxygen System Flow Rate

Required

1382

Oxygen Delivery System Code

O 1

Code to indicate if a particular form of delivery was prescribed

CODE

DEFINITION

Nasal Cannula

Oxygen Conserving Device

Oxygen Conserving Device with Oxygen Pulse System

Oxygen Conserving Device with Reservoir System

Transtracheal Catheter

Situational

1348

Oxygen Equipment Type Code

O 1

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

SITUATIONAL RULE: Required when CR503 and CR504 are present and more than two types of equipment are required to administer the oxygen therapy. If not required by this implementation guide, do not send.

CODE

DEFINITION

Concentrator

Liquid Stationary

Gaseous Stationary

Liquid Portable

Gaseous Portable

Other

CR6 - HOME HEALTH CARE INFORMATION

X12 Name:

Home Health Care Certification

X12 Purpose:

To supply information related to the certification of a home health care patient

X12 Syntax:

P0304
If either CR603 or CR604 is present, then the other is required.
P091011
If either CR609, CR610 or CR611 are present, then the others are required.
P151617
If either CR615, CR616 or CR617 are present, then the others are required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.

TR3 Notes:

Requests for home health care must include a principal diagnosis (HI01 = BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.

TR3 Example:

CR6✱7✱19980601✱✱✱✱✱N✱I~

Required

923

Prognosis Code

M 1

Code indicating physician's prognosis for the patient

CODE

DEFINITION

Poor

Guarded

Fair

Good

Very Good

Excellent

Less than 6 Months to Live

Terminal

Required

373

Date

M 1

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

SEMANTIC: CR602 is the date covered home health services began.

INDUSTRY NAME: Home Health Start Date

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

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

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the event date has not been identified in DTP, Event Date in this loop and the duration of this plan of treatment is known. If not required by this implementation guide, do not send.

CODE

DEFINITION

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

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

SEMANTIC: CR604 is the certification period covered by this plan of treatment.

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Home Health Certification Period

Not Used

373

Date

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.

INDUSTRY NAME: Medicare Coverage Indicator

CODE

DEFINITION

Not Applicable

Required

1322

Certification Type Code

M 1

Code indicating the type of certification

This element must have the same value as UM02.

CODE

DEFINITION

Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

Appeal - Standard

Use this value for appeals of review decisions where the level of service is not emergency or urgent.

Cancel

Extension

Notification

Verification

This code is used to request the UMO to reconsider a previously denied referral or certification request.

Initial

Renewal

Revised

Not Used

373

Date

O 1

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

1137

Medical Code Value

O 1

1/15

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1384

Patient Location Code

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

Not Used

373

Date

O 1

PWK - ADDITIONAL PATIENT INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify missing teeth for dental services, or to identify additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.

TR3 Notes:

This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number inPWK06 would be referenced in the electronic attachment.
The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

TR3 Example:

PWK✱OB✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Expected outcomes of rehabilitative services.

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use for medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Information to support necessity of ambulance trip.

Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

Purchase Order Attachment

Use for purchase of medical or dental equipment.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

History and Physical

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Quality Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Therapy Notes

Death Notification

Photographs

Required

756

Report Transmission Code

O 1

1/2

Code defining timing, transmission method or format by which reports are to be sent

CODE

DEFINITION

By Mail

Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

E-Mail

By Fax

Voice

Use this for voicemail or phone communication.

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Situational

Identification Code Qualifier

O 1

1/2

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

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a code number.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Attachment Control Number

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Attachment Control Number

Situational

352

Description

O 1

1/80

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

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

SITUATIONAL RULE: Required when needed to report tooth number(s) of missing teeth or if needed to add any additional information about the attachment described in this segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Description

To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.

TR3 Notes:

Free form text or description fields are not recommended because they require human interpretation.
Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.

TR3 Example:

MSG✱This is a free-form text message~

MSG

✱

933

Free-Form
Message Txt

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

O 1

Not Used

1470

Number

O 1

1/9

NM1 - PATIENT EVENT 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued of if loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.

TR3 Notes:

If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱34✱987654321~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Attending Physician

Operating Physician

Other Physician

Service Location

AAJ

Admitting Services

Assistant Surgeon

Ordering Physician

Referring Provider

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service 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 identifying a specialty person, facility, group practice, or clinic and NM108/NM109 are not present. Not used if identifying a specialty entity. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when military title or rank was used to determine the appropriate benefit/level of care. If not required by this implementation, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Provider Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is present and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when identifying the services of a specific person, facility, group practice, or clinic and the provider ID is known by the information source. If not required by this implementation guide, do not send.

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Event 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

REF - PATIENT EVENT PROVIDER SUPPLEMENTAL 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 or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
If not required by this implementation guide, do not send.

TR3 Notes:

Use the NM1 segment for the primary identifier.

TR3 Example:

REF✱1G✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

Facility ID Number

Employer's Identification Number

Not used if NM108 = 24.

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

The social security number may not be used for Medicare. Not used if NM108 = 34.

Carrier Assigned Reference Number

Use when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010A has assigned its own identifier for this provider.

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 Event Provider Supplemental Identifier

Situational

352

Description

O 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

Not Used

C040

Reference Identifier

O 1

N3 - PATIENT EVENT PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

TR3 Example:

N3✱77 HOLLY BLVD~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Address Line

Use this element for the first line of the patient event provider's address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Event Provider Address Line

N4 - PATIENT EVENT PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Patient Event Provider City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Patient Event Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Patient Event Provider Postal Zone or ZIP Code

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

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - PATIENT EVENT PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

TR3 Example:

PER✱IC✱M TUCKER✱TE✱8189993456✱FX✱8185551212~

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 the Information Source needs to indicate a particular contact and the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Name

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued or when the Information Source needs to transmit a contact communication number. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued or when the Information Source needs to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Contact Communication Number

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 Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

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: Patient Event Provider 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 Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

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: Patient Event Provider Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

AAA - PATIENT EVENT PROVIDER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

TR3 Example:

AAA✱N✱✱43~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.

Input Errors

Use for input errors not covered by another reject reason code.

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Use for patient event dates.

Invalid Participant Identification

Use for invalid/missing service provider supplemental identifier.

Invalid or Missing Provider Address

Inappropriate Provider Role

Not Used

889

Follow-up Action Code

O 1

PRV - PATIENT EVENT PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop 2010EB - ADDITIONAL PATIENT INFORMATION CONTACT NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the notification is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.

TR3 Example:

PRV✱PE✱PXC✱203BS0133X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Use only when NM101 = AAJ.

Assistant Surgeon

Use only when NM101 = DD.

Attending

Use only when NM101 = 71.

Operating

Use only when NM101 = 72.

Ordering

Use only when NM101 = DK.

Other Physician

Use only when NM101 = 73.

Primary Care Physician

Use only when NM101 = P3.

Performing

Use only when NM101 = SJ.

Referring

Use only when NM101 = DN.

Required

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

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: P0203

INDUSTRY NAME: Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

NM1*L5 - ADDITIONAL PATIENT INFORMATION CONTACT 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when additional information is sent by an information contact that is different from the information source identified in loop 2010A. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱L5✱2✱ACME THIRD PARTY ADMINISTRATOR~

NM1

✱

✱

Loop 2010EB - ADDITIONAL PATIENT INFORMATION CONTACT NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Contact

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Use this name only if the destination is an individual, such as an individual primary care physician.

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 information source needs to identify the destination by name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the destination is an individual (NM102 = 1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is valued and the middle name/initial of the individual is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact 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 NM104 is valued and the suffix of the individual's name; e.g. Sr., Jr., or III., is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the information source needs to identify the destination. If not required by this implementation guide, do not send.

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

Use until the National PlanID is mandated if the destination is a payer.

Centers for Medicare and Medicaid Services PlanID

Use if the destination is a payer.

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

Use if the destination is a provider.

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM108 is used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact 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

N3 - ADDITIONAL PATIENT INFORMATION CONTACT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

TR3 Example:

N3✱43 SUNRISE BLVD✱SUITE 1000~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Response Contact Address Line

Use this element for the first line of the requester's address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Response Contact Address Line

N4 - ADDITIONAL PATIENT INFORMATION CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop 2010EB - ADDITIONAL PATIENT INFORMATION CONTACT NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Additional Patient Information Contact City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Additional Patient Information Contact State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Additional Patient Information Contact Postal Zone or ZIP Code

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

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - ADDITIONAL PATIENT INFORMATION 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 2010EB - ADDITIONAL PATIENT INFORMATION CONTACT NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request for additional patient information must be routed to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

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 telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
By definition of the standard, if PER03 is used, PER04 is required.

TR3 Example:

PER✱IC✱MARY✱FX✱3135551212~

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 the response must be directed to a particular contact and the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Name

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the Information Source needs to indicate a particular contact telephone number versus the PER02. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Response Contact Communication Number

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 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: Response 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 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: Response Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1 - PATIENT EVENT TRANSPORT INFORMATION

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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.

TR3 Notes:

At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop

TR3 Example:

NM1✱PW✱2✱PATIENT DIALYSIS CENT~NM1✱FS✱2~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Drop-off Location

Final Scheduled Destination

Next Destination

Pickup Address

Next Scheduled Destination

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

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 name of the location for which the patient is being transported is known. If not required by this implementation, do not send.

INDUSTRY NAME: Patient Event Provider Transport Location 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

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

N3 - PATIENT EVENT TRANSPORT LOCATION ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱77 HOLLY BLVD~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Transport Location Address Line

Use this element for the first line of the transport location address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Event Provider Transport Location Address Line

N4 - PATIENT EVENT TRANSPORT LOCATION CITY/STATE/ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱HOLLYWOOD✱CA✱90214~

✱

✱

✱

✱

✱

✱

✱

Situational

City Name

O 1

2/30

Free-form text for city name

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

SITUATIONAL RULE: Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

SITUATIONAL RULE: Required when N401 and N402 are not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Transport Location Postal Zone or ZIP Code

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

Not Used

Country Code

O 1

2/3

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Not Used

1715

Country Subdivision Code

O 1

1/3

AAA - PATIENT EVENT TRANSPORT INFORMATION REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

AAA✱N✱✱47✱C~

AAA

✱

Loop 2010ED - PATIENT EVENT OTHER UMO NAME

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the transport information.

Input Errors

Use for input errors not covered by another reject reason code.

Invalid/Missing Provider State

Use to code to indicate that the transport location state is invalid or missing.

Invalid or Missing Provider Address

Use this code to indicate that the transport location address is invalid or missing.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

NM1 - PATIENT EVENT OTHER UMO 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱CA✱2~

NM1

✱

✱

Loop 2010ED - PATIENT EVENT OTHER UMO NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Alternate Insurer

Use this code to indate that the other UMO is commerical insurance.

Carrier

Use this code to indicate that the other UMO is Medicare Part B.

Intermediary

Use this code to indicate that the other UMO is Medicare Part A.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

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 NM101 is equal to "00" to indicate the name of the other UMO. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other UMO 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

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

REF*ZZ - OTHER UMO DENIAL REASON

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 Example:

REF✱ZZ✱0M~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

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: Other UMO Denial Reason

Not Used

352

Description

O 1

1/80

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Required

4-2

127

Reference Identification

M 1

1/50

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

INDUSTRY NAME: Other UMO Denial Reason

Situational

4-3

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the other UMO denied the request for more than two reasons. If not required by this implementation guide, do not send.

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Situational

4-4

127

Reference Identification

O 1

1/50

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when the other UMO denied the request for more than two reasons. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other UMO Denial Reason

Situational

4-5

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

COMPOSITE SYNTAX: P0506

SITUATIONAL RULE: Required when the other UMO denied the request for more than three reasons. If not required by this implementation guide, do not send.

CODE

DEFINITION

Mutually Defined

Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

Situational

4-6

127

Reference Identification

O 1

1/50

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

COMPOSITE SYNTAX: P0506

SITUATIONAL RULE: Required when the other UMO denied the request for more than three reasons. If not required by this implementation guide, do not send.

DTP*598 - OTHER UMO DENIAL 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 2010ED - PATIENT EVENT OTHER UMO NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱598✱D8✱20050516~

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

598

Rejected

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: Other UMO Denial Date

HL - 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 Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when identifying specific services associated with this patient event. If not required by this implementation guide, do not send.

TR3 Notes:

This segment identifies the service(s) and conveys the review outcome related to that service(s).

TR3 Example:

HL✱6✱5✱SS✱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

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

Services

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.

TRN - SERVICE TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This enables the requester to
• uniquely identify this service line request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional service information related to this service line request.
If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.

TR3 Example:

TRN✱1✱111099✱9012345678✱RADIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 notification transaction (the information source).

Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.

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: Service Trace Number

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction. If TRN01 is "1", use this information to identify the UMO organization that assigned this trace number.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.

Situational

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: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when necessary to further identify a specific component, such as a specific division or group, of the company identified in the previous data element (TRN03). If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

AAA - SERVICE REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this is a notification of a health care services review that was rejected due to invalid or missing service information. If not required by this implementation guide, do not send.

TR3 Notes:

If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.

TR3 Example:

AAA✱N✱✱52~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.

Input Errors

Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid procedure codes and procedure dates.

Service Dates Not Within Provider Plan Enrollment

Invalid/Missing Date(s) of Service

Use for invalid/missing service, admission, surgery, or discharge dates.

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Invalid/Missing Procedure Code(s)

Certification Information Missing

Use to indicate missing previous certification number information.

Not Used

889

Follow-up Action Code

O 1

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

Certificate
Type Code

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Health Services Review

Use this value to identify services related to an episode of care.

Specialty Care Review

Use this value to identify a referral to a specialty provider.

Situational

1322

Certification Type Code

O 1

Code indicating the type of certification

SITUATIONAL RULE: Required when different from the UM02 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

Appeal - Standard

Use this value for appeals of review decisions where the level of service is not emergency or urgent.

Cancel

Extension

Use this value for an extension request to a prior approved service.

Notification

Initial

Renewal

Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

Revised

Use this value when revising the specifics of a notification for which services have not been rendered. For example, the Information Source may be identifying additional procedures or other procedures for the same patient event.

Situational

1365

Service Type Code

O 1

1/2

Code identifying the classification of service

SITUATIONAL RULE: Required when different from the UM03 value at the Patient Event level (Loop 2000E) or when the SV1, or SV2, or SV3 is not valued in this Service loop. If not required by this implementation guide, do not send.

Values at the Service Level override the values entered at the Patient Event Level for this service.

CODE

DEFINITION

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Second Surgical Opinion

Third Surgical Opinion

Diagnostic Dental

Periodontics

Restorative

Use for restorative dental services.

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Chiropractic

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Home Health Care

Home Health Visits

Hospice

Respite Care

Long Term Care

Medically Related Transportation

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Pharmacy

Podiatry

Psychiatric

Psychotherapy

Rehabilitation

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Experimental Drug Therapy

Burn Care

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Cardiac

Gastrointestinal

Endocrine

Neurology

Invasive Procedures

Physician Visit - Office: Sick

Physician Visit - Office: Well

Coronary Care

Allergy

Intensive Care

Mental Health

Neonatal Intensive Care

Oncology

Physical Therapy

Pulmonary

Renal

Residential Psychiatric Treatment

Transitional Care

Transitional Nursery Care

Situational

C023

Health Care Service Location Information

O 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

X12 COMPOSITE SEMANTIC NOTES: C023-02 qualifies C023-01 and C023-03.

SITUATIONAL RULE: Required when different from the UM04 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

Values at the Service Level override the values entered at the Patient Event Level for this service.

Required

4-1

1331

Facility Code Value

M 1

1/2

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-2.

Required

4-2

1332

Facility Code Qualifier

O 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE: 237: Place of Service Codes for Professional Claims

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the HCR segment is not used in 2000E, or if HCR01 in 2000E is A2. If not required by this implementation guide, do not send.

TR3 Notes:

If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.

TR3 Example:

HCR✱A1✱20020713~

HCR

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

Certification Action Code

CODE

DEFINITION

Certified in total

Not Certified

Pended

Modified

Cancelled

Contact Payer

No Action Required

Use only if certification is not required.

Situational

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: HCR02 is the number assigned by the information source to this review outcome.

SITUATIONAL RULE: Required when HCR01 = A1, or A6. If not required by this implementation guide, do not send.

INDUSTRY NAME: Review Identification Number

Situational

1271

Industry Code

O 5

1/30

Code indicating a code from a specific industry code list

SEMANTIC: HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886

SITUATIONAL RULE: Required when HCR01 = A3, or A4. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Review Decision Reason Code

The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Second Surgical Opinion Indicator

CODE

DEFINITION

Yes

REF*BB - PREVIOUS REVIEW AUTHORIZATION 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 different from the Previous Review Authorization Number specified at the Patient Event Level (2000E). If not required by this implementation guide, do not send.

TR3 Notes:

This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.

TR3 Example:

REF✱BB✱123A~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Authorization 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: Previous Review Authorization Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - ADMINISTRATIVE REFERENCE 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 different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

This is the administrative number assigned by the Information receiver for the original acknowledgment of the notification associated with this service review. This is not the trace number assigned by the requester.

TR3 Example:

REF✱NT✱Y789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Administrator's Reference 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: Administrative Reference Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment for the valid date(s) during which the service can be performed.

TR3 Example:

DTP✱472✱D8✱20050723~

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: Proposed or Actual Service Date

DTP*102 - CERTIFICATION ISSUE 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 Certification Issue Date is different from the Patient Event Certification Issue Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment for the date when the certification was issued.

TR3 Example:

DTP✱102✱D8✱20050701~

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

102

Issue

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: Certification Issue Date

DTP*036 - CERTIFICATION EXPIRATION 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 Certification Expiration Date is different from the Patient Event Certification Expiration Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱036✱D8✱20050731~

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

036

Expiration

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: Certification Expiration Date

DTP*007 - CERTIFICATION EFFECTIVE 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 different from the Certification Effective Date in Loop 2000E. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱007✱RD8✱20050701-20050731~

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

007

Effective

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: Certification Effective Date

SV1 - PROFESSIONAL SERVICE

X12 Name:

Professional Service

X12 Purpose:

To specify the service line item detail for a health care professional

X12 Syntax:

P0304
If either SV103 or SV104 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific Professional Service. If not required by this implementation guide, do not send.

TR3 Example:

SV1✱HC:99211:25✱12.25✱UN✱1✱✱✱1:2:3✱✱✱✱N~

SV1

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

✱

Comp. Diag.
Code Point.

✱

✱

✱

✱

✱

✱

✱

✱

✱

Healthcare
Short Code

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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: Product or Service ID Qualifier

CODE

DEFINITION

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

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.

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

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

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 the information source needs to convey additional clarification to miscellaneous, unspecified, or non descriptive procedures or modifiers. If not required by this implementation guide, do not send.

Use this data element for the first procedure code modifier.

Situational

1-4

1339

Procedure Modifier

O 1

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

Use this data element for the second procedure code modifier.

Situational

1-5

1339

Procedure Modifier

O 1

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

Use this data element for the third procedure code modifier.

Situational

1-6

1339

Procedure Modifier

O 1

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

Use this data element for the fourth procedure code modifier.

Situational

1-7

352

Description

O 1

1/80

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

INDUSTRY NAME: Procedure Code Description

Situational

1-8

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SITUATIONAL RULE: Required when the information source has not determined the intensity or complexity of the services and therefore identifies a range of procedures. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV101-2 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV102 is the submitted service line item amount.

SITUATIONAL RULE: Required when the Notification or Information Copy had monetary limitations for the service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when service units were not provided in the HSD segment and a specific number of services are being identified for this procedure. If not required by this implementation guide, do not send.

CODE

DEFINITION

International Unit

International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Minutes

Unit

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Service Unit Count

Not Used

1331

Facility Code Value

O 1

1/2

Not Used

1365

Service Type Code

O 1

1/2

Situational

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

X12 COMPOSITE SEMANTIC NOTES:

C004-01 identifies the primary diagnosis code for this service line.
C004-02 identifies the second diagnosis code for this service line.
C004-03 identifies the third diagnosis code for this service line.
C004-04 identifies the fourth diagnosis code for this service line.

SITUATIONAL RULE: Required when this procedure relates to a specific diagnosis reported in HI Loop 2000E to point to the specific diagnosis. If not required by this implementation guide, do not send.

If no diagnosis pointer is provided, then this procedure applies to all diagnoses.

Required

7-1

1328

Diagnosis Code Pointer

M 1

1/2

A pointer to the diagnosis code in the order of importance to this service

Situational

7-2

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when procedure is related to more than one diagnosis. If not required by this implementation guide, do not send.

Use this pointer for the second diagnosis code pointer.

Situational

7-3

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when procedure is related to more than two diagnosis. If not required by this implementation guide, do not send.

Use this pointer for the third diagnosis code pointer.

Situational

7-4

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when procedure is related to more than three diagnosis. If not required by this implementation guide, do not send.

Use this pointer for the fourth diagnosis code pointer.

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1340

Multiple Procedure Code

O 1

1/2

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.

SITUATIONAL RULE: Required when the review decision is based on EPSDT. If not required by this implementation guide, do not send.

INDUSTRY NAME: EPSDT Indicator

CODE

DEFINITION

Yes

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1364

Review Code

O 1

1/2

Not Used

1341

National or Local Assigned Review Value

O 1

1/2

Not Used

1327

Copay Status Code

O 1

Not Used

1334

Health Care Professional Shortage Area Code

O 1

Not Used

127

Reference Identification

O 1

1/50

Not Used

116

Postal Code

O 1

3/15

Not Used

782

Monetary Amount

O 1

1/18

Situational

1337

Level of Care Code

O 1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when needed to further clarify the level of care in which a patient resides. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

Not Used

1360

Provider Agreement Code

O 1

SV2 - INSTITUTIONAL SERVICE LINE

X12 Name:

Institutional Service

X12 Purpose:

To specify the service line item detail for a health care institution

X12 Syntax:

R0102
At least one of SV201 or SV202 is required.
P0405
If either SV204 or SV205 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific Institutional Service, or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

TR3 Example:

SV2✱300✱HC:80019✱73.42✱UN✱1~
SV2✱120✱✱1500✱DA✱5✱300~

SV2

✱

✱

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

✱

✱

1345

Nurse Home
Status Code

✱

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SEMANTIC: SV201 is the revenue code.

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required when the service review decision was determined using a revenue code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Revenue Code

See Code Source 132: National Uniform Billing Committee (NUBC) Codes.

Situational

C003

Composite Medical Procedure Identifier

O 1

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

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.

SITUATIONAL RULE: Required when identifying a specific procedure code. If not required by this implementation guide, do not send.

Required

2-1

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

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

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.

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

Advanced Billing Concepts (ABC) 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 Complimentary, Alternative, or Holistic Procedure 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 service reviews which are not covered under HIPAA.

CODE SOURCE: 843: Advanced Billing Concepts (ABC) Codes

Mutually Defined

Use this code when reporting ICD-10-PCS. This code can only be used if mandated by HIPAA or for services not covered under HIPAA.
CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System

Required

2-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

2-3

1339

Procedure Modifier

O 1

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

Use this data element for the first procedure code modifier.

Situational

2-4

1339

Procedure Modifier

O 1

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

Use this data element for the second procedure code modifier.

Situational

2-5

1339

Procedure Modifier

O 1

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

Use this data element for the third procedure code modifier.

Situational

2-6

1339

Procedure Modifier

O 1

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

Use this data element for the fourth procedure code modifier.

Situational

2-7

352

Description

O 1

1/80

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

INDUSTRY NAME: Procedure Code Description

Situational

2-8

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SITUATIONAL RULE: Required when the information source has not determined the intensity or complexity of the service to be performed and therefore identifies a range of procedures. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV202-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV203 is the submitted service line item amount.

SITUATIONAL RULE: Required when the Notification or Information Copy had monetary limitations for the service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

CODE

DEFINITION

Days

International Unit

International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Unit

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

INDUSTRY NAME: Service Unit Count

Situational

1371

Unit Rate

O 1

1/10

The rate per unit of associate revenue for hospital accommodation

SITUATIONAL RULE: Required when SV201 is used and the Notification or Information Copy had monetary limitations on the accommodation rate. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Rate

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

1345

Nursing Home Residential Status Code

O 1

Code specifying the status of a nursing home resident at the time of service

SITUATIONAL RULE: Required when identifying services for Long Term Care. If not required by this implementation guide, do not send.

CODE

DEFINITION

Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)

Newly Admitted

Newly Eligible

No Longer Eligible

Still a Resident

Temporary Absence - Hospital

Temporary Absence - Other

Transferred to Intermediate Care Facility - Level II (ICF II)

Situational

1337

Level of Care Code

O 1

Code specifying the level of care provided by a nursing home facility

SITUATIONAL RULE: Required when needed to further clarify the level of care being identified for admissions to a nursing facility, or for identification for a non-nursing facility and the level of care in which the patient resides is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nursing Home Level of Care

CODE

DEFINITION

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Intermediate Care Facility - Mentally Retarded (ICF-MR)

Chronic Disease Hospital (CD)

Intermediate Care Facility (ICF) Level II

Special Skilled Nursing Facility (SNF)

Nursing Facility (NF)

Hospice

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying a specific Dental Service. If not required by this implementation guide, do not send.

TR3 Example:

SV3✱AD:D2150✱80✱✱✱✱1~

SV3

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

Oral Cavity
Designat.

✱

1358

Prosthesis/
Inlay Code

✱

✱

✱

✱

✱

✱

C004

Comp. Diag.
Code Point.

Required

C003

Composite Medical Procedure Identifier

M 1

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

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: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

1-3

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
Use this data element for the first procedure code modifier.

Situational

1-4

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
Use this data element for the second procedure code modifier.

Situational

1-5

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
Use this data element for the third procedure code modifier.

Situational

1-6

1339

Procedure Modifier

O 1

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

A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
Use this data element for the fourth procedure code modifier.

Situational

1-7

352

Description

O 1

1/80

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

SITUATIONAL RULE: Required when the service information is for a "Not Otherwise Classified" (NOC) or "By Report" procedure code or to report the following information on this service line: Date of Initial Impression, Date of Initial Preparation Crown, Initial Preparation Crown Tooth Number, or InitialEndodontic Treatment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Situational

1-8

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SITUATIONAL RULE: Required when the information source has not determined the intensity or complexity of the service to be performed and therefore indicates a range of procedures. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV301-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV302 is the submitted service line item amount.

SITUATIONAL RULE: Required when the Notification or Information Copy had monetary limitations for the service. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Amount

Not Used

1331

Facility Code Value

O 1

1/2

Situational

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when necessary to report areas of the mouth that are being treated. If not required by this implementation guide, do not send.

Required

4-1

1361

Oral Cavity Designation Code

M 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

CODE SOURCE 135: American Dental Association

Situational

4-2

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

4-3

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

4-4

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

4-5

1361

Oral Cavity Designation Code

O 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

SITUATIONAL RULE: Required when needed to identify additional oral cavity designation codes. If not required by this implementation guide, do not send.

Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.

CODE SOURCE 135: American Dental Association

Situational

1358

Prosthesis, Crown or Inlay Code

O 1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when needed to indicate the placement status of the prosthetic. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

INDUSTRY NAME: Service Unit Count

Number of procedures.

Situational

352

Description

O 1

1/80

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

SEMANTIC: SV307 is the reason for replacement.

SITUATIONAL RULE: Required when necessary to describe to the reason for replacement. If not required by this implementation guide, do not send.

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

C004

Composite Diagnosis Code Pointer

O 1

TOO*JP - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when reporting tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a second tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-1.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a third tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-1.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a fourth tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-1.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when necessary to report a fifth tooth surface. If not required by this implementation guide, do not send.

Use code values from TOO03-1.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identifying services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

An explanation of the uses of this segment follows.

HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days".

Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days".

An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".

TR3 Example:

HSD✱VS✱1✱DA✱1✱7✱10~ (This indicates "1 visit every (per) 1 day (daily) for 10 days".)
HSD✱VS✱1✱DA✱✱✱✱W~ (This indicates "1 visit per day whenever necessary".)

HSD

✱

✱

✱

✱

✱

Time Period
Qualifier

✱

✱

Ship/Del or
Calend Code

✱

Situational

673

Quantity Qualifier

O 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when needed to indicate the type of service count quantified in HSD02. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when HSD01 is valued to indicate the service quantity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Service Quantity

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SITUATIONAL RULE: Required when needed to indicate the timeframe in which the quantity of services in HSD02 will be rendered. If not required by this implementation guide, do not send.

If HSD02 is not valued, do not use.

CODE

DEFINITION

Days

Months

Week

Situational

1167

Sample Selection Modulus

O 1

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

SITUATIONAL RULE: Required when needed to indicate sampling frequency for this service. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

O 1

1/2

Code defining periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when HSD06 is valued to qualify the time period in which the quantity of services (HSD02) will be continued. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Episode

Visit

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to indicate the number of time periods in HSD05 that are requested. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when needed to indicate the calendar delivery pattern for the services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Sunday, Monday, Thursday, Friday, Saturday

Tuesday through Saturday

Sunday, Wednesday, Thursday, Friday, Saturday

Monday, Wednesday, Thursday, Friday, Saturday

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

1/3 Mon., 1/3 Wed., 1/3 Fri.

Whenever Necessary

1/2 By Wed., Bal. By Fri.

None (Also Used to Cancel or Override a Previous Pattern)

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code which specifies the time for routine shipments or deliveries

SITUATIONAL RULE: Required when needed to indicate the time delivery pattern for the services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

None (Also Used to Cancel or Override a Previous Pattern)

PWK - ADDITIONAL SERVICE INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information source has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) in this Service loop, and the 278 Notification, or Information Copy (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.

TR3 Notes:

Additional information requested at the Service level should apply to a specific service and/or all the services requested in this service loop.
This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

TR3 Example:

PWK✱OB✱BM✱✱✱AC✱DMN0012~

PWK

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

755

Report Type Code

M 1

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

INDUSTRY NAME: Attachment Report Type Code

CODE

DEFINITION

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Expected outcomes of rehabilitative services.

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use for medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Information to support necessity of ambulance trip.

Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

Purchase Order Attachment

Use for purchase of medical or dental equipment.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

History and Physical

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Quality Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Therapy Notes

Death Notification

Photographs

Required

756

Report Transmission Code

O 1

1/2

Code defining timing, transmission method or format by which reports are to be sent

CODE

DEFINITION

Available on Request at Provider Site

This means that the paperwork is not being sent with the notification at this time. Instead, it is available to the Information Receiver upon request.

By Mail

Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

E-Mail

By Fax

Voice

Use this for voicemail or phone communication.

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Situational

Identification Code Qualifier

O 1

1/2

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

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a code number.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK06 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Attachment Control Number

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PWK02 equals BM, EL, EM or FX. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Attachment Control Number

The Information Source can use when PWK02 equals "AA" if the Inforamtion Source wants to send a document control number for an attachment remaining at the Provider's office.

Situational

352

Description

O 1

1/80

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

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

SITUATIONAL RULE: Required when needed to add any additional information about the attachment described in this segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Description

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

To provide a free-form format that allows the transmission of text information

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to transmit a message to the Information Receiver about the service. If not required by this implementation guide, do not send.

TR3 Notes:

Free form text or description fields are not recommended because they require human interpretation.
Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.

TR3 Example:

MSG✱This is a free-form text message~

MSG

✱

933

Free-Form
Message Txt

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

O 1

Not Used

1470

Number

O 1

1/9

NM1 - SERVICE PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when identifying a service provider, specialist, or specialty entity for this service and is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱34✱987654321~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Physician, Clinic or Group Practice

Operating Physician

Other Physician

Service Location

Assistant Surgeon

Ordering Physician

Supervising Physician

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service 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 identifying a specialty person, facility, group practice, or clinic and NM108/NM109 are not present. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Service Provider Last or Organization Name

Not Used if identifying a specialty entity.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Middle Name or Initial

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when military title or rank further identifies the provider. If not required by this implementation, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Service Provider Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the suffix is needed to further identify the Service Provider: e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when requesting the services of a specific person, facility, group practice, or clinic and the provider ID is known by the requester. If not required by this implementation guide, do not send.

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Service 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

REF - SERVICE PROVIDER SUPPLEMENTAL 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:

TR3 Notes:

Use the NM1 segment for the primary identifier.

TR3 Example:

REF✱1G✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

Facility ID Number

Employer's Identification Number

Not used if NM108 = 24.

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS. Not used if NM108 = 34.

Carrier Assigned Reference Number

Use for the provider ID as assigned by the UMO identified in Loop 2000A.

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: Service Provider Supplemental Identifier

Situational

352

Description

O 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

See code source 22: State and Outlying Areas of the US.

Not Used

C040

Reference Identifier

O 1

N3 - SERVICE PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.

TR3 Example:

N3✱77 HOLLY BLVD~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Service Provider Address Line

Use this element for the first line of the service provider's address.

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Service Provider Address Line

N4 - SERVICE PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Service Provider City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Service Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Service Provider Postal Zone or ZIP Code

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

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - SERVICE PROVIDER CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

TR3 Example:

PER✱IC✱M TUCKER✱TE✱8189993456✱FX✱8185551212~

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

INDUSTRY NAME: Service Provider Contact Name

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the Information Source needs to indicate a particular contact telephone number versus the PER02. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not valued or when the information source needs to transmit a contact communication number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Contact Communication Number

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 Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

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: Service Provider 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 Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Telephone

Uniform Resource Locator (URL)

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: Service Provider Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

AAA - SERVICE PROVIDER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

To specify the validity of the request and indicate follow-up action authorized

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

AAA✱N✱✱43~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Situational

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

SITUATIONAL RULE: Required when AAA01 = "N". If not required by this implementation guide, do not send.

CODE

DEFINITION

Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the service provider.

Input Errors

Use for input errors not covered by another reject reason code.

Out of Network

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Invalid Participant Identification

Invalid or Missing Provider Address

Not Used

889

Follow-up Action Code

O 1

PRV - SERVICE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop: