277 Health Care Claim Pending Status Information (005010X228, 005010X228E1)

Loop 2000A - INFORMATION SOURCE LEVEL

Required

1005

Hierarchical Structure Code

M 1

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

CODE

DEFINITION

0085

Information Source, Information Receiver, Provider of Service, Patient

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Status

Required

127

Reference Identification

O 1

1/50

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

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

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

INDUSTRY NAME: Transaction Set Creation Time

Required

640

Transaction Type Code

O 1

Code specifying the type of transaction

CODE

DEFINITION

Notice

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

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

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

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

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

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*PR - PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100A - PAYER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱PR✱2✱ABC INSURANCE✱✱✱✱✱PI✱12345~

NM1

✱

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Payer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Payor Identification

Payer identification number established through trading partner agreement.

Centers for Medicare and Medicaid Services PlanID

Required when the National Payer Identification is mandated for use.

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

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - INFORMATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

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

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

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*41 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100B - INFORMATION RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

Loop 2000C - SERVICE PROVIDER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Information Receiver Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Information Receiver Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Information Receiver Identification Number

The ETIN is established through Trading Partner agreement.

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - SERVICE PROVIDER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱3✱2✱19✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

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

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

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Provider of Service

Required

736

Hierarchical Child Code

O 1

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

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

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*1P - PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100C - PROVIDER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This is the billing provider from the original submitted claim. This may also be the service provider from the original submitted claim. The provider identified facilitates identification of the claim within a payer's system.
During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop may be sent with the NPI reported in the NM109 and NM108=XX.

TR3 Example:

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

NM1

✱

✱

Loop 2000D - PATIENT LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Provider Name Suffix

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Service Provider Number

Centers for Medicare and Medicaid Services National Provider Identifier

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

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

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Provider Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - PATIENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

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

X12 Comments:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

HL✱4✱3✱PT~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

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

HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

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

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

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Patient

Not Used

736

Hierarchical Child Code

O 1

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop 2100D - PATIENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

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

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

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

INDUSTRY NAME: Patient Name Suffix

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Required if the HIPAA Individual Patient Identifier is mandated for use. If not required use MI.

Member Identification Number

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Identification Number

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

TRN*1 - PAYER CLAIM CONTROL NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

TRN✱1✱0612991010987~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

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

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Payer Claim Control Number

Not Used

509

Originating Company Identifier

O 1

Not Used

127

Reference Identification

O 1

1/50

STC - CLAIM LEVEL STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

STC✱P1:56✱20070201✱✱50~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

For this business function, use Pending "P" type Category Codes.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

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

Situational

1-3

Entity Identifier Code

O 1

2/3

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

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

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

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

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: STC04 is the amount of original submitted charges.

INDUSTRY NAME: Total Claim Charge Amount

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

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

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

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

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

Situational

10-3

Entity Identifier Code

O 1

2/3

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

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

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

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when a third claim status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

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

Situational

11-3

Entity Identifier Code

O 1

2/3

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

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

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

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

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

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

REF*EJ - PATIENT CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

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

TR3 Example:

REF✱EJ✱PT12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Patient Account Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - INSTITUTIONAL BILL TYPE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱BLT✱111~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

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

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Pharmacy Prescription Number was submitted on the claim and the number applies to the entire claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Pharmacy Prescription Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

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

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, recipients are not required to return this number. Trading partners may voluntarily agree to this interaction if they wish.

TR3 Example:

REF✱D9✱20041513010001~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Claim Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Clearinghouse Trace Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - CLAIM SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

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

TR3 Example:

DTP✱472✱RD8✱20070101-20070105~ DTP✱472✱D8✱20070101~

DTP

✱

✱

Date Time
Format Qual

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Claim Service Period

DTP*050 - CLAIM 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:

Required

Segment Repeat:

TR3 Notes:

This is the date the claim was accepted into the payer's adjudication system for processing.

TR3 Example:

DTP✱050✱D8✱20070129~

DTP

✱

✱

Date Time
Format Qual

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Missing

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.

INDUSTRY NAME: Missing

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: Missing

SVC - SERVICE LINE INFORMATION

X12 Name:

Service Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the reason for the pended claim is at the service line. If not required by this implementation guide, do not send.

TR3 Notes:

Only those service lines that caused the pended status are to be reported.
For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.

TR3 Example:

SVC✱HC:99214✱50✱✱✱✱✱1~ orSVC✱NU:0710✱100✱✱✱✱✱1~

SVC

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

Comp. Med.
Proced. ID

✱

Required

C003

Composite Medical Procedure Identifier

M 1

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

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

COMMENT: For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

X12 COMPOSITE SEMANTIC NOTES:

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

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

Required

1-1

235

Product/Service ID Qualifier

M 1

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

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

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

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

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

CODE SOURCE: 130: Healthcare Common Procedure Coding System

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

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

Home Infusion EDI Coalition (HIEC) Product/Service Code

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

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

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

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

Advanced Billing Concepts (ABC) Codes

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

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

Required

1-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

If the value in SVC01-1 is "NU", then this element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-2, then SVC04 is not used.

Situational

1-3

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-2. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-2. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-2. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

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

SITUATIONAL RULE: Required when modifiers have been applied to the procedure code reported in SVC01-2. If not required by this implementation guide, do not send.

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/48

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

This is the line item total on the current claim service status.
Zero is an acceptable amount.

Not Used

782

Monetary Amount

O 1

1/18

Situational

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

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

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

INDUSTRY NAME: Product or Service ID

Not Used

380

Quantity

O 1

1/15

Not Used

C003

Composite Medical Procedure Identifier

O 1

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

INDUSTRY NAME: Units of Service Count

STC - SERVICE LINE STATUS INFORMATION

X12 Name:

Status Information

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

STC✱P3:297✱20070201✱✱✱✱✱✱✱✱P3:331~

STC

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

933

Free-Form
Message Txt

1/264

Required

C043

Health Care Claim Status

M 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

Required

1-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

For this business function, use Pending "P" type Category Codes.

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

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

Situational

1-3

Entity Identifier Code

O 1

2/3

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

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

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

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

1-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Required

373

Date

O 1

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

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

INDUSTRY NAME: Status Information Effective Date

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

Not Used

306

Action Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

373

Date

O 1

Not Used

591

Payment Method Code

O 1

Not Used

373

Date

O 1

Not Used

429

Check Number

O 1

1/16

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

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

Required

10-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

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

Situational

10-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

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

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

10-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Situational

C043

Health Care Claim Status

O 1

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required when a third claim status is needed. If not required by this implementation guide, do not send.

Required

11-1

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Health Care Claim Status Category Code

See STC01-1 for valid values.

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Status Code

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

Situational

11-3

Entity Identifier Code

O 1

2/3

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

See STC01-3 for valid values.

CODE

DEFINITION

Dependent

Contracted Service Provider

Consultant's Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

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

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children's General Facility

Children's Hospital Unit of an Institution

Children's Psychiatric Facility

Children's Tuberculosis and Other Respiratory Diseases Facility

Children's Eye, Ear, Nose and Throat Facility

Children's Rehabilitation Facility

Children's Orthopedic Facility

Children's Chronic Disease Facility

Children's Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer's Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography (SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women's Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber's Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

MSC

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization (PPO)

Third Party Repricing Preferred Provider Organization (PPO)

PRP

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

SEP

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

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

Testing Laboratory

Third Party Reviewing Organization (TPO)

Transfer To

TTP

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

Situational

11-4

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

National Council for Prescription Drug Programs Reject/Payment Codes

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

Not Used

933

Free-form Message Text

O 1

1/264

REF*FJ - SERVICE LINE ITEM IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Notes:

Only 1 REF Segment may be reported in the 2220 Loop.

TR3 Example:

REF✱FJ✱6042201~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Line Item Control Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*XZ - PHARMACY PRESCRIPTION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Pharmacy Prescription Number was submitted for this service and the Service Line Item Identification REF Segment is not used. If not required by this implementation guide, do not send.

TR3 Notes:

Only 1 REF Segment may be reported in the 2220 Loop.

TR3 Example:

REF✱XZ✱1234567~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Pharmacy Prescription Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Pharmacy Prescription Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE LINE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop: