837 Health Care Claim: Professional (005010X222, 005010X222E1, 005010X222A1, 005010X222A2)

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

This element is fixed in length with identical minimum and maximum lengths. Spaces are inserted to meet the minimum length in an AN data element. With the associated code 00 in ISA01 or ISA03, an all space value indicates no information.

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

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

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

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

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

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

Required

I05

Interchange ID Qualifier

M 1

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

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

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

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

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

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

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

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

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

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

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

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

GS*HC - 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✱RECEIVERCODE✱19991231✱0802✱1✱X✱005010X222A2~

✱

✱

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 Claim (837)

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

005010X222A2

Health Care Claim: Professional

ST*837 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱837✱987654✱005010X222A2~

✱

✱

✱

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

837

Health Care Claim

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 Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.

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 (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.

CODE

DEFINITION

005010X222A2

Health Care Claim: Professional

BHT*0019 - 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 Notes:

The second example denotes the case where the entire transaction set contains ENCOUNTERS.

TR3 Example:

BHT✱0019✱00✱0123✱20040618✱0932✱CH~
BHT✱0019✱00✱44445✱20040213✱0345✱RP~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 1000A - SUBMITTER NAME

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

0019

Information Source, Subscriber, Dependent

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.

CODE

DEFINITION

Original

Original transmissions are transmissions which have never been sent to the receiver.

Reissue

If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent.

Required

127

Reference Identification

O 1

1/50

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

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

INDUSTRY NAME: Originator Application Transaction Identifier

The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
This field is limited to 30 characters.

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

This is the date that the original submitter created the claim file from their business application system.

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

This is the time that the original submitter created the claim file from their business application system.

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

INDUSTRY NAME: Claim or Encounter Identifier

CODE

DEFINITION

Subrogation Demand

The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.

Chargeable

Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.

Reporting

Use RP when the entire ST-SE envelope contains only capitated encounters.
Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes.

NM1*41 - SUBMITTER 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.

X12 Set Notes:

NOTE: Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The submitter is the entity responsible for the creation and formatting of this transaction.

TR3 Example:

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

NM1

✱

✱

Loop 1000A - SUBMITTER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Submitter Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Submitter Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*IC - SUBMITTER EDI 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:

Required

Segment Repeat:

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 1000B - RECEIVER NAME

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 contact name is different than the name contained in the Submitter Name (NM1) segment of this loopANDit is the first iteration of the Submitter EDI Contact Information (PER) segment.If not required by this implementation guide, do not send.

INDUSTRY NAME: Submitter Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. 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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. 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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*40 - 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.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱40✱2✱XYZ RECEIVER✱✱✱✱✱46✱111222333~

NM1

✱

✱

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Receiver

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Receiver Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Receiver Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - BILLING PROVIDER HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

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

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code 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.

PRV*BI - BILLING PROVIDER SPECIALTY 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 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer's adjudication is known to be impacted by the provider taxonomy code.
If not required by this implementation guide, do not send.

TR3 Example:

PRV✱BI✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Billing

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

CUR*85 - FOREIGN CURRENCY INFORMATION

X12 Name:

Currency

X12 Purpose:

To specify the currency (dollars, pounds, francs, etc.) used in a transaction

X12 Syntax:

C0807
If CUR08 is present, then CUR07 is required.
C0907
If CUR09 is present, then CUR07 is required.
L101112
If CUR10 is present, then at least one of CUR11 or CUR12 are required.
C1110
If CUR11 is present, then CUR10 is required.
C1210
If CUR12 is present, then CUR10 is required.
L131415
If CUR13 is present, then at least one of CUR14 or CUR15 are required.
C1413
If CUR14 is present, then CUR13 is required.
C1513
If CUR15 is present, then CUR13 is required.
L161718
If CUR16 is present, then at least one of CUR17 or CUR18 are required.
C1716
If CUR17 is present, then CUR16 is required.
C1816
If CUR18 is present, then CUR16 is required.
L192021
If CUR19 is present, then at least one of CUR20 or CUR21 are required.
C2019
If CUR20 is present, then CUR19 is required.
C2119
If CUR21 is present, then CUR19 is required.

X12 Comments:

See Figures Appendix for examples detailing the use of the CUR segment.

Loop:

Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.

TR3 Notes:

It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.

TR3 Example:

CUR✱85✱CAD~

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

100

Currency Code

M 1

Code (Standard ISO) for country in whose currency the charges are specified

The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.

CODE SOURCE 5:Countries, Currencies and Funds

Not Used

280

Exchange Rate

O 1

4/10

Not Used

Entity Identifier Code

O 1

2/3

Not Used

100

Currency Code

O 1

Not Used

669

Currency Market/Exchange Code

O 1

Not Used

374

Date/Time Qualifier

O 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

Not Used

374

Date/Time Qualifier

O 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

Not Used

374

Date/Time Qualifier

O 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

Not Used

374

Date/Time Qualifier

O 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

Not Used

374

Date/Time Qualifier

O 1

Not Used

373

Date

O 1

Not Used

337

Time

O 1

4/8

NM1*85 - BILLING PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.

TR3 Example:

NM1✱85✱2✱ABC Group Practice✱✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Billing Provider Last or Organizational Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing 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 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.ORRequired 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.ORRequired 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

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Billing Provider Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - BILLING PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Billing Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Billing Provider Address Line

N4 - BILLING 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:

Required

Segment Usage:

Required

Segment Repeat:

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: Billing 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: Billing 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)

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: Billing Provider Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

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

REF - BILLING PROVIDER TAX 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:

Required

Segment Repeat:

TR3 Notes:

This is the tax identification number (TIN) of the entity to be paid for the submitted services.

TR3 Example:

REF✱EI✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Tax Identification Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - BILLING PROVIDER UPIN/LICENSE INFORMATION

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 a UPIN and/or license number is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.

TR3 Notes:

Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification.

TR3 Example:

REF✱0B✱654321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

INDUSTRY NAME: Identification Code Qualifier

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider License and/or UPIN Information

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

PER*IC - BILLING 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:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. 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 must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2010AB - PAY-TO ADDRESS NAME

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 in the first iteration of the Billing Provider Contact Information segment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Billing Provider Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. 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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. 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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*87 - PAY-TO ADDRESS 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.

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.

TR3 Example:

NM1✱87✱2~

NM1

✱

✱

Loop 2010AB - PAY-TO ADDRESS NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Pay-to Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - PAY-TO ADDRESS - 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✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Pay-To Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Pay-To Address Line

N4 - PAY-TO ADDRESS 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 2010AB - PAY-TO ADDRESS NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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: Pay-to Address 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: Pay-to Address 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: Pay-to Address 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

NM1*PE - PAY-TO PLAN 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.

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when willing trading partners agree to use this implementation for their subrogation payment requests.

TR3 Notes:

This loop may only be used when BHT06 = 31.

TR3 Example:

NM1✱PE✱2✱ANY STATE MEDICAID✱✱✱✱✱PI✱12345~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payee

PE is used to indicate the subrogated payee.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Pay-To Plan Organizational Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR
2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.

CODE

DEFINITION

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Pay-To Plan Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - PAY-TO PLAN 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✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Pay-To Plan Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Pay-To Plan Address Line

N4 - PAY-TO PLAN 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✱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: Pay-To Plan 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: Pay-To Plan 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: Pay-To Plan 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

REF - PAY-TO PLAN SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

Claim Office Number

National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE 245: National Association of Insurance Commissioners (NAIC) Code

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: Pay-to Plan Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EI - PAY-TO PLAN TAX IDENTIFICATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱EI✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Employer's Identification Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Pay-To Plan Tax Identification Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

HL - SUBSCRIBER HIERARCHICAL 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:

If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used.
If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are required.

TR3 Example:

HL✱2✱1✱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

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

Required

734

Hierarchical Parent ID Number

O 1

1/12

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

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

Required

735

Hierarchical Level Code

M 1

1/2

Code 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.

The claim (Loop ID-2300) can be used when HL04 has no subordinate levels (HL04 = 0) or when HL04 has subordinate levels indicated (HL04 = 1).
In the first case (HL04 = 0), the subscriber is the patient and there are no dependent claims.
The second case (HL04 = 1) happens when claims for one or more dependents of the subscriber are being sent under the same billing provider HL (for example, a spouse and son are both treated by the same provider). In that case, the subscriber HL04 = 1 because there is at least one dependent to this subscriber. The dependent HL (spouse) would then be sent followed by the Loop ID-2300 for the spouse. The next HL would be the dependent HL for the son followed by the Loop ID-2300 for the son.
In order to send claims for the subscriber and one or more dependents, the Subscriber HL, with Relationship Code SBR02=18 (Self), would be followed by the Subscriber's Loop ID-2300 for the Subscriber's claims. Then the Subscriber HL would be repeated, followed by one or more Patient HL loops for the dependents, with the proper Relationship Code in PAT01, each followed by their respective Loop ID-2300 for each dependent's claims.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SBR - SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

To record information specific to the primary insured and the insurance carrier for that insured

Loop:

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SBR✱P✱✱GRP01020102✱✱✱✱✱✱CI~

SBR

✱

1138

Payer Resp
Seq No Code

✱

✱

✱

✱

✱

✱

✱

584

Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.

CODE

DEFINITION

Payer Responsibility Four

Payer Responsibility Five

Payer Responsibility Six

Payer Responsibility Seven

Payer Responsibility Eight

Payer Responsibility Nine

Payer Responsibility Ten

Payer Responsibility Eleven

Primary

Secondary

Tertiary

Unknown

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

Situational

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

SITUATIONAL RULE: Required when the patient is the subscriber or is considered to be the subscriber. If not required by this implementation guide, do not send.

CODE

DEFINITION

Self

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: SBR03 is policy or group number.

SITUATIONAL RULE: Required when the subscriber's identification card for the destination payer (Loop ID-2010BB) shows a group number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Group or Policy Number

This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.

Situational

Name

O 1

1/60

Free-form name

SEMANTIC: SBR04 is plan name.

SITUATIONAL RULE: Required when SBR03 is not used and the group name is available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Group Name

Situational

1336

Insurance Type Code

O 1

1/3

Code identifying the type of insurance policy within a specific insurance program

SITUATIONAL RULE: Required when the destination payer (Loop ID-2010BB) is Medicare and Medicare is not the primary payer (SBR01 does not equal "P"). If not required by this implementation guide, do not send.

CODE

DEFINITION

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

Medicare Secondary Public Health Service (PHS)or Other Federal Agency

Medicare Secondary Black Lung

Medicare Secondary Veteran's Administration

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

Medicare Secondary, Other Liability Insurance is Primary

Not Used

1143

Coordination of Benefits Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Required

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

CODE

DEFINITION

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Blue Cross/Blue Shield

Champus

Commercial Insurance Co.

Disability

Federal Employees Program

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Other Federal Program

Use code OF when submitting Medicare Part D claims.

Title V

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Use Code ZZ when Type of Insurance is not known.

PAT - PATIENT INFORMATION

X12 Name:

Patient Information

X12 Purpose:

To supply patient information

X12 Syntax:

P0506
If either PAT05 or PAT06 is present, then the other is required.
P0708
If either PAT07 or PAT08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send.

TR3 Example:

PAT✱✱✱✱✱D8✱19970314~PAT✱✱✱✱✱✱✱01✱146~

PAT

✱

✱

✱

✱

✱

✱

✱

✱

✱

Not Used

1069

Individual Relationship Code

O 1

Not Used

1384

Patient Location Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

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: P0506

SITUATIONAL RULE: Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format 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: PAT06 is the date of death.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Death Date

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: P0708

SITUATIONAL RULE: Required when claims involve Medicare Durable Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or DME MAC 10.03.If not required by this implementation guide, do not send.

CODE

DEFINITION

Actual Pounds

Situational

Weight

O 1

1/10

Numeric value of weight

SEMANTIC: PAT08 is the patient's weight.

SEGMENT SYNTAX: P0708

INDUSTRY NAME: Patient Weight

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant.

SITUATIONAL RULE: Required when mandated by law. The determination of pregnancy shall be completed in compliance with applicable law. The "Y" code indicates that the patient is pregnant. If PAT09 is not used, it means that the patient is not pregnant or that the pregnancy indicator is not mandated by law.If not required by this implementation guide, do not send.

INDUSTRY NAME: Pregnancy Indicator

For this implementation, the listed value takes precedence over the semantic note.

CODE

DEFINITION

Yes

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.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.

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 NM102 = 1 (person). If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM102 = 1 (person). If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when there is a second address line. 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:

Required when the patient is the subscriber or considered to be the subscriber. 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: 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 the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

✱

✱

✱

✱

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

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

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

REF*SY - SUBSCRIBER SECONDARY 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 an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

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

REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.

TR3 Notes:

This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.
This segment is not a HIPAA requirement as of this writing.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

PER*IC - PROPERTY AND CASUALTY SUBSCRIBER 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 for Property and Casualty claims when this information is deemed necessary by the submitter. 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 must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~

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 Subscriber contact is a person other than the person identified in the Subscriber Name NM1 (Loop ID-2000BA). If not required by this implementation guide, do not send.

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the destination payer.
For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Payer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - PAYER 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 payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Payer Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Payer Address Line

N4 - PAYER 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: Payer 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: Payer 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: Payer 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

REF - PAYER SECONDARY 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 an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

TR3 Example:

REF✱FY✱435261708~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

Employer's Identification Number

Claim Office Number

National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE 245: National Association of Insurance Commissioners (NAIC) Code

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - BILLING PROVIDER SECONDARY 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 2000C - PATIENT HIERARCHICAL LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Billing Provider Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

HL - PATIENT HIERARCHICAL LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is a dependent of the subscriber identified in Loop ID-2000B and cannot be uniquely identified to the payer using the subscriber's identifier in the Subscriber Level. If not required by this implementation guide, do not send.

TR3 Notes:

There are no HLs subordinate to the Patient HL.
If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Identification Number, then the patient is considered the subscriber and is to be identified in the Subscriber Level.

TR3 Example:

HL✱3✱2✱23✱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

Dependent

The code DEPENDENT conveys that the information in this HL applies to the patient when the subscriber and the patient are not the same person.

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.

PAT - PATIENT INFORMATION

X12 Name:

Patient Information

X12 Purpose:

To supply patient information

X12 Syntax:

P0506
If either PAT05 or PAT06 is present, then the other is required.
P0708
If either PAT07 or PAT08 is present, then the other is required.

Loop:

Loop 2000C - PATIENT HIERARCHICAL LEVEL

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

PAT✱01~

PAT

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

Specifies the patient's relationship to the person insured.

CODE

DEFINITION

Spouse

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Not Used

1384

Patient Location Code

O 1

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

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: P0506

SITUATIONAL RULE: Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format 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: PAT06 is the date of death.

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Death Date

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: P0708

CODE

DEFINITION

Actual Pounds

Situational

Weight

O 1

1/10

Numeric value of weight

SEMANTIC: PAT08 is the patient's weight.

SEGMENT SYNTAX: P0708

INDUSTRY NAME: Patient Weight

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant.

INDUSTRY NAME: Pregnancy Indicator

For this implementation, the listed value takes precedence over the semantic note.

CODE

DEFINITION

Yes

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Patient Name Suffix

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - PATIENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Patient Address Line

N4 - PATIENT 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:

Required

Segment Repeat:

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 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 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: Patient 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 - PATIENT 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:

Required

Segment Repeat:

TR3 Example:

DMG✱D8✱19690815✱M~

DMG

✱

1250

✱

✱

✱

✱

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: Patient Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Patient 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

REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.

TR3 Notes:

This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.
This segment is not a HIPAA requirement as of this writing.

TR3 Example:

REF✱Y4✱4445555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Agency Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Property Casualty Claim Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - PROPERTY AND CASUALTY PATIENT IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Member Identification Number

This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim.

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

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: Property and Casualty Patient Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

PER*IC - PROPERTY AND CASUALTY PATIENT 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 for Property and Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID-2010BA and this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~

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 Patient contact is a person other than the person identified in the Patient Name NM1 (Loop ID-2010CA). If not required by this implementation guide, do not send.

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

Not Used

443

Contact Inquiry Reference

O 1

1/20

CLM - CLAIM INFORMATION

X12 Name:

Health Claim

X12 Purpose:

To specify basic data about the claim

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.

TR3 Example:

CLM✱A37YH556✱500✱✱✱11:B:1✱Y✱A✱Y✱I✱P~

CLM

✱

1028

Claim Submt
Identifier

✱

✱

✱

✱

Health Care
Serv Loc.

✱

1073

✱

✱

✱

✱

Patient Sig
Source Code

✱

✱

✱

✱

✱

✱

✱

✱

✱

1383

Claim Submt
Reason Code

✱

Required

1028

Claim Submitter's Identifier

M 1

1/38

Identifier used to track a claim from creation by the health care provider through payment

INDUSTRY NAME: Patient Control Number

The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CLM02 is the total amount of all submitted charges of service segments for this claim.

INDUSTRY NAME: Total Claim Charge Amount

The Total Claim Charge Amount must be greater than or equal to zero.
The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim.

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

Not Used

1343

Non-Institutional Claim Type Code

O 1

1/2

Required

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.

CLM05 applies to all service lines unless it is over written at the line level.

Required

5-1

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: Place of Service Code

Required

5-2

1332

Facility Code Qualifier

O 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Place of Service Codes for Professional or Dental Services

CODE SOURCE 237: Place of Service Codes for Professional Claims

Required

5-3

1325

Claim Frequency Type Code

O 1

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

INDUSTRY NAME: Claim Frequency Code

CODE SOURCE 235:Claim Frequency Type Code

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.

INDUSTRY NAME: Provider or Supplier Signature Indicator

CODE

DEFINITION

Yes

Required

1359

Provider Accept Assignment Code

O 1

Code indicating whether the provider accepts assignment

INDUSTRY NAME: Assignment or Plan Participation Code

Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.

CODE

DEFINITION

Assigned

Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

Assignment Accepted on Clinical Lab Services Only

Required when the provider accepts assignment for Clinical Lab Services only.

Not Assigned

Required when neither codes `A' nor `B' apply.

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.

INDUSTRY NAME: Benefits Assignment Certification Indicator

This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.

CODE

DEFINITION

Not Applicable

Use code `W' when the patient refuses to assign benefits.

Yes

Required

1363

Release of Information Code

O 1

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

The Release of Information response is limited to the information carried in this claim.

CODE

DEFINITION

Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

Situational

1351

Patient Signature Source Code

O 1

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

SITUATIONAL RULE: Required when a signature was executed on the patient's behalf under state or federal law. If not required by this implementation guide, do not send.

CODE

DEFINITION

Signature generated by provider because the patient was not physically present for services

Signature generated by an entity other than the patient according to State or Federal law.

Situational

C024

Related Causes Information

O 1

To identify one or more related causes and associated state or country information

X12 COMPOSITE COMMENTS: C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".

SITUATIONAL RULE: Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.

If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required.

Required

11-1

1362

Related-Causes Code

M 1

2/3

Code identifying an accompanying cause of an illness, injury or an accident

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Situational

11-2

1362

Related-Causes Code

O 1

2/3

Code identifying an accompanying cause of an illness, injury or an accident

SITUATIONAL RULE: Required when more than one related cause code applies. See CLM11-1 for valid values. If not required by this implementation guide, do not send.

INDUSTRY NAME: Related Causes Code

CODE

DEFINITION

Auto Accident

Employment

Other Accident

Not Used

11-3

1362

Related-Causes Code

O 1

2/3

Situational

11-4

156

State or Province Code

O 1

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

SITUATIONAL RULE: Required when CLM11-1 or CLM11-2 has a value of `AA' to identify the state, province or sub-country code in which the automobile accident occurred. If accident occurred in a country or location that does not have states, provinces or sub-country codes named in Code Source 22, do not use.If not required by this implementation guide, do not send.

INDUSTRY NAME: Auto Accident State or Province Code

CODE SOURCE 22:States and Provinces

Situational

11-5

Country Code

O 1

2/3

Code identifying the country

SITUATIONAL RULE: Required when CLM11-1 or CLM11-2 = AA and the accident occurred in a country other than US or Canada. If not required by this implementation guide, do not send.

CODE SOURCE 5:Countries, Currencies and Funds

Situational

1366

Special Program Code

O 1

2/3

Code indicating the Special Program under which the services rendered to the patient were performed

SITUATIONAL RULE: Required when the services were rendered under one of the following circumstances, programs, or projects. If not required by this implementation guide, do not send.

INDUSTRY NAME: Special Program Indicator

CODE

DEFINITION

Physically Handicapped Children's Program

This code is used for Medicaid claims only.

Special Federal Funding

This code is used for Medicaid claims only.

Disability

This code is used for Medicaid claims only.

Second Opinion or Surgery

This code is used for Medicaid claims only.

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1029

Claim Status Code

O 1

1/2

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1383

Claim Submission Reason Code

O 1

Situational

1514

Delay Reason Code

O 1

1/2

Code indicating the reason why a request was delayed

SITUATIONAL RULE: Required when the claim is submitted late (past contracted date of filing limitations). If not required by this implementation guide, do not send.

CODE

DEFINITION

Proof of Eligibility Unknown or Unavailable

Litigation

Authorization Delays

Delay in Certifying Provider

Delay in Supplying Billing Forms

Delay in Delivery of Custom-made Appliances

Third Party Processing Delay

Delay in Eligibility Determination

Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

Administration Delay in the Prior Approval Process

Other

Natural Disaster

DTP*431 - ONSET OF CURRENT ILLNESS OR SYMPTOM 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 for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send.

TR3 Notes:

This date is the onset of acute symptoms for the current illness or condition.

TR3 Example:

DTP✱431✱D8✱20050108~

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 of Current Illness or Injury Date

DTP*454 - INITIAL TREATMENT 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 Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send.

TR3 Notes:

Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

TR3 Example:

DTP✱454✱D8✱20050108~

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

454

Initial Treatment

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: Initial Treatment Date

DTP*304 - LAST SEEN 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 claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.

TR3 Notes:

This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.

TR3 Example:

DTP✱304✱D8✱20050108~

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

304

Latest Visit or Consultation

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 Seen Date

DTP*453 - ACUTE MANIFESTATION 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 Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱453✱D8✱20050108~

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

453

Acute Manifestation of a Chronic Condition

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: Acute Manifestation Date

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 CLM11-1 or CLM11-2 has a value of `AA' or `OA'.
OR
Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
If not required by this implementation guide, do not send.

TR3 Example:

DTP✱439✱D8✱20060108~

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, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱484✱D8✱20050108~

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*455 - LAST X-RAY 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 claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

DTP✱455✱D8✱20050108~

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

455

Last X-Ray

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 X-Ray Date

DTP*471 - HEARING AND VISION PRESCRIPTION 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 on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱471✱D8✱20050108~

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

471

Prescription

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: Prescription Date

DTP - DISABILITY DATES

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 on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work.
OR
Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor.
If not required by this implementation guide, do not send.

TR3 Example:

DTP✱360✱D8✱20050108~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Certification Expiration Date

CODE

DEFINITION

314

Disability

Use code 314 when both disability start and end date are being reported.

360

Initial Disability Period Start

Use code 360 if patient is currently disabled and disability end date is unknown.

361

Initial Disability Period End

Use code 361 if patient is no longer disabled and the start date is unknown.

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

Use code D8 when DTP01 is 360 or 361.

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use code RD8 when DTP01 is 314.

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: Level of Service Code

DTP*297 - LAST WORKED 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 on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.

TR3 Example:

DTP✱297✱D8✱20050108~

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

297

Initial Disability Period Last Day Worked

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 Worked Date

DTP*296 - AUTHORIZED RETURN TO WORK DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

DTP✱296✱D8✱20050108~

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

296

Initial Disability Period Return To Work

This is the date the provider has authorized the patient to return to work.

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: Work Return 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 on all ambulance claims when the patient was known to be admitted to the hospital.
OR
Required on all claims involving inpatient medical visits.
If not required by this implementation guide, do not send.

TR3 Example:

DTP✱435✱D8✱20030108~

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

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: Related Hospitalization 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 for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱096✱D8✱20050108~

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: Related Hospitalization Discharge Date

DTP - ASSUMED AND RELINQUISHED CARE DATES

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 to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send.

TR3 Notes:

Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates.

Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".

TR3 Example:

DTP✱090✱D8✱20050108~

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

090

Report Start

Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care.

091

Report End

Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider.

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: Assumed or Relinquished Care Date

DTP*444 - PROPERTY AND CASUALTY DATE OF FIRST CONTACT

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 for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send.

TR3 Notes:

This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.

TR3 Example:

DTP✱444✱D8✱20041013~

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

444

First Visit or Consultation

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

DTP*050 - REPRICER RECEIVED DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱050✱D8✱20051030~

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

050

Received

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Repricer Received Date

PWK - CLAIM SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.

TR3 Example:

PWK✱OZ✱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

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Admission Summary

Prescription

Physician Order

Referral Form

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Consent Form(s)

Certification

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

Health Certificate

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Models

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Support Data for Claim

Pathology Report

Patient Medical History Document

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

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

INDUSTRY NAME: Attachment Transmission Code

CODE

DEFINITION

Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

By Mail

Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

E-Mail

File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

By Fax

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 = "BM", "EL", "EM", "FX" or "FT". 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 = "BM", "EL", "EM", "FX" or "FT". If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Control Number

PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
For the purpose of this implementation, the maximum field length is 50.

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.

TR3 Notes:

The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.

TR3 Example:

CN1✱02✱550~

CN1

✱

✱

✱

✱

✱

✱

Required

1166

Contract Type Code

M 1

Code identifying a contract type

CODE

DEFINITION

Diagnosis Related Group (DRG)

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

SITUATIONAL RULE: Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Amount

Situational

332

Percent, Decimal Format

O 1

1/6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

SEMANTIC: CN103 is the allowance or charge percent.

SITUATIONAL RULE: Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Percentage

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: CN104 is the contract code.

SITUATIONAL RULE: Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Code

Situational

338

Terms Discount Percent

O 1

1/6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

SITUATIONAL RULE: Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Terms Discount Percentage

Situational

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.

SITUATIONAL RULE: Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Version Identifier

AMT*F5 - PATIENT AMOUNT PAID

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.

TR3 Notes:

Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).

TR3 Example:

AMT✱F5✱152.45~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Patient Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Patient Amount Paid

Not Used

478

Credit/Debit Flag Code

O 1

REF*4N - SERVICE AUTHORIZATION EXCEPTION CODE

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 mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.

TR3 Example:

REF✱4N✱1~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Special Payment 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: Service Authorization Exception Code

Allowable values for this element are:
1 Immediate/Urgent Care
2 Services Rendered in a Retroactive Period
3 Emergency Care
4 Client has Temporary Medicaid
5 Request from County for Second Opinion to Determine if Recipient Can Work
6 Request for Override Pending
7 Special Handling

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F5 - MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR

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 submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱F5✱N~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Medicare Version Code

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: Medicare Section 4081 Indicator

The allowed values for this element are:
Y 4081
N Regular crossover

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EW - MAMMOGRAPHY CERTIFICATION 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 mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EW✱T554~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Mammography Certification 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: Mammography Certification Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9F - REFERRAL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
AND
a referral is involved.
If not required by this implementation guide, do not send.

TR3 Notes:

Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral 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: Referral Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*G1 - PRIOR AUTHORIZATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an authorization number is assigned by the payer or UMO
AND
the services on this claim were preauthorized.
If not required by this implementation guide, do not send.

TR3 Notes:

Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.

TR3 Example:

REF✱G1✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior 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: Prior Authorization Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F8 - PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.

TR3 Example:

REF✱F8✱R555588~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Original 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: Payer Claim Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*X4 - CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) 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 for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send.

TR3 Notes:

If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.

TR3 Example:

REF✱X4✱12D4567890~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Clinical Laboratory Improvement Amendment 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: Clinical Laboratory Improvement Amendment Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9A - REPRICED CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.

TR3 Example:

REF✱9A✱RJ55555~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Repriced Claim 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: Repriced Claim Reference Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9C - ADJUSTED REPRICED CLAIM NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.

TR3 Example:

REF✱9C✱RP44444444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Adjusted Repriced Claim 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: Adjusted Repriced Claim Reference Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*LX - INVESTIGATIONAL DEVICE EXEMPTION 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 claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.

TR3 Example:

REF✱LX✱432907~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Qualified Products List

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: Investigational Device Exemption Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.

TR3 Notes:

Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.

TR3 Example:

REF✱D9✱TJ98UU321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Number assigned by clearinghouse, van, etc.

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Value Added Network Trace Number

The value carried in this element is limited to a maximum of 20 positions.

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EA - MEDICAL RECORD 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 provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EA✱44444TH56~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Medical Record Identification Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Medical Record Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*P4 - DEMONSTRATION PROJECT IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.

TR3 Example:

REF✱P4✱THJ1222~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Project Code

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: Demonstration Project Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*1J - CARE PLAN OVERSIGHT

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 physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send.

TR3 Notes:

This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished.
Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number.
On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI.

TR3 Example:

REF✱1J✱12345678~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Facility ID 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: Care Plan Oversight Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when ALL of the following conditions are met:
• A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement;
• The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement
• X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send.

TR3 Notes:

At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

TR3 Example:

K3✱STATE DATA REQUIREMENT~

✱

449

Fixed Form
Information

✱

✱

Required

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

NTE - CLAIM NOTE

X12 Name:

Note/Special Instruction

X12 Purpose:

To transmit information in a free-form format, if necessary, for comment or special instruction

X12 Comments:

The NTE segment permits free-form information/data which, under ANSI X12 standard implementations, is not machine processible. The use of the NTE segment should therefore be avoided, if at all possible, in an automated environment.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send.

TR3 Notes:

Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300.
The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.

TR3 Example:

NTE✱ADD✱SURGERY WAS UNUSUALLY LONG BECAUSE [FILL IN REASON]~

NTE

✱

✱

Required

363

Note Reference Code

O 1

Code identifying the functional area or purpose for which the note applies

CODE

DEFINITION

ADD

Additional Information

CER

Certification Narrative

DCP

Goals, Rehabilitation Potential, or Discharge Plans

DGN

Diagnosis Description

TPO

Third Party Organization Notes

Required

352

Description

M 1

1/80

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

INDUSTRY NAME: Claim Note Text

CR1*LB - 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.

X12 Set Notes:

NOTE: The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send.

TR3 Notes:

The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101.

TR3 Example:

CR1✱LB✱140✱✱A✱DH✱12✱✱✱✱UNCONSCIOUS~

CR1

✱

✱

✱

✱

Ambulance
Reason Code

✱

✱

✱

✱

✱

✱

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: P0102

SITUATIONAL RULE: Required when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send.

CODE

DEFINITION

Pound

Situational

Weight

O 1

1/10

Numeric value of weight

SEMANTIC: CR102 is the weight of the patient at time of transport.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Weight

Not Used

1316

Ambulance Transport Code

O 1

Required

1317

Ambulance Transport Reason Code

O 1

Code indicating the reason for ambulance transport

CODE

DEFINITION

Patient was transported to nearest facility for care of symptoms, complaints, or both

Can be used to indicate that the patient was transferred to a residential facility.

Patient was transported for the benefit of a preferred physician

Patient was transported for the nearness of family members

Patient was transported for the care of a specialist or for availability of specialized equipment

Patient Transferred to Rehabilitation Facility

Required

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

CODE

DEFINITION

Miles

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR106 is the distance traveled during transport.

SEGMENT SYNTAX: P0506

INDUSTRY NAME: Transport Distance

0 (zero) is a valid value when ambulance services do not include a charge for mileage.

Not Used

166

Address Information

O 1

1/55

Not Used

166

Address Information

O 1

1/55

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR109 is the purpose for the round trip ambulance service.

SITUATIONAL RULE: Required when the ambulance service is for a round trip. If not required by this implementation guide, do not send.

INDUSTRY NAME: Round Trip Purpose Description

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR110 is the purpose for the usage of a stretcher during ambulance service.

SITUATIONAL RULE: Required when needed to justify usage of stretcher. If not required by this implementation guide, do not send.

INDUSTRY NAME: Stretcher Purpose Description

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 on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

CR2✱✱✱✱✱✱✱✱M~

CR2

✱

✱

✱

Subluxation
Level Code

✱

1367

Subluxation
Level Code

✱

✱

✱

✱

✱

✱

✱

✱

Not Used

609

Count

O 1

1/9

Not Used

380

Quantity

O 1

1/15

Not Used

1367

Subluxation Level Code

O 1

2/3

Not Used

1367

Subluxation Level Code

O 1

2/3

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

Required

1342

Nature of Condition Code

O 1

Code indicating the nature of a patient's condition

INDUSTRY NAME: Patient Condition Code

CODE

DEFINITION

Acute Condition

Chronic Condition

Non-acute

Non-Life Threatening

Routine

Symptomatic

Acute Manifestation of a Chronic Condition

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR210 is a description of the patient's condition.

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Condition Description

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR211 is an additional description of the patient's condition.

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Condition Description

Not Used

1073

Yes/No Condition or Response Code

O 1

CRC*07 - AMBULANCE CERTIFICATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim involves ambulance transport services
AND
when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send.

TR3 Notes:

The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01.
Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07.

TR3 Example:

CRC✱07✱Y✱01~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

CODE

DEFINITION

Ambulance Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

The codes for CRC03 also can be used for CRC04 through CRC07.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a second condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a third condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a fourth condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a fifth condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

CRC - PATIENT CONDITION INFORMATION: VISION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱E1✱Y✱L1~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

CODE

DEFINITION

Spectacle Lenses

Contact Lenses

Spectacle Frames

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

CODE

DEFINITION

General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met

Replacement Due to Loss or Theft

Replacement Due to Breakage or Damage

Replacement Due to Patient Preference

Replacement Due to Medical Reason

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a second condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met

Replacement Due to Loss or Theft

Replacement Due to Breakage or Damage

Replacement Due to Patient Preference

Replacement Due to Medical Reason

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a third condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met

Replacement Due to Loss or Theft

Replacement Due to Breakage or Damage

Replacement Due to Patient Preference

Replacement Due to Medical Reason

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a fourth condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met

Replacement Due to Loss or Theft

Replacement Due to Breakage or Damage

Replacement Due to Patient Preference

Replacement Due to Medical Reason

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a fifth condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met

Replacement Due to Loss or Theft

Replacement Due to Breakage or Damage

Replacement Due to Patient Preference

Replacement Due to Medical Reason

CRC*75 - HOMEBOUND INDICATOR

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱75✱Y✱IH~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

CODE

DEFINITION

Functional Limitations

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Homebound Indicator

CODE

DEFINITION

Independent at Home

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

CRC*ZZ - EPSDT REFERRAL

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.

TR3 Example:

CRC✱ZZ✱Y✱ST~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

INDUSTRY NAME: Code Qualifier

CODE

DEFINITION

Mutually Defined

EPSDT Screening referral information.

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Code Applies Indicator

The response answers the question: Was an EPSDT referral given to the patient?

CODE

DEFINITION

If no, then choose "NU" in CRC03 indicating no referral given.

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

The codes for CRC03 also can be used for CRC04 through CRC05.

CODE

DEFINITION

Available - Not Used

Patient refused referral.

Not Used

This conditioner indicator must be used when the submitter answers "N" in CRC02.

Under Treatment

Patient is currently under treatment for referred diagnostic or corrective health problem.

New Services Requested

Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR
Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a second condition code is necessary. If not required by this implementation guide, do not send.

Use the codes listed in CRC03.

CODE

DEFINITION

Available - Not Used

Patient refused referral.

Not Used

This conditioner indicator must be used when the submitter answers "N" in CRC02.

Under Treatment

Patient is currently under treatment for referred diagnostic or corrective health problem.

New Services Requested

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a third condition code is necessary. If not required by this implementation guide, do not send.

Use the codes listed in CRC03.

CODE

DEFINITION

Available - Not Used

Patient refused referral.

Not Used

This conditioner indicator must be used when the submitter answers "N" in CRC02.

Under Treatment

Patient is currently under treatment for referred diagnostic or corrective health problem.

New Services Requested

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

HI - HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Do not transmit the decimal point for ICD codes. The decimal point is implied.

TR3 Example:

HI✱BK:8901✱BF:87200✱BF:5559~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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.

The diagnosis listed in this element is assumed to be the principal diagnosis.

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

ABK

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

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 ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

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

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

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 it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. 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)

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

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

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

3-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

4-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

5-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

6-4

1251

Date Time Period

O 1

1/35

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.

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)

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

ICD-9 Codes

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

Not Used

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

7-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

8-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

9-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

9-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

10-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

10-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

11-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

11-4

1251

Date Time Period

O 1

1/35

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.

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)

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

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

Not Used

12-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

12-4

1251

Date Time Period

O 1

1/35

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

HI - ANESTHESIA RELATED PROCEDURE

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 on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send.

TR3 Example:

HI✱BP:33414~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Health Care Financing Administration Common Procedural Coding System Principal Procedure

CODE SOURCE 130: Healthcare Common Procedural Coding System

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Anesthesia Related Surgical Procedure

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

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 it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. 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

CODE

DEFINITION

Health Care Financing Administration Common Procedural Coding System

CODE SOURCE 130: Healthcare Common Procedural Coding System

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

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

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

HI - CONDITION INFORMATION

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 condition information applies to the claim.
If not required by this implementation guide, do not send.

TR3 Example:

HI✱BG:17✱BG:67~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

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 it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. 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

CODE

DEFINITION

Condition

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

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

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.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

3-4

1251

Date Time Period

O 1

1/35

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.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

4-4

1251

Date Time Period

O 1

1/35

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.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

5-4

1251

Date Time Period

O 1

1/35

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.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

6-4

1251

Date Time Period

O 1

1/35

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.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

7-4

1251

Date Time Period

O 1

1/35

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.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

8-4

1251

Date Time Period

O 1

1/35

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.

Required

9-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

9-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

9-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

9-4

1251

Date Time Period

O 1

1/35

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.

Required

10-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

10-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

10-4

1251

Date Time Period

O 1

1/35

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.

Required

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

11-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

11-4

1251

Date Time Period

O 1

1/35

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.

Required

12-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Condition

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

Required

12-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Condition Code

Not Used

12-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

12-4

1251

Date Time Period

O 1

1/35

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

HCP - CLAIM PRICING/REPRICING INFORMATION

X12 Name:

Health Care Pricing

X12 Purpose:

To specify pricing or repricing information about a health care claim or line item

X12 Syntax:

R0113
At least one of HCP01 or HCP13 is required.
P0910
If either HCP09 or HCP10 is present, then the other is required.
P1112
If either HCP11 or HCP12 is present, then the other is required.

Loop:

Loop 2310A - REFERRING PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

TR3 Example:

HCP✱03✱100✱10✱RPO12345~

HCP

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1473

Pricing Methodology

O 1

Code specifying pricing methodology at which the claim or line item has been priced or repriced

SEGMENT SYNTAX: R0113

Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.

CODE

DEFINITION

Zero Pricing (Not Covered Under Contract)

Priced as Billed at 100%

Priced at the Standard Fee Schedule

Priced at a Contractual Percentage

Bundled Pricing

Peer Review Pricing

Flat Rate Pricing

Combination Pricing

Maternity Pricing

Other Pricing

Lower of Cost

Ratio of Cost

Cost Reimbursed

Adjustment Pricing

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP02 is the allowed amount.

INDUSTRY NAME: Repriced Allowed Amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP03 is the savings amount.

SITUATIONAL RULE: Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.

INDUSTRY NAME: Repriced Saving Amount

This information is specific to the destination payer reported in Loop ID-2010BB.

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: HCP04 is the repricing organization identification number.

INDUSTRY NAME: Repricing Organization Identifier

This information is specific to the destination payer reported in Loop ID-2010BB.

Situational

118

Rate

O 1

1/9

Rate expressed in the standard monetary denomination for the currency specified

SEMANTIC: HCP05 is the pricing rate associated with per diem or flat rate repricing.

INDUSTRY NAME: Repricing Per Diem or Flat Rate Amount

This information is specific to the destination payer reported in Loop ID-2010BB.

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: HCP06 is the approved DRG code.

COMMENT: HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.

INDUSTRY NAME: Repriced Approved Ambulatory Patient Group Code

This information is specific to the destination payer reported in Loop ID-2010BB.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP07 is the approved DRG amount.

INDUSTRY NAME: Repriced Approved Ambulatory Patient Group Amount

This information is specific to the destination payer reported in Loop ID-2010BB.

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

355

Unit or Basis for Measurement Code

O 1

Not Used

380

Quantity

O 1

1/15

Situational

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

SEMANTIC: HCP13 is the rejection message returned from the third party organization.

SEGMENT SYNTAX: R0113

This information is specific to the destination payer reported in Loop ID-2010BB.

CODE

DEFINITION

Cannot Identify Provider as TPO (Third Party Organization) Participant

Cannot Identify Payer as TPO (Third Party Organization) Participant

Cannot Identify Insured as TPO (Third Party Organization) Participant

Payer Name or Identifier Missing

Certification Information Missing

Claim does not contain enough information for re-pricing

Situational

1526

Policy Compliance Code

O 1

1/2

Code specifying policy compliance

This information is specific to the destination payer reported in Loop ID-2010BB.

CODE

DEFINITION

Procedure Followed (Compliance)

Not Followed - Call Not Made (Non-Compliance Call Not Made)

Not Medically Necessary (Non-Compliance Non-Medically Necessary)

Not Followed Other (Non-Compliance Other)

Emergency Admit to Non-Network Hospital

Situational

1527

Exception Code

O 1

1/2

Code specifying the exception reason for consideration of out-of-network health care services

SEMANTIC: HCP15 is the exception reason generated by a third party organization.

This information is specific to the destination payer reported in Loop ID-2010BB.

CODE

DEFINITION

Non-Network Professional Provider in Network Hospital

Emergency Care

Services or Specialist not in Network

Out-of-Service Area

State Mandates

Other

NM1 - REFERRING 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.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when this claim involves a referral. If not required by this implementation guide, do not send.

TR3 Notes:

When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

TR3 Example:

NM1✱DN✱1✱WELBY✱MARCUS✱W✱✱JR✱XX✱1234567891~

NM1

✱

✱

Loop 2310A - REFERRING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Referring Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Referring Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Referring 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 for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.ORRequired for providers prior to the mandated HIPAA 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

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Referring 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 - REFERRING PROVIDER SECONDARY 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 prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.

TR3 Notes:

The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial 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: Referring Provider Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*82 - RENDERING 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.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop 2310B - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider.
If not required by this implementation guide, do not send.

TR3 Notes:

Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~

NM1

✱

✱

Loop 2310B - RENDERING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering 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

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Rendering 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

PRV*PE - RENDERING PROVIDER SPECIALTY 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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.

TR3 Notes:

The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

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

REF - RENDERING PROVIDER SECONDARY 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 2310B - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*77 - SERVICE FACILITY LOCATION 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.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
If not required by this implementation guide, do not send.

TR3 Notes:

When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location.
Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

TR3 Example:

NM1✱77✱2✱ABC CLINIC✱✱✱✱✱XX✱1234567891~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Service Location

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Laboratory or Facility 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

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 service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity.If not required by this implementation guide, do not send.

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Laboratory or Facility Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - SERVICE FACILITY 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 Notes:

If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Laboratory or Facility Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Laboratory or Facility Address Line

N4 - SERVICE FACILITY 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✱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: Laboratory or Facility 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: Laboratory or Facility 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: Laboratory or Facility Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

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

REF - SERVICE FACILITY LOCATION SECONDARY 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 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Laboratory or Facility Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

PER*IC - SERVICE FACILITY 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 for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter.
If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱IC✱JOHN SMITH✱TE✱5555551234✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2310D - SUPERVISING PROVIDER NAME

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 name is different than the name in the Loop ID-1000A Submitter EDI Contact Information PER segment and in the Loop ID-2010AA Billing Provider Contact Information PER. If not required by this implementation guide, do not send.

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1*DQ - SUPERVISING 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.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send.

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

TR3 Example:

NM1✱DQ✱1✱DOE✱JOHN✱B✱✱✱XX✱1234567891~

NM1

✱

✱

Loop 2310D - SUPERVISING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Supervising Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Supervising 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

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Supervising 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 - SUPERVISING PROVIDER SECONDARY 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 prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Supervising Provider Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*PW - AMBULANCE PICK-UP LOCATION

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.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop 2310E - AMBULANCE PICK-UP LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

TR3 Example:

NM1✱PW✱2~

NM1

✱

✱

Loop 2310E - AMBULANCE PICK-UP LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Pickup Address

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - AMBULANCE PICK-UP 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 Notes:

If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Ambulance Pick-up Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Ambulance Pick-up Address Line

N4 - AMBULANCE PICK-UP 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 2310E - AMBULANCE PICK-UP LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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: Ambulance Pick-up 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: Ambulance Pick-up 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: Ambulance Pick-up 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

NM1*45 - AMBULANCE DROP-OFF LOCATION

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.

X12 Set Notes:

NOTE: Loop 2310 contains information about the rendering, referring, or attending provider.

Loop:

Loop 2310F - AMBULANCE DROP-OFF LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.

TR3 Notes:

Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.

TR3 Example:

NM1✱45✱2~

NM1

✱

✱

Loop 2310F - AMBULANCE DROP-OFF LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

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 drop-off location name is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Ambulance Drop-off Location

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 - AMBULANCE DROP-OFF 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✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Ambulance Drop-off Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Ambulance Drop-off Address Line

N4 - AMBULANCE DROP-OFF 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 2310F - AMBULANCE DROP-OFF LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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: Ambulance Drop-off 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: Ambulance Drop-off 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: Ambulance Drop-off 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

SBR - OTHER SUBSCRIBER INFORMATION

X12 Name:

Subscriber Information

X12 Purpose:

To record information specific to the primary insured and the insurance carrier for that insured

X12 Set Notes:

NOTE: Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.

TR3 Notes:

All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.
See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

SBR✱S✱01✱GR00786✱✱✱✱✱✱13~

SBR

✱

1138

Payer Resp
Seq No Code

✱

✱

✱

✱

✱

✱

✱

584

✱

Required

1138

Payer Responsibility Sequence Number Code

M 1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.

CODE

DEFINITION

Payer Responsibility Four

Payer Responsibility Five

Payer Responsibility Six

Payer Responsibility Seven

Payer Responsibility Eight

Payer Responsibility Nine

Payer Responsibility Ten

Payer Responsibility Eleven

Primary

Secondary

Tertiary

Unknown

Required

1069

Individual Relationship Code

O 1

Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

CODE

DEFINITION

Spouse

Self

Child

Employee

Unknown

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

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: SBR03 is policy or group number.

SITUATIONAL RULE: Required when the subscriber's identification card for the non-destination payer identified in Loop ID-2330B of this iteration of Loop ID-2320 shows a group number. If not required by this implemetation guide, do not send.

INDUSTRY NAME: Insured Group or Policy Number

This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.

Situational

Name

O 1

1/60

Free-form name

SEMANTIC: SBR04 is plan name.

SITUATIONAL RULE: Required when SBR03 is not used and the group name is available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Group Name

Situational

1336

Insurance Type Code

O 1

1/3

Code identifying the type of insurance policy within a specific insurance program

SITUATIONAL RULE: Required when the payer identified in Loop ID-2330B for this iteration of Loop ID-2320 is Medicare and Medicare is not the primary payer (Loop ID-2320 SBR01 is not P). If not required by this implementation guide, do not send.

CODE

DEFINITION

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

Medicare Secondary Public Health Service (PHS)or Other Federal Agency

Medicare Secondary Black Lung

Medicare Secondary Veteran's Administration

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

Medicare Secondary, Other Liability Insurance is Primary

Not Used

1143

Coordination of Benefits Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

584

Employment Status Code

O 1

Required

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

CODE

DEFINITION

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Blue Cross/Blue Shield

Champus

Commercial Insurance Co.

Disability

Federal Employees Program

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Other Federal Program

Use code OF when submitting Medicare Part D claims.

Title V

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Use Code ZZ when Type of Insurance is not known.

CAS - CLAIM LEVEL ADJUSTMENTS

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Syntax:

L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
C0605
If CAS06 is present, then CAS05 is required.
C0705
If CAS07 is present, then CAS05 is required.
L080910
If CAS08 is present, then at least one of CAS09 or CAS10 are required.
C0908
If CAS09 is present, then CAS08 is required.
C1008
If CAS10 is present, then CAS08 is required.
L111213
If CAS11 is present, then at least one of CAS12 or CAS13 are required.
C1211
If CAS12 is present, then CAS11 is required.
C1311
If CAS13 is present, then CAS11 is required.
L141516
If CAS14 is present, then at least one of CAS15 or CAS16 are required.
C1514
If CAS15 is present, then CAS14 is required.
C1614
If CAS16 is present, then CAS14 is required.
L171819
If CAS17 is present, then at least one of CAS18 or CAS19 are required.
C1817
If CAS18 is present, then CAS17 is required.
C1917
If CAS19 is present, then CAS17 is required.

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.

TR3 Notes:

Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.
A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

CODE

DEFINITION

Contractual Obligations

Correction and Reversals

Other adjustments

Payor Initiated Reductions

Patient Responsibility

Required

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

See CODE SOURCE 139: Claim Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the number of service units has been adjusted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

SITUATIONAL RULE: Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

SITUATIONAL RULE: Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

SITUATIONAL RULE: Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

SITUATIONAL RULE: Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

SITUATIONAL RULE: Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

AMT*D - COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
If not required by this implementation guide, do not send.

TR3 Example:

AMT✱D✱411~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Payor Amount Paid

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Payer Paid Amount

It is acceptable to show "0" as the amount paid.
When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.

Not Used

478

Credit/Debit Flag Code

O 1

AMT*A8 - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.

TR3 Notes:

When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.

TR3 Example:

AMT✱A8✱273~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Noncovered Charges - Actual

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Non-Covered Charge Amount

Not Used

478

Credit/Debit Flag Code

O 1

AMT*EAF - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
OR
Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
If not required by this implementation guide, do not send.

TR3 Notes:

In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.

TR3 Example:

AMT✱EAF✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

EAF

Amount Owed

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Remaining Patient Liability

Not Used

478

Credit/Debit Flag Code

O 1

OI - OTHER INSURANCE COVERAGE INFORMATION

X12 Name:

Other Health Insurance Information

X12 Purpose:

To specify information associated with other health insurance coverage

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.

TR3 Example:

OI✱✱✱Y✱B✱✱Y~

✱

✱

Claim Submt
Reason Code

✱

1073

✱

1351

Patient Sig
Source Code

✱

✱

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

Not Used

1383

Claim Submission Reason Code

O 1

Required

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.

INDUSTRY NAME: Benefits Assignment Certification Indicator

This is a crosswalk from CLM08 when doing COB.
This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.

CODE

DEFINITION

Not Applicable

Use code `W' when the patient refuses to assign benefits.

Yes

Situational

1351

Patient Signature Source Code

O 1

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

SITUATIONAL RULE: Required when a signature was executed on the patient's behalf under state or federal law. If not required by this implementation guide, do not send.

This is a crosswalk from CLM10 when doing COB.

CODE

DEFINITION

Signature generated by provider because the patient was not physically present for services

Signature generated by an entity other than the patient according to State or Federal law.

Not Used

1360

Provider Agreement Code

O 1

Required

1363

Release of Information Code

O 1

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

This is a crosswalk from CLM09 when doing COB.
The Release of Information response is limited to the information carried in this claim.

CODE

DEFINITION

Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Medicare Outpatient Adjudication

X12 Purpose:

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when outpatient adjudication information is reported in the remittance advice
OR
Required when it is necessary to report remark codes.
If not required by this implementation guide, do not send.

TR3 Example:

MOA✱✱✱A4~

MOA

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SEMANTIC: MOA01 is the reimbursement rate.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Reimbursement Rate

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: HCPCS Payable Amount

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: MOA03 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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: MOA04 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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: MOA05 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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: MOA06 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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: MOA07 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA08 is the End Stage Renal Disease (ESRD) payment amount.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: End Stage Renal Disease Payment Amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA09 is the professional component amount billed but not payable.

SITUATIONAL RULE: Required when returned in the remittance advice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Non-Payable Professional Component Billed Amount

NM1*IL - OTHER 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.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.
If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Insured Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Insured Name Suffix

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

Member Identification Number

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Insured 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 - OTHER 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 information is available. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Subscriber Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Other Insured Address Line

N4 - OTHER 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:

Required when the information is available. 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: Other 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: Other Subscriber 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: Other 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

REF*SY - OTHER SUBSCRIBER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

REF✱SY✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

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 Insured Additional Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*PR - OTHER PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Other Payer Organization Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Other Payer Primary Identifier

When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.

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 - OTHER PAYER 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:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Other Payer Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Other Payer Address Line

N4 - OTHER PAYER 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: Other Payer 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: Other Payer 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: Other Payer 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

DTP*573 - CLAIM CHECK OR REMITTANCE 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 payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱573✱D8✱20040203~

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

573

Date Claim Paid

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: Adjudication or Payment Date

REF - OTHER PAYER SECONDARY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

Employer's Identification Number

Claim Office Number

National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE 245: National Association of Insurance Commissioners (NAIC) Code

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 Payer Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*G1 - OTHER PAYER PRIOR 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 payer identified in this loop has assigned a prior authorization number to this claim.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱G1✱AB333-Y5~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior 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: Other Payer Prior Authorization Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9F - OTHER PAYER REFERRAL 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 payer identified in this loop has assigned a referral number to this claim.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral 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: Other Payer Prior Authorization or Referral Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*T4 - OTHER PAYER CLAIM ADJUSTMENT INDICATOR

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim is being sent in the payer-to-payer COB model,
AND
the destination payer is secondary to the payer identified in this Loop ID-2330B,
AND
the payer identified in this Loop ID-2330B has re-adjudicated the claim.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱T4✱Y~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Signal Code

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 Payer Claim Adjustment Indicator

The only valid value for this element is `Y'.

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F8 - OTHER PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2330C - OTHER PAYER REFERRING PROVIDER

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payer's Claim Control Number is available.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱F8✱R555588~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

INDUSTRY NAME: Hierarchical Level Code

CODE

DEFINITION

Original 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: Hierarchical Child Code

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1 - OTHER PAYER REFERRING PROVIDER

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.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send.

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

NM1✱DN✱1~

NM1

✱

✱

Loop 2330C - OTHER PAYER REFERRING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Non-destination (COB) payer's provider identification number(s).
See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

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 Payer Referring Provider Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*82 - OTHER PAYER RENDERING PROVIDER

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.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop 2330D - OTHER PAYER RENDERING PROVIDER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

NM1✱82✱1~

NM1

✱

✱

Loop 2330D - OTHER PAYER RENDERING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Rendering Provider Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*77 - OTHER PAYER SERVICE FACILITY LOCATION

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.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop 2330E - OTHER PAYER SERVICE FACILITY LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

NM1✱77✱2~

NM1

✱

✱

Loop 2330E - OTHER PAYER SERVICE FACILITY LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Service Location

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Service Facility Location Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*DQ - OTHER PAYER SUPERVISING PROVIDER

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.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop 2330F - OTHER PAYER SUPERVISING PROVIDER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

NM1✱DQ✱1~

NM1

✱

✱

Loop 2330F - OTHER PAYER SUPERVISING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - OTHER PAYER SUPERVISING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Supervising Provider Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*85 - OTHER PAYER BILLING PROVIDER

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.

X12 Set Notes:

NOTE: Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Loop:

Loop 2330G - OTHER PAYER BILLING PROVIDER

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

NM1✱85✱2~

NM1

✱

✱

Loop 2330G - OTHER PAYER BILLING PROVIDER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Billing Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

See Crosswalking COB Data Elements section for more information on handling COB in the 837.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Payer Billing Provider Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

LX - SERVICE LINE NUMBER

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

NOTE: Loop 2400 contains Service Line information.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The LX functions as a line counter.
The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/6

Number assigned for differentiation within a transaction set

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:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SV1✱HC:99211:25✱12.25✱UN✱1✱11✱✱1:2:3✱✱Y~

SV1

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

✱

Comp. Diag.
Code Point.

✱

✱

✱

✱

✱

1073

✱

✱

✱

✱

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

The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID-2410 only.

CODE

DEFINITION

Jurisdiction Specific Procedure and Supply Codes

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

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

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

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

CODE SOURCE 130: Healthcare Common Procedural 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. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

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

Advanced Billing Concepts (ABC) Codes

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

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

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 a modifier clarifies or improves the reporting accuracy of the associated procedure code. This is the first procedure code modifier. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when a second modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when a third modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

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, in the judgment of the submitter, the Procedure Code does not definitively describe the service/product/supply and loop 2410 is not used.ORRequired when SV101-2 is a non-specific Procedure Code. Non-specific codes may include in their descriptors terms such as: Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug, Generic; or Prescription Drug, Brand Name.If not required by this implementation guide, do not send.

Not Used

1-8

234

Product/Service ID

O 1

1/48

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV102 is the submitted service line item amount.

INDUSTRY NAME: Line Item Charge Amount

This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments.
Zero "0" is an acceptable value for this element.

Required

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

CODE

DEFINITION

Minutes

Required for Anesthesia claims.

Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel.

Unit

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Service Unit Count

Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.

Situational

1331

Facility Code Value

O 1

1/2

SEMANTIC: SV105 is the place of service.

SITUATIONAL RULE: Required when value is different than value carried in CLM05-1 in Loop ID-2300. If not required by this implementation guide, do not send.

INDUSTRY NAME: Place of Service Code

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

Not Used

1365

Service Type Code

O 1

1/2

Required

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.

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

This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300.

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 it is necessary to point to a second diagnosis related to this service line. Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send.

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 it is necessary to point to a third diagnosis related to this service line. Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send.

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 it is necessary to point to a fourth diagnosis related to this service line. Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send.

Not Used

782

Monetary Amount

O 1

1/18

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related.

SITUATIONAL RULE: Required when the service is known to be an emergency by the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Emergency Indicator

For this implementation, the listed value takes precedence over the semantic note.

Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.

CODE

DEFINITION

Yes

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 Medicaid services are the result of a screening referral.If not required by this implementation guide, do not send.

INDUSTRY NAME: EPSDT Indicator

For this implementation, the listed value takes precedence over the semantic note.
When this element is used, this service is not the screening service.

CODE

DEFINITION

Yes

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement.

SITUATIONAL RULE: Required when applicable for Medicaid claims. If not required by this implementation guide, do not send.

INDUSTRY NAME: Family Planning Indicator

For this implementation, the listed value takes precedence over the semantic note.

CODE

DEFINITION

Yes

Not Used

1364

Review Code

O 1

1/2

Not Used

1341

National or Local Assigned Review Value

O 1

1/2

Situational

1327

Copay Status Code

O 1

Code indicating whether or not co-payment requirements were met on a line by line basis

SITUATIONAL RULE: Required when patient is exempt from co-pay. If not required by this implementation guide, do not send.

INDUSTRY NAME: Co-Pay Status Code

CODE

DEFINITION

Copay exempt

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

Not Used

1337

Level of Care Code

O 1

Not Used

1360

Provider Agreement Code

O 1

SV5 - DURABLE MEDICAL EQUIPMENT SERVICE

X12 Name:

Durable Medical Equipment Service

X12 Purpose:

To specify the claim service detail for durable medical equipment

X12 Syntax:

R0405
At least one of SV504 or SV505 is required.
C0604
If SV506 is present, then SV504 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send.

TR3 Example:

SV5✱HC:A4631✱DA✱30✱50✱5000✱4~

SV5

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

✱

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: Procedure Identifier

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 Procedural Coding System

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

This value must be the same as that reported in SV101-2.

Not Used

1-3

1339

Procedure Modifier

O 1

Not Used

1-4

1339

Procedure Modifier

O 1

Not Used

1-5

1339

Procedure Modifier

O 1

Not Used

1-6

1339

Procedure Modifier

O 1

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/48

Required

355

Unit or Basis for Measurement Code

M 1

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

CODE

DEFINITION

Days

Required

380

Quantity

M 1

1/15

Numeric value of quantity

SEMANTIC: SV503 is the length of medical treatment required.

INDUSTRY NAME: Length of Medical Necessity

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV504 is the rental price.

SEGMENT SYNTAX: R0405, C0604

INDUSTRY NAME: DME Rental Price

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SV505 is the purchase price.

SEGMENT SYNTAX: R0405

INDUSTRY NAME: DME Purchase Price

Required

594

Frequency Code

O 1

Code indicating frequency or type of activities or actions being reported

SEMANTIC: SV506 is the frequency at which the rental equipment is billed.

SEGMENT SYNTAX: C0604

INDUSTRY NAME: Rental Unit Price Indicator

CODE

DEFINITION

Weekly

Monthly

Daily

Not Used

923

Prognosis Code

O 1

PWK - LINE SUPPLEMENTAL INFORMATION

X12 Name:

Paperwork

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

PWK✱OZ✱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

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Admission Summary

Prescription

Physician Order

Referral Form

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Consent Form(s)

Certification

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

Health Certificate

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Models

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Support Data for Claim

Pathology Report

Patient Medical History Document

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

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

INDUSTRY NAME: Attachment Transmission Code

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

CODE

DEFINITION

Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

By Mail

Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

E-Mail

File Transfer

By Fax

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 = "BM", "EL", "EM", "FX" or "FT". 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 = "BM", "EL", "EM", "FX" or "FT". If not required by this implementation guide, do not send.

INDUSTRY NAME: Attachment Control Number

PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
For the purpose of this implementation, the maximum field length is 50.

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

PWK*CT - DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR

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 on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.

TR3 Example:

PWK✱CT✱AB~

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

Certification

Required

756

Report Transmission Code

O 1

1/2

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

INDUSTRY NAME: Attachment Transmission Code

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

CODE

DEFINITION

Previously Submitted to Payer

Certification Included in this Claim

Narrative Segment Included in this Claim

No Documentation is Required

Not Specified

NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

Not Used

757

Report Copies Needed

O 1

1/2

Not Used

Entity Identifier Code

O 1

2/3

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

352

Description

O 1

1/80

Not Used

C002

Actions Indicated

O 1

Not Used

1525

Request Category Code

O 1

1/2

CR1*LB - 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.

X12 Set Notes:

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

TR3 Example:

CR1✱LB✱140✱✱A✱DH✱12✱✱✱✱UNCONSCIOUS~

CR1

✱

✱

✱

✱

Ambulance
Reason Code

✱

✱

✱

✱

✱

✱

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: P0102

SITUATIONAL RULE: Required when CR102 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Pound

Situational

Weight

O 1

1/10

Numeric value of weight

SEMANTIC: CR102 is the weight of the patient at time of transport.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Weight

Not Used

1316

Ambulance Transport Code

O 1

Required

1317

Ambulance Transport Reason Code

O 1

Code indicating the reason for ambulance transport

CODE

DEFINITION

Patient was transported to nearest facility for care of symptoms, complaints, or both

Patient was transported for the benefit of a preferred physician

Patient was transported for the nearness of family members

Patient was transported for the care of a specialist or for availability of specialized equipment

Patient Transferred to Rehabilitation Facility

Required

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

CODE

DEFINITION

Miles

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CR106 is the distance traveled during transport.

SEGMENT SYNTAX: P0506

INDUSTRY NAME: Transport Distance

0 (zero) is a valid value when ambulance services do not include a charge for mileage.

Not Used

166

Address Information

O 1

1/55

Not Used

166

Address Information

O 1

1/55

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR109 is the purpose for the round trip ambulance service.

SITUATIONAL RULE: Required when the ambulance service is for a round trip. If not required by this implementation guide, do not send.

INDUSTRY NAME: Round Trip Purpose Description

Situational

352

Description

O 1

1/80

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

SEMANTIC: CR110 is the purpose for the usage of a stretcher during ambulance service.

SITUATIONAL RULE: Required when needed to justify usage of stretcher. If not required by this implementation guide, do not send.

INDUSTRY NAME: Stretcher Purpose Description

CR3 - DURABLE MEDICAL EQUIPMENT CERTIFICATION

X12 Name:

Durable Medical Equipment Certification

X12 Purpose:

To supply information regarding a physician's certification for durable medical equipment

X12 Syntax:

P0203
If either CR302 or CR303 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line.
If not required by this implementation guide, do not send.

TR3 Example:

CR3✱I✱MO✱6~

CR3

✱

1322

Certificate
Type Code

✱

✱

✱

✱

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

CODE

DEFINITION

Initial

Renewal

Revised

Required

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

SEMANTIC: CR302 and CR303 specify the time period covered by this certification.

SEGMENT SYNTAX: P0203

CODE

DEFINITION

Months

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Durable Medical Equipment Duration

Length of time DME equipment is needed.

Not Used

1335

Insulin Dependent Code

O 1

Not Used

352

Description

O 1

1/80

CRC*07 - AMBULANCE CERTIFICATION

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

TR3 Notes:

The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.

TR3 Example:

CRC✱07✱Y✱01~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

CODE

DEFINITION

Ambulance Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

INDUSTRY NAME: Condition Code

The codes for CRC03 also can be used for CRC04 through CRC07.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a second condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a third condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a fourth condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a fifth condition code is necessary. If not required by this implementation guide, do not send.

INDUSTRY NAME: Condition Code

Use the codes listed in CRC03.

CODE

DEFINITION

Patient was admitted to a hospital

Patient was moved by stretcher

Patient was unconscious or in shock

Patient was transported in an emergency situation

Patient had to be physically restrained

Patient had visible hemorrhaging

Ambulance service was medically necessary

Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

CRC*70 - HOSPICE EMPLOYEE INDICATOR

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send.

TR3 Notes:

The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
The example shows the method used to indicate whether the rendering provider is an employee of the hospice.

TR3 Example:

CRC✱70✱Y✱65~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

CODE

DEFINITION

Hospice

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Hospice Employed Provider Indicator

A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice.

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

CODE

DEFINITION

Open

This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement.

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

CRC*09 - CONDITION INDICATOR/DURABLE MEDICAL EQUIPMENT

X12 Name:

Conditions Indicator

X12 Purpose:

To supply information on conditions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication.
If not required by this implementation guide, do not send.

TR3 Notes:

The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
The first example shows a case where an item billed was not a replacement item.

TR3 Example:

CRC✱09✱N✱ZV~
CRC✱09✱Y✱38~

CRC

✱

✱

✱

✱

✱

✱

✱

Required

1136

Code Category

M 1

Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

CODE

DEFINITION

Durable Medical Equipment Certification

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

INDUSTRY NAME: Certification Condition Indicator

CODE

DEFINITION

Yes

Required

1321

Condition Indicator

M 1

2/3

Code indicating a condition

CODE

DEFINITION

Certification signed by the physician is on file at the supplier's office

Replacement Item

Situational

1321

Condition Indicator

O 1

2/3

Code indicating a condition

SITUATIONAL RULE: Required when a second condition code is necessary. If not required by this implementation guide, do not send.

Use the codes listed in CRC03.

CODE

DEFINITION

Certification signed by the physician is on file at the supplier's office

Replacement Item

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

Not Used

1321

Condition Indicator

O 1

2/3

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.

TR3 Example:

DTP✱472✱RD8✱20050314-20050325~

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.

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Service Date

DTP*471 - PRESCRIPTION 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 a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send.

TR3 Example:

DTP✱471✱D8✱20050108~

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

471

Prescription

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: Prescription Date

DTP*607 - CERTIFICATION REVISION/RECERTIFICATION 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 CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send.

TR3 Example:

DTP✱607✱D8✱20050112~

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

607

Certification Revision

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 Revision or Recertification Date

DTP*463 - BEGIN THERAPY 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 a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱463✱D8✱20050112~

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

463

Begin Therapy

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: Begin Therapy Date

DTP*461 - LAST CERTIFICATION 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 a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.

TR3 Notes:

This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF).

TR3 Example:

DTP✱461✱D8✱20050112~

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

461

Last Certification

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 Certification Date

DTP*304 - LAST SEEN 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 a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱304✱D8✱20050108~

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

304

Latest Visit or Consultation

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: Treatment or Therapy Date

DTP - TEST 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 on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱738✱D8✱20050112~

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

738

Most Recent Hemoglobin or Hematocrit or Both

739

Most Recent Serum Creatine

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: Test Performed Date

DTP*011 - SHIPPED 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 billing or reporting shipped products. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱011✱D8✱20050112~

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

011

Shipped

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: Shipped Date

DTP*455 - LAST X-RAY 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 claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

TR3 Example:

DTP✱455✱D8✱20050108~

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

455

Last X-Ray

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 X-Ray Date

DTP*454 - INITIAL TREATMENT 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 Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱454✱D8✱20050108~

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

454

Initial Treatment

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: Initial Treatment Date

QTY*PT - AMBULANCE PATIENT COUNT

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.

TR3 Notes:

The QTY02 is the only place to report the number of patients when there are multiple patients transported.

TR3 Example:

QTY✱PT✱2~

QTY

✱

✱

✱

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Patients

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Ambulance Patient Count

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

O 1

1/30

QTY*FL - OBSTETRIC ANESTHESIA ADDITIONAL UNITS

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time.
If not required by this implementation guide, do not send.

TR3 Example:

QTY✱FL✱3~

QTY

✱

✱

✱

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Units

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Obstetric Additional Units

The number of additional units reported by an anesthesia provider to reflect additional complexity of services.

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

O 1

1/30

MEA - TEST RESULT

X12 Name:

Measurements

X12 Purpose:

To specify physical measurements or counts, including dimensions, tolerances, variances, and weights

(See Figures Appendix for example of use of C001)

X12 Syntax:

R03050608
At least one of MEA03, MEA05, MEA06 or MEA08 is required.
E0412
Only one of MEA04 or MEA12 may be present.
L050412
If MEA05 is present, then at least one of MEA04 or MEA12 are required.
L060412
If MEA06 is present, then at least one of MEA04 or MEA12 are required.
L07030506
If MEA07 is present, then at least one of MEA03, MEA05 or MEA06 are required.
E0803
Only one of MEA08 or MEA03 may be present.
P1112
If either MEA11 or MEA12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results.
OR
Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier.
If not required by this implementation guide, do not send.

TR3 Example:

MEA✱TR✱R1✱113.4~

MEA

✱

737

Measurement
Ref ID Code

✱

738

Measurement
Qualifier

✱

✱

✱

✱

✱

✱

Measurement
Attrib Code

✱

✱

✱

✱

Required

737

Measurement Reference ID Code

O 1

Code identifying the broad category to which a measurement applies

INDUSTRY NAME: Measurement Reference Identification Code

CODE

DEFINITION

Original

Use OG to report Starting Dosage.

Test Results

Required

738

Measurement Qualifier

O 1

1/3

Code identifying a specific product or process characteristic to which a measurement applies

CODE

DEFINITION

Height

Hemoglobin

Hematocrit

Epoetin Starting Dosage

Creatinine

Required

739

Measurement Value

O 1

1/20

The value of the measurement

SEGMENT SYNTAX: R03050608, L07030506, E0803

INDUSTRY NAME: Test Results

Not Used

C001

Composite Unit of Measure

O 1

Not Used

740

Range Minimum

O 1

1/20

Not Used

741

Range Maximum

O 1

1/20

Not Used

935

Measurement Significance Code

O 1

Not Used

936

Measurement Attribute Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

1373

Measurement Method or Device

O 1

2/4

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

CN1 - CONTRACT INFORMATION

X12 Name:

Contract Information

X12 Purpose:

To specify basic data about the contract or contract line item

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

CN1✱02✱550~

CN1

✱

✱

✱

✱

✱

✱

Required

1166

Contract Type Code

M 1

Code identifying a contract type

CODE

DEFINITION

Diagnosis Related Group (DRG)

Per Diem

Variable Per Diem

Flat

Capitated

Percent

Other

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

SITUATIONAL RULE: Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Amount

Situational

332

Percent, Decimal Format

O 1

1/6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

SEMANTIC: CN103 is the allowance or charge percent.

SITUATIONAL RULE: Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Percentage

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: CN104 is the contract code.

SITUATIONAL RULE: Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Code

Situational

338

Terms Discount Percent

O 1

1/6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

SITUATIONAL RULE: Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send.

INDUSTRY NAME: Terms Discount Percentage

Situational

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.

SITUATIONAL RULE: Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send.

INDUSTRY NAME: Contract Version Identifier

REF*9B - REPRICED LINE ITEM 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 a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.

TR3 Example:

REF✱9B✱444444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Repriced Line Item 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: Repriced Line Item Reference Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9D - ADJUSTED REPRICED LINE ITEM 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 a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.

TR3 Example:

REF✱9D✱444444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Adjusted Repriced Line Item 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: Adjusted Repriced Line Item Reference Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*G1 - PRIOR AUTHORIZATION

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 service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).
If not required by this implementation guide, do not send.

TR3 Notes:

When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.

TR3 Example:

REF✱G1✱13579~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Prior 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: Prior Authorization or Referral Number

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 Prior Authorization Number reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.

TR3 Notes:

The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

The maximum number of characters to be supported for this field is `30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is `30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EW - MAMMOGRAPHY CERTIFICATION 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 mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EW✱T554~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Mammography Certification 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: Mammography Certification Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*X4 - CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) 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 for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.

TR3 Example:

REF✱X4✱12D4567890~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Clinical Laboratory Improvement Amendment 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: Clinical Laboratory Improvement Amendment Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F4 - REFERRING CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) FACILITY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send.

TR3 Example:

REF✱F4✱34D1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Facility Certification 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: Referring CLIA Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BT - IMMUNIZATION BATCH 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 mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BT✱DTP22333444~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Batch 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: Immunization Batch Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*9F - REFERRAL 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 service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).
If not required by this implementation guide, do not send.

TR3 Notes:

When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.

TR3 Example:

REF✱9F✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Referral 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: Referral Number

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 Referral Number reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

AMT*T - SALES TAX AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.

TR3 Notes:

When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount.

TR3 Example:

AMT✱T✱45~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Tax

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Sales Tax Amount

Not Used

478

Credit/Debit Flag Code

O 1

AMT*F4 - POSTAGE CLAIMED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send.

TR3 Notes:

When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount.

TR3 Example:

AMT✱F4✱56.78~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Postage Claimed

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Postage Claimed Amount

Not Used

478

Credit/Debit Flag Code

O 1

K3 - FILE INFORMATION

X12 Name:

File Information

X12 Purpose:

To transmit a fixed-format record or matrix contents

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).

TR3 Example:

K3✱STATE DATA REQUIREMENT~

✱

449

Fixed Form
Information

✱

✱

Required

449

Fixed Format Information

M 1

1/80

Data in fixed format agreed upon by sender and receiver

Not Used

1333

Record Format Code

O 1

1/2

Not Used

C001

Composite Unit of Measure

O 1

NTE - LINE NOTE

X12 Name:

Note/Special Instruction

X12 Purpose:

To transmit information in a free-form format, if necessary, for comment or special instruction

X12 Comments:

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description.

TR3 Example:

NTE✱DCP✱PATIENT GOAL TO BE OFF OXYGEN BY END OF MONTH~

NTE

✱

✱

Required

363

Note Reference Code

O 1

Code identifying the functional area or purpose for which the note applies

CODE

DEFINITION

ADD

Additional Information

DCP

Goals, Rehabilitation Potential, or Discharge Plans

Required

352

Description

M 1

1/80

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

INDUSTRY NAME: Line Note Text

NTE*TPO - THIRD PARTY ORGANIZATION NOTES

X12 Name:

Note/Special Instruction

X12 Purpose:

To transmit information in a free-form format, if necessary, for comment or special instruction

X12 Comments:

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.

TR3 Example:

NTE✱TPO✱STATE REGULATION 123 WAS APPLIED DURING THE PRICING OF THIS CLAIM~

NTE

✱

✱

Required

363

Note Reference Code

O 1

Code identifying the functional area or purpose for which the note applies

CODE

DEFINITION

TPO

Third Party Organization Notes

Required

352

Description

M 1

1/80

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

INDUSTRY NAME: Line Note Text

PS1 - PURCHASED SERVICE INFORMATION

X12 Name:

Purchase Service

X12 Purpose:

To specify the information about services that are purchased

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source.
OR
Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses.
If not required by this implementation guide, do not send.

TR3 Example:

PS1✱PN222222✱110~

PS1

✱

✱

✱

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: PS101 is provider identification number.

INDUSTRY NAME: Purchased Service Provider Identifier

This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109.

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: PS102 is cost of the purchased service.

INDUSTRY NAME: Purchased Service Charge Amount

Not Used

156

State or Province Code

O 1

HCP - LINE PRICING/REPRICING INFORMATION

X12 Name:

Health Care Pricing

X12 Purpose:

To specify pricing or repricing information about a health care claim or line item

X12 Syntax:

R0113
At least one of HCP01 or HCP13 is required.
P0910
If either HCP09 or HCP10 is present, then the other is required.
P1112
If either HCP11 or HCP12 is present, then the other is required.

Loop:

Loop 2410 - DRUG IDENTIFICATION

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

This information is specific to the destination payer reported in Loop ID-2010BB.
For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

TR3 Example:

HCP✱03✱100✱10✱RPO12345~

HCP

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1473

Pricing Methodology

O 1

Code specifying pricing methodology at which the claim or line item has been priced or repriced

SEGMENT SYNTAX: R0113

Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.

CODE

DEFINITION

Zero Pricing (Not Covered Under Contract)

Priced as Billed at 100%

Priced at the Standard Fee Schedule

Priced at a Contractual Percentage

Bundled Pricing

Peer Review Pricing

Per Diem Pricing

Flat Rate Pricing

Combination Pricing

Maternity Pricing

Other Pricing

Lower of Cost

Ratio of Cost

Cost Reimbursed

Adjustment Pricing

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP02 is the allowed amount.

INDUSTRY NAME: Repriced Allowed Amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP03 is the savings amount.

INDUSTRY NAME: Repriced Saving Amount

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: HCP04 is the repricing organization identification number.

INDUSTRY NAME: Repricing Organization Identifier

Situational

118

Rate

O 1

1/9

Rate expressed in the standard monetary denomination for the currency specified

SEMANTIC: HCP05 is the pricing rate associated with per diem or flat rate repricing.

INDUSTRY NAME: Repricing Per Diem or Flat Rate Amount

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: HCP06 is the approved DRG code.

COMMENT: HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.

INDUSTRY NAME: Repriced Approved Ambulatory Patient Group Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: HCP07 is the approved DRG amount.

INDUSTRY NAME: Repriced Approved Ambulatory Patient Group Amount

Not Used

234

Product/Service ID

O 1

1/48

Situational

235

Product/Service ID Qualifier

O 1

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

SEGMENT SYNTAX: P0910

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

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

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

CODE SOURCE 130: Healthcare Common Procedural Coding System

Home Infusion EDI Coalition (HIEC) Product/Service Code

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

Advanced Billing Concepts (ABC) Codes

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SEMANTIC: HCP10 is the approved procedure code.

SEGMENT SYNTAX: P0910

INDUSTRY NAME: Repriced Approved HCPCS Code

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: P1112

CODE

DEFINITION

Minutes

Unit

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: HCP12 is the approved service units or inpatient days.

SEGMENT SYNTAX: P1112

INDUSTRY NAME: Repriced Approved Service Unit Count

Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.

Situational

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

SEMANTIC: HCP13 is the rejection message returned from the third party organization.

SEGMENT SYNTAX: R0113

CODE

DEFINITION

Cannot Identify Provider as TPO (Third Party Organization) Participant

Cannot Identify Payer as TPO (Third Party Organization) Participant

Cannot Identify Insured as TPO (Third Party Organization) Participant

Payer Name or Identifier Missing

Certification Information Missing

Claim does not contain enough information for re-pricing

Situational

1526

Policy Compliance Code

O 1

1/2

Code specifying policy compliance

CODE

DEFINITION

Procedure Followed (Compliance)

Not Followed - Call Not Made (Non-Compliance Call Not Made)

Not Medically Necessary (Non-Compliance Non-Medically Necessary)

Not Followed Other (Non-Compliance Other)

Emergency Admit to Non-Network Hospital

Situational

1527

Exception Code

O 1

1/2

Code specifying the exception reason for consideration of out-of-network health care services

SEMANTIC: HCP15 is the exception reason generated by a third party organization.

CODE

DEFINITION

Non-Network Professional Provider in Network Hospital

Emergency Care

Services or Specialist not in Network

Out-of-Service Area

State Mandates

Other

LIN - DRUG IDENTIFICATION

X12 Name:

Item Identification

X12 Purpose:

To specify basic item identification data

X12 Syntax:

P0405
If either LIN04 or LIN05 is present, then the other is required.
P0607
If either LIN06 or LIN07 is present, then the other is required.
P0809
If either LIN08 or LIN09 is present, then the other is required.
P1011
If either LIN10 or LIN11 is present, then the other is required.
P1213
If either LIN12 or LIN13 is present, then the other is required.
P1415
If either LIN14 or LIN15 is present, then the other is required.
P1617
If either LIN16 or LIN17 is present, then the other is required.
P1819
If either LIN18 or LIN19 is present, then the other is required.
P2021
If either LIN20 or LIN21 is present, then the other is required.
P2223
If either LIN22 or LIN23 is present, then the other is required.
P2425
If either LIN24 or LIN25 is present, then the other is required.
P2627
If either LIN26 or LIN27 is present, then the other is required.
P2829
If either LIN28 or LIN29 is present, then the other is required.
P3031
If either LIN30 or LIN31 is present, then the other is required.

X12 Set Notes:

NOTE: Loop 2410 contains compound drug components, quantities and prices.

X12 Comments:

See the Data Dictionary for a complete list of IDs.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.
OR
Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
OR
Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners.
OR
Required when government regulation mandates that medical and surgical supplies are reported with UPN's.

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

TR3 Notes:

Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.

TR3 Example:

LIN✱✱N4✱01234567891~

LIN

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Not Used

350

Assigned Identification

O 1

1/20

Required

235

Product/Service ID Qualifier

M 1

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

COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU.

INDUSTRY NAME: Product or Service ID Qualifier

At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation.

CODE

DEFINITION

EAN/UCC - 13

CODE SOURCE 41: EAN.UCC Global Trade Item Number (GTIN), includes Universal Product Code

EAN/UCC - 8

CODE SOURCE 41: EAN.UCC Global Trade Item Number (GTIN), includes Universal Product Code

HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

Customer Order Number

GTIN 14-digit Data Structure

CODE SOURCE 41: EAN.UCC Global Trade Item Number (GTIN), includes Universal Product Code

UCC - 12

CODE SOURCE 41: EAN.UCC Global Trade Item Number (GTIN), includes Universal Product Code

Required

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: National Drug Code or Universal Product Number

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

Not Used

235

Product/Service ID Qualifier

O 1

Not Used

234

Product/Service ID

O 1

1/48

CTP - DRUG QUANTITY

X12 Name:

Pricing Information

X12 Purpose:

To specify pricing information

X12 Syntax:

P0405
If either CTP04 or CTP05 is present, then the other is required.
C0607
If CTP06 is present, then CTP07 is required.
C0902
If CTP09 is present, then CTP02 is required.
C1002
If CTP10 is present, then CTP02 is required.
C1103
If CTP11 is present, then CTP03 is required.

Loop:

Loop 2410 - DRUG IDENTIFICATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

CTP✱✱✱✱2✱UN~

CTP

✱

✱

✱

✱

✱

Loop 2410 - DRUG IDENTIFICATION

✱

✱

✱

✱

Basis Unit
Price Code

✱

✱

Not Used

687

Class of Trade Code

O 1

Not Used

236

Price Identifier Code

O 1

Not Used

212

Unit Price

O 1

1/17

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

INDUSTRY NAME: National Drug Unit Count

Required

C001

Composite Unit of Measure

O 1

To identify a composite unit of measure

(See Figures Appendix for examples of use)

X12 COMPOSITE COMMENTS:

If C001-02 is not used, its value is to be interpreted as 1.
If C001-03 is not used, its value is to be interpreted as 1.
If C001-05 is not used, its value is to be interpreted as 1.
If C001-06 is not used, its value is to be interpreted as 1.
If C001-08 is not used, its value is to be interpreted as 1.
If C001-09 is not used, its value is to be interpreted as 1.
If C001-11 is not used, its value is to be interpreted as 1.
If C001-12 is not used, its value is to be interpreted as 1.
If C001-14 is not used, its value is to be interpreted as 1.
If C001-15 is not used, its value is to be interpreted as 1.

Required

5-1

355

Unit or Basis for Measurement Code

M 1

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

INDUSTRY NAME: Code Qualifier

CODE

DEFINITION

International Unit

Gram

Milligram

Milliliter

Unit

Not Used

5-2

1018

Exponent

O 1

1/15

Not Used

5-3

649

Multiplier

O 1

1/10

Not Used

5-4

355

Unit or Basis for Measurement Code

O 1

Not Used

5-5

1018

Exponent

O 1

1/15

Not Used

5-6

649

Multiplier

O 1

1/10

Not Used

5-7

355

Unit or Basis for Measurement Code

O 1

Not Used

5-8

1018

Exponent

O 1

1/15

Not Used

5-9

649

Multiplier

O 1

1/10

Not Used

5-10

355

Unit or Basis for Measurement Code

O 1

Not Used

5-11

1018

Exponent

O 1

1/15

Not Used

5-12

649

Multiplier

O 1

1/10

Not Used

5-13

355

Unit or Basis for Measurement Code

O 1

Not Used

5-14

1018

Exponent

O 1

1/15

Not Used

5-15

649

Multiplier

O 1

1/10

Not Used

648

Price Multiplier Qualifier

O 1

Not Used

649

Multiplier

O 1

1/10

Not Used

782

Monetary Amount

O 1

1/18

Not Used

639

Basis of Unit Price Code

O 1

Not Used

499

Condition Value

O 1

1/10

Not Used

289

Multiple Price Quantity

O 1

1/2

REF - PRESCRIPTION OR COMPOUND DRUG ASSOCIATION 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 dispensing of the drug has been done with an assigned prescription number.
OR
Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.
If not required by this implementation guide, do not send.

TR3 Notes:

In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.

TR3 Example:

REF✱XZ✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Link Sequence Number

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prescription Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

NM1*82 - RENDERING 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.

X12 Set Notes:

NOTE: Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same.

Loop:

Loop 2420A - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider.
OR
Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider.
If not required by this implementation guide, do not send.

TR3 Notes:

Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.

TR3 Example:

NM1✱82✱1✱DOE✱JANE✱C✱✱✱XX✱1234567804~

NM1

✱

✱

Loop 2420A - RENDERING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering 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

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Rendering 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

PRV*PE - RENDERING PROVIDER SPECIALTY 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 Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱208D00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Performing

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

REF - RENDERING PROVIDER SECONDARY 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 2420A - RENDERING PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

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 identifier reported in REF02 of this segment is for a non-destination payer.

Do not use this composite when the value reported in REF01 is either 0B or 1G.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

NM1*QB - PURCHASED 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.

X12 Set Notes:

Loop:

Loop 2420B - PURCHASED SERVICE PROVIDER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send.

TR3 Notes:

Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations.

TR3 Example:

NM1✱QB✱2✱✱✱✱✱✱XX✱1234567891~

NM1

✱

✱

Loop 2420B - PURCHASED SERVICE PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.

CODE

DEFINITION

Purchase 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

Not Used

1035

Name Last or Organization Name

O 1

1/60

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

Situational

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

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Purchased 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 - PURCHASED SERVICE PROVIDER SECONDARY 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:

When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial 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: Purchased Service Provider Secondary Identifier

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 identifier reported in REF02 of this segment is for a non-destination payer.

Do not use this composite when the value reported in REF01 is either 0B or 1G.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

NM1*77 - SERVICE FACILITY LOCATION 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.

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.

TR3 Notes:

When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.

TR3 Example:

NM1✱77✱2✱ABC CLINIC✱✱✱✱✱XX✱1234567891~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Service Location

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Laboratory or Facility 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

Situational

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

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Laboratory or Facility Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - SERVICE FACILITY 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 Notes:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Laboratory or Facility Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Laboratory or Facility Address Line

N4 - SERVICE FACILITY 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✱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: Laboratory or Facility 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: Laboratory or Facility 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: Laboratory or Facility Postal Zone or ZIP Code

When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.

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

REF - SERVICE FACILITY LOCATION SECONDARY 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 2420D - SUPERVISING PROVIDER NAME

Loop Usage:

Situational

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 receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.

TR3 Notes:

When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Facility Location Secondary Identifier

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 identifier reported in REF02 of this segment is for a non-destination payer.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

NM1*DQ - SUPERVISING 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.

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱DQ✱1✱DOE✱JOHN✱B✱✱✱XX✱1234567891~

NM1

✱

✱

Loop 2420D - SUPERVISING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Supervising Physician

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Supervising Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Supervising Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Supervising Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Supervising 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

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Supervising 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 - SUPERVISING PROVIDER SECONDARY 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:

When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Supervising Provider Secondary Identifier

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 identifier reported in REF02 of this segment is for a non-destination payer.

Do not use this composite when the value reported in REF01 is either 0B or 1G.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

NM1*DK - ORDERING 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.

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line.
If not required by this implementation guide, do not send.

TR3 Example:

NM1✱DK✱1✱RICHARDSON✱TRENT✱✱✱✱XX✱1234567891~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.

CODE

DEFINITION

Ordering Physician

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Ordering Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Ordering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Ordering Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Ordering 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

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Ordering 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

N3 - ORDERING 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:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Ordering Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Ordering Provider Address Line

N4 - ORDERING 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:

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: Ordering 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: Ordering 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: Ordering 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

REF - ORDERING PROVIDER SECONDARY 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:

When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial 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: Ordering Provider Secondary Identifier

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 identifier reported in REF02 of this segment is for a non-destination payer.

Do not use this composite when the value reported in REF01 is either 0B or 1G.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

PER*IC - ORDERING 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✱JOHN SMITH✱TE✱5555551234✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2420F - REFERRING PROVIDER NAME

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 in the first iteration of the Ordering Provider Contact Information segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Ordering Provider Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. 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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when this information is deemed necessary by the submitter. 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 this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

NM1 - REFERRING 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.

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.

TR3 Example:

NM1✱DN✱1✱WELBY✱MARCUS✱W✱✱JR✱XX✱1234567891~

NM1

✱

✱

Loop 2420F - REFERRING PROVIDER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Referring Provider Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Referring Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Referring Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Referring 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

CODE

DEFINITION

Centers for Medicare and Medicaid Services National Provider Identifier

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

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Referring 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 - REFERRING PROVIDER SECONDARY 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:

When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.

TR3 Example:

REF✱G2✱12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

Provider Commercial 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: Referring Provider Secondary Identifier

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 identifier reported in REF02 of this segment is for a non-destination payer.

Do not use this composite when the value reported in REF01 is either 0B or 1G.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

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 Payer Primary Identifier

The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.

Not Used

4-3

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-4

127

Reference Identification

O 1

1/50

Not Used

4-5

128

Reference Identification Qualifier

O 1

2/3

Not Used

4-6

127

Reference Identification

O 1

1/50

NM1*PW - AMBULANCE PICK-UP LOCATION

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.

X12 Set Notes:

Loop:

Loop 2420G - AMBULANCE PICK-UP LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱PW✱2~

NM1

✱

✱

Loop 2420G - AMBULANCE PICK-UP LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Pickup Address

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 - AMBULANCE PICK-UP 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 Notes:

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Ambulance Pick-up Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Ambulance Pick-up Address Line

N4 - AMBULANCE PICK-UP 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 2420G - AMBULANCE PICK-UP LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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: Ambulance Pick-up 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: Ambulance Pick-up 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: Ambulance Pick-up 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

NM1*45 - AMBULANCE DROP-OFF LOCATION

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.

X12 Set Notes:

Loop:

Loop 2420H - AMBULANCE DROP-OFF LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱45✱2~

NM1

✱

✱

Loop 2420H - AMBULANCE DROP-OFF LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

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 drop-off location name is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Ambulance Drop-off Location

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 - AMBULANCE DROP-OFF 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 Notes:

If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Ambulance Drop-off Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Ambulance Drop-off Address Line

N4 - AMBULANCE DROP-OFF 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 2420H - AMBULANCE DROP-OFF LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

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: Ambulance Drop-off 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: Ambulance Drop-off 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: Ambulance Drop-off 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

SVD - LINE ADJUDICATION INFORMATION

X12 Name:

Service Line Adjudication

X12 Purpose:

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

X12 Set Notes:

NOTE: SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.

TR3 Notes:

To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.

TR3 Example:

SVD✱43✱55✱HC:84550✱✱3~

SVD

✱

✱

✱

Comp. Med.
Proced. ID

✱

✱

✱

Required

Identification Code

M 1

2/80

Code identifying a party or other code

SEMANTIC: SVD01 is the payer identification code.

INDUSTRY NAME: Other Payer Primary Identifier

This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVD02 is the amount paid for this service line.

INDUSTRY NAME: Service Line Paid Amount

Zero "0" is an acceptable value for this element.

Required

C003

Composite Medical Procedure Identifier

O 1

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

COMMENT: SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.

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.

This element contains the procedure code that was used to pay this service line.

Required

3-1

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

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE 576: Workers Compensation Specific Procedure and Supply Codes

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

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

CODE SOURCE 130: Healthcare Common Procedural Coding System

Home Infusion EDI Coalition (HIEC) Product/Service Code

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

Advanced Billing Concepts (ABC) Codes

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

3-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

3-3

1339

Procedure Modifier

O 1

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

Situational

3-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when a second modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

Situational

3-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when a third modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

Situational

3-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.

Situational

3-7

352

Description

O 1

1/80

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

SITUATIONAL RULE: Required when SVC01-7 was returned in the 835 transaction. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Not Used

3-8

234

Product/Service ID

O 1

1/48

Not Used

234

Product/Service ID

O 1

1/48

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVD05 is the paid units of service.

INDUSTRY NAME: Paid Service Unit Count

This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.

Situational

554

Assigned Number

O 1

1/6

Number assigned for differentiation within a transaction set

COMMENT: SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.

SITUATIONAL RULE: Required when payer bundled this service line. If not required by this implementation guide, do not send.

INDUSTRY NAME: Bundled or Unbundled Line Number

CAS - LINE ADJUSTMENT

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Syntax:

L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
C0605
If CAS06 is present, then CAS05 is required.
C0705
If CAS07 is present, then CAS05 is required.
L080910
If CAS08 is present, then at least one of CAS09 or CAS10 are required.
C0908
If CAS09 is present, then CAS08 is required.
C1008
If CAS10 is present, then CAS08 is required.
L111213
If CAS11 is present, then at least one of CAS12 or CAS13 are required.
C1211
If CAS12 is present, then CAS11 is required.
C1311
If CAS13 is present, then CAS11 is required.
L141516
If CAS14 is present, then at least one of CAS15 or CAS16 are required.
C1514
If CAS15 is present, then CAS14 is required.
C1614
If CAS16 is present, then CAS14 is required.
L171819
If CAS17 is present, then at least one of CAS18 or CAS19 are required.
C1817
If CAS18 is present, then CAS17 is required.
C1917
If CAS19 is present, then CAS17 is required.

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.

TR3 Notes:

A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

TR3 Example:

CAS✱PR✱1✱7.93~
CAS✱OA✱93✱15.06~

CAS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

CODE

DEFINITION

Contractual Obligations

Correction and Reversals

Other adjustments

Payor Initiated Reductions

Patient Responsibility

Required

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the number of service units has been adjusted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

SITUATIONAL RULE: Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Reason Code

See CODE SOURCE 139: Claim Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

See CODE SOURCE 139: Claim Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

SITUATIONAL RULE: Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

See CODE SOURCE 139: Claim Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

SITUATIONAL RULE: Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

See CODE SOURCE 139: Claim Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

SITUATIONAL RULE: Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

See CODE SOURCE 139: Claim Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

SITUATIONAL RULE: Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

DTP*573 - LINE CHECK OR REMITTANCE 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:

Required

Segment Repeat:

TR3 Example:

DTP✱573✱D8✱20040203~

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

573

Date Claim Paid

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: Adjudication or Payment Date

AMT*EAF - REMAINING PATIENT LIABILITY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 2440 - FORM IDENTIFICATION CODE

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.

TR3 Notes:

In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.

TR3 Example:

AMT✱EAF✱75~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

EAF

Amount Owed

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Remaining Patient Liability

Not Used

478

Credit/Debit Flag Code

O 1

LQ - FORM IDENTIFICATION CODE

X12 Name:

Industry Code Identification

X12 Purpose:

To identify standard industry codes

X12 Syntax:

C0102
If LQ01 is present, then LQ02 is required.

X12 Set Notes:

NOTE: Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send.

TR3 Notes:

Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used.
An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services.

TR3 Example:

LQ✱UT✱01.02~

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: C0102

CODE

DEFINITION

Form Type Code

Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02.

CODE SOURCE 656: Form Type Codes

Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms

CODE SOURCE 582: Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms

Required

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: C0102

INDUSTRY NAME: Form Identifier

FRM - SUPPORTING DOCUMENTATION

X12 Name:

Supporting Documentation

X12 Purpose:

To specify information in response to a codified questionnaire document

X12 Syntax:

R02030405
At least one of FRM02, FRM03, FRM04 or FRM05 is required.

X12 Set Notes:

NOTE: FRM segment provides question numbers and responses for the questions on the medical necessity information form identified in LQ position 551.

X12 Comments:

The FRM segment can only be used in the context of an identified questionnaire or list of questions. The source of the questions can be identified by an associated segment or by transaction set notes in a particular transaction.

Loop:

Loop 2440 - FORM IDENTIFICATION CODE

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair.

The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQ*UT*08.02~).

TR3 Example:

FRM✱1A✱✱J0234~FRM✱1B✱✱500~FRM✱1C✱✱4~FRM✱4✱Y~FRM✱5A✱✱5~FRM✱5B✱✱3~FRM✱8✱✱Methodist Hospital~FRM✱9✱✱Indianapolis~FRM✱10✱✱IN~FRM✱11✱✱✱19971101~FRM✱12✱N~

FRM

✱

✱