Integrated Rules Institutional Claims JSON-to-EDI Mappings

Preface

X12 is a non-profit organization chartered by the American National Standards Institute (ANSI) to develop and maintain business to business transaction standards. Several of the X12 Implementation Guides (X12 Type 3 Technical Report (TR3), also known as an X12 Implementation Guide (IG)) have been adopted under HIPAA for use by covered entities in the health care and insurance industry. These standards are widely adopted across providers, payers, and technology vendors such as Change Healthcare. These TR3s and the X12 metadata contained in them are intended to be used in conjunction with Change Healthcare’s APIs so that your organization will have access to the reference industry standards that include the codes and rules necessary to submit Eligibility, Claims, and Claim Status transactions. To obtain a license that also provides access to the full requirements for these transactions, you can visit https://x12.org/licensing. We make every effort to ensure consistency between Change Healthcare’s APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.

How to Use this Document

Use this document with our Open API Spec (Swagger) as a reference for development. Notes on the data in the following sections include:

  • A light blue table header row denotes each EDI segment.
  • The Constraints column describes the minimum and maximum number of alphanumeric characters that a field entry can occupy: For example, 1/60 R is a Required field with a minimum of one and maximum of 60 characters.
  • If a field is required, the Constraint entry notes it.

For the Constraints column in each table, the following letters stand for specific meanings:

R = Required (must be used if/when the object is part of the transaction);
S = Situational (may be required depending on how the transaction content is structured).

Situational loops, segments, or elements can be Situational in two forms:

  • Required IF a condition is met, but can be used at the discretion of the sender if it isn't required (for example, some descriptive notes can be added to a claim if necessary);
  • Required IF a condition is met, but if not, the sender must not use it in their request ("Do not send").

The Consolidated 837i Implementation Guide, p. 53 discusses this in further detail.

Table of Mappings Tables

Institutional Claims Request JSON-to-EDI Mappings

Transaction Header (Request)

Submitter

Receiver

Subscriber

Other Subscriber Information (2320)

Dependent

Providers

Provider Contact Information

Billing Provider Pay to Plan Name

Billing Provider Address

Operating Physician

Other Operating Physician

Other Payer (2330B)

Other Payer Referring Provider (2330H)

Other Payer Rendering Provider (2330G)

Claim Information

Claim Notes

EPSDT Referral

Claim Date Information

Claim Code Information

Claim Contract Information

Claim Supplemental/Report Information (Paperwork)

Claim Supplemental/Reference Information

Condition Codes

Principal Diagnosis

Admitting Diagnosis

Patient’s Reason for Visit

External Cause of Injury

Diagnosis Related Group Information

Other Diagnosis Information List

Principal Procedure Information

Other Procedure Information List

Occurrence Span Information List

Occurrence Information List

Value Information List

Treatment Code Information List

Claim Pricing Information

Service Facility Location

Institutional Service Lines

Drug Identification (2410)

Line Adjudication (2430)

Claim Line Adjustment (2430)

FieldDescriptionC/R
controlNumber



Transaction Set Control Number.
This is provided by the submitter.
Unique ID used to trace the request.
Value goes in ISA13 (no loop)
R 9/9



tradingPartnerServiceId




ID used by the CHC Clearinghouse for the trading partner.
Loop 2100A, NM109.
You can use the ConnectCenter CPID value
as the tradingPartnerServiceId,
from the searchable Change Healthcare Payer List.
2/80 R




NameElementLoopDescriptionC/R
submitter (Object)Full name of an individual or organization
  organizationName

NM103

1000A

Organization name for the submitter.
Can use organization or last name.
1/60 R

  taxId

NM108

1000A

Electronic Transmitter
Identification Number (ETIN) 46
1/2 R

  contactInformationR
     name

PER02

1000A

Submitter name.

1/60 R

     phoneNumber

PER04

1000A

Phone number of the submitter.
PER03 = TE
1/256 R

     faxNumber

PER04

1000A

Fax number of the submitter.
PER03 = FX
1/256 S

     email

PER04

1000A

Email address of the submitter.
PER03 = EM
1/256 S

NameElementLoopDescriptionC/R
receiver (Object)R
  organizationName

NM103

1000B

Organization name for the holder
of the insurance policy.
1/60 R

  taxId

NM108

1000B

Electronic Transmitter
Identification Number (ETIN) 46
1/2 S

Contains the information about the person holding the insurance policy.

NameElementLoopDescriptionC/R
subscriber
(Object)
The person that holds
the insurance policy
R

  lastName

NM103

2010BA

The subscriber’s last name
as shown on their policy.
1/60 R

  firstName

NM104

2010BA

The subscriber’s first name
as shown on their policy.
1/35 S

  middleNameNM1052010BASubscribers middle name.1/25 S
  memberId



NM109



2010BA



The subscriber’s insurance member ID.
NM108 = MI (Standard Unique Health
Identifier for each Individual in
the United States)
2/80 R



  ssn

REF02

2010BA

Subscriber’s social security number.
REF01=SY
1/50 S

  standardHealthId




NM109




2010BA




Standard health Identifier.
NM108 = II (Standard Unique Health
Identifier for each U.S. Individual)
Note: Only sent if Member ID is
not assigned by payer
2/80 S




  paymentResponsibilityLevelCode



SBR01



2320



Code identifying the payer's
level of responsibility
for payment of claim.
Example: P = Primary
1/1 R



  dateOfBirth



DMG02



2010BA



The subscriber’s birth date
listed on their policy.
Required when the subscriber is
the patient.
1/35 S



  gender




DMG03




2010BA




The subscriber’s gender
as shown on their policy.
F = Female; M = Male; U = Unknown
Required when the subscriber
is the patient.
1/1 S




  address (Object)
    address1


N301


2010BA


Subscriber’s address line 1.
Required when the subscriber
is the patient.
1/35 S


    address2N3022010BASubscriber’s address line 2.1/35 S
    city


N401


2010BA


Subscriber’s city.
Required when the subscriber
is the patient.
2/30 S


    state



N402



2010BA



Subscriber’s state.
Required when the subscriber
is the patient and when
the claim is inside US or CA.
2/2 S



    postalCode



N403



2010BA



Subscriber’s postal code.
Required when the subscriber
is the patient and when
the claim is inside US or CA
3/15 S



countryCodeN4042010BAPay-to country code1/35 S
countrySubDivisionCodeN4042010BAPay-to country code1/35 S

NameElementLoopDescriptionC/R
  otherSubscriberInformation (Object)The insurance policy holderS
    individualRelationshipCode


SBR02


2320


Code indicating the relationship
between two individuals or entities.
Example: 01 = Spouse
Required when patient is the subscriber
2/2


    policyNumber


SBR03


2320


Deprecated
The subscriber’s policy number
as shown on their policy.
1/50


    groupNumber

SBR03

2320

The subscriber’s group number
as shown on their policy.
1/50 S

    otherInsuredGroupNameSBR042320Plan name.1/60 S
    claimFilingIndicatorCode

SBR09

2320

Code identifying the claim type.
Example: 13 = Point of Service
1/2 R

NOTE: When the dependent is the Patient, elements marked with “R” in the C/R column are required.

NameElementLoopDescriptionC/R
dependent (Object)Dependent of the policy holderS
  lastName



NM103



2010CA



Dependent’s last name.
Required if patient
is a dependent of subscriber
and cannot be uniquely identified
1/60 S



  firstNameNM1042010CADependent’s first name.1/35 R
  middleNameNM1052010CADependent’s middle name.1/25 S
  dateOfBirth



DMG02



2010CA



Dependent’s birth date.
Required if patient is a dependent
of subscriber and cannot
be uniquely identified
1/35 S



  gender




DMG03




2010CA




Dependent’s gender code.
Options: F or M
Required if patient
is a dependent of subscriber
and cannot be uniquely identified
1/1 S




  ssn

REF02

2010CA

Dependent social security number.
REF01=SY
1/50 S

  relationshipToSubscriberCode




PAT01




2000C




Patient’s relationship to insured.
Example: 01 = Spouse
Required if patient is
a dependent of subscriber
and cannot be uniquely identified
2/2 R




Another way to set billing, referring, rendering and attending provider information. If used, it will overwrite anything you send in billing, referring, rendering, and attending. Loop: 2000A, 2310F, 2310D, 2310A
NameElementLoopDescriptionC/R
providers (Array of Objects)

List and details of the providers
involved in the claim
R

  providerType



NM101



As noted



Code for provider type.
85 = Billing Provider 2010BB;
82 = Rendering Provider 2310D;
DN = Referring Provider 2310F
2/3 R



  npi


NM109


As noted


National Provider Identification value.
NM108 = XX Billing Provider 2010AA;
Rendering 2310D; Referring 2310F
2/80 S


  ssn

REF02

2010AA

Provider’s social
security number. REF01=SY
S

  employerId

REF02

2010AA

Provider tax ID number.
REF01 = EI
1/50
R
Obsolete/Deprecated REF02
values for this segment/object
include the following:
  commercialNumber
  locationNumber
  stateLicenseNumber
  providerUpinNumber
See otherPayerRenderingProvider
and otherPayerReferringProvider
for current values.

NameElementLoopDescriptionC/R
contactInformation (Object)Each provider's contact information
  organizationName

NM103

2010AA

Provider’s organization name.
Can use organization or last name.
1/60 R

  lastNameNM103

2010AA

Provider last name.
Can use organization or last name.
1/60 R

  firstNameNM1042010AAProvider first name.1/35 S
  middleNameNM1052010AAMiddle initial.1/25 S
  address (Object)
    address1N3012010AAProvider’s address line 11/35 R
    address2N3022010AAProvider’s address line 21/35 S
    cityN4012010AAProvider’s city1/60 R
    state

N402

2010AA

Provider’s state (Required
for claims inside the US/CA)
1/35 S

    postalCode


N403


2010AA


Provider’s postal code
All claims inside the US/CA
require a 9-digit zip code.
3/15 S


    countryCodeN4042010AAPay-to countryCode1/35 S
    countrySubDivisionCodeN4042010AAPay-to countryCode1/35 S
  contactInformation (Object)
    namePER022010AAProvider contact name.1/60 R
    faxNumberPER042010AAProvider fax number. PER03=FX1/256 S
    phoneNumber

PER04

2010AA

Provider contact phone number.
PER03=TE
1/256 R

NameElementLoopDescriptionC/R
billingPayToPlanName (Object)

NM1

Provide full name and identification
of an individual or entity
S

  organizationName

NM103

2010AC

NM103 where NM102=2

1/60
R
  identificationCodeQualifier


NM108


2010AC


Identification Code Qualifier.
If this value is present,
then NM108 is required.
1/2 R


  identificationCode

NM109

2010AC

If this value is present
then NM108 is required.
2/80
R
  payerIdentificationNumberREF022010ACREF02 where REF01=2U1/50 S
  claimOfficeNumber


REF02


2010AC


Electronic Transmitter
ID Number (ETIN) 46
REF02 where REF01=FY
1/2 S


  taxIdREF022010ACREF02 where REF01=EI9/9 S
  naic

REF02

2010AC

REF02 where REF01=NF.
Employer's Identification Number.
6/6 S

  address (Object)R
    address1

N301

2010AC

Provider’s address line 1

1/35
R
    address2

N302

2010AC

Provider’s address line 2

1/35
S
    city

N401

2010AC

Provider’s city

1/60
R
    state

N402

2010AC

Provider’s state or province code
Required for claims in US/CA
1/35 S

    postalCode


N403


2010AC


Provider’s postal code.
All claims inside the US/CA
require a 9-digit zip code.
3/15
R
    countryCodeN4042010ACPay-to country code1/35 S
    countrySubDivisionCodeN4042010ACPay-to country code1/35 S

NameElementLoopDescriptionC/R
billingPayToAddressName (Object)Billing provider location record
  entityTypeQualifier


NM102


2010AB


Billing Provider Qualifier
1 = Person
2 = Non-Person Entity
1/1 R


  address (Object)R
    address1

N301

2010AB

Billing Provider’s
address line 1
1/35 R

    address2N3022010ABBilling Provider’s
address line 2
1/35 S

    cityN4012010ABBilling Provider’s city1/60 R
    state

N402

2010AB

Billing Provider’s state/province
Required for claims in US/CA)
1/35 R

    postalCode


N403


2010AB


Billing Provider’s postal code.
All claims inside the US/CA
require a 9-digit zip code.
3/15 R


    countryCodeN4042010ABBilling Pay-to countryCode1/35 S
    countrySubDivisionCodeN4042010ABBilling Pay-to countryCode1/35 S

NameElementLoopDescriptionC/R
operatingPhysician (Object)Doctor's information
  organizationName

NM103

2010AA

Provider’s organization name.
Can use organization or last name.
1/60 R

  lastName

NM103

2010AA

Provider last name
(Can use organization or last name).
1/60 R

  firstNameNM1042010AAProvider first name.1/35 S
  middleNameNM1052010AAMiddle initial.1/25 S
Obsolete/Deprecated REF02
values for this segment/object
include the following:
  commercialNumber
  locationNumber
  stateLicenseNumber
  providerUpinNumber
See otherPayerRenderingProvider
and otherPayerReferringProvider
for current values.

NameElementLoopDescriptionC/R
otherOperatingPhysician
(Object)
Records for any other physicians
involved in the claim
S
  organizationName

NM103

2010AA

Provider’s organization name.
Can use organization or last name.
1/60 R

  lastName

NM103

2010AA

Provider last name
(Can use organization or last name).
1/60 R

  firstNameNM1042010AAProvider first name.1/35 S
  middleNameNM1052010AAMiddle initial.1/25 S
Obsolete/Deprecated REF02
values for this segment/object
include the following:
  commercialNumber
  locationNumber
  stateLicenseNumber
  providerUpinNumber
See otherPayerRenderingProvider
and otherPayerReferringProvider
for current values.

NameElementLoopDescriptionC/R
otherPayerName
(Object)
The other organization that pays
for the insurance policy.
R

  otherPayerOrganizationName

NM103

2330B

The Payer’s name
as specified on their policy.
1/60
R
  otherPayerIdentifierTypeCode

NM108

2330B

Type of identification.
Example: PI = Payer ID Number
1/2

  otherPayerIdentifier

NM109

2330B

Code identifying a party
or other code.
2/80
R
  otherPayerAddress (Object)S
    address1


N301


2330B


Payer’s address line 1.
Required when other payer
is payer for the patient.
1/35 S


    address2N3022330BPayer’s address line 21/35 S
    city


N401


2330B


Payer’s city.
Required when other is payer
for the patient.
1/60 S


    state


N402


2330B


Payer’s state of residence
Required when other payer
is payer for the patient.
1/35 S


    postalCode


N403


2330B


Payer’s postal code.
Required when other payer
is the payer for the patient.
3/15 S


    countryCodeN4042330BcountryCode1/35 S
    countrySubDivisionCodeN4042330BCountry Sub Division Code1/35
otherPayerAdjudicationOrPaymentDate


DTP03


2330B


Expression of a date.
DTP01=573 (Date Claim Paid)
DTP02=D8
1/35


otherPayerSecondaryIdentifierR
  qualifier

REF01

2330B

Other payer secondary identifier
REF01=2U/EI/FY/NF
2/3

  identifierREF022330BValue of the ID.1/50
  otherPayerClaimAdjustmentIndicator


REF02


2330B


Used for payer-to-payer
Coordination of Benefits.
Req'd if REF01=T4 (Signal Code)
1/50
S

  otherPayerClaimControlNumber


REF02


2330B


Used to assist payer-to-payer
Coordination of Benefits actions.
REF01=F8
1/50 S


NameElementLoopDescriptionC/R
otherPayerReferringProvider (Object)




2330H




NM101=DN (Referring Provider)
NM102=1 (Person)
Array[Other Payer Referring Provider]
Note: be sure to review the OpenAPI
to understand this object
S




  otherPayerReferringProviderIdentifier

2330H

NM101 = P3 (Primary Care Provider)
NM102=1 (Person) Array[ReferenceIdentification]
R
  referenceIdentification (Object)2330HR
    qualifier




REF01




2330H




Type of ID.
REF01=0B/1G/G2
OB - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
2/3 S




    identifier

REF02

2330H

REF01 ID/number.

1/50
S

NameElementLoopDescriptionC/R
otherPayerRenderingProvider
(Object)
2330G

Supplies the full name
of an individual or organization.
S

  entityTypeQualifier


2330G


NM102


NM101=82 (Rendering Provider)
NM102 = 1 (Person)
or 2 (Non-Person Entity)
  otherPayerRenderingProviderIdentifierREF012330GProvider who provided medical care1/1 R
  referenceIdentification
(Object)

2330G


REF02


Reference ID as specified by
the transaction set or by the
REF01 qualifier
1/50 R


    qualifier





REF01





2330G





Type of ID.
REF01=0B/1G/G2:
OB - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
LU – Location Number
2/3 R





    identifierREF022330GREF01 ID/number.1/50 R

See Page 146 of the Consolidated 837 TR3 for more details. Note that the claimChargeAmount field in this object is the sum total of all service lines' individual lineItemChargeAmountvalues. The amount in the claimChargeAmount MUST equal the sum of all service line charge amounts.

NameElementLoopDescriptionC/R
claimInformation (Object)A series of required data fields comprising the core information for the claim
  claimFilingCodeSBR092000BSubscriber claim filing code.
Example: 12 = PPO
1/2R
  propertyCasualtyClaimNumber

REF02

2010CA

Patient property and casualty
claim number. REF01=Y4
1/50

  patientWeight


PAT08


Deprecated
Patient weight.
1/10


  patientControlNumber


CLM01


2300


Identifier to track a claim
from creation by the
provider through payment.
1/38
R

  claimChargeAmount






CLM02






2300






Total claim charge amount.
This value must equal
the sum total of all
service line charge amounts

(reported in Loop 2400
SV203 for each
service line)
1/18 R






  placeOfServiceCode



CLM05
-01

2300


Code identifying where
services were or may be
performed.
1/2
R

  claimFrequencyCode

CLM05
-03
2300

Code defining
claim frequency.
1/1
R
  signatureIndicator

CLM06

2300

Provider signature is on file
indicator. Yes = Y, No = N
1/1
R
  signatureIndicator

CLM06

2300

Provider signature is on file
indicator. Yes = Y, No = N
1/1
R
  planParticipationCode





CLM07





2300





Code indicating whether
the provider accepts assignment.
A = Assigned
B = Assignment accepted only on
clinical lab services
C = Not Assigned
1/1 R





  benefitsAssignmentCertificationIndicator




CLM08




2300




Code indicating the insured
or authorized person
authorizes benefits to be
assigned to the provider.
Yes = Y, No = N
1/1
R



  releaseInformationCode





CLM09





2300





Code indicating whether the
provider has on file
a patient's signed statement
authorizing release of
medical data to other
organizations.
Informed = I, Yes = Y
1/1
R




  delayReasonCode

CLM20

2300

R for late-submitted claims.
If not required, do not send.
S

  patientEstimatedAmountDue

AMT02

2300

Patient responsibility
amount. AMT01=F3
1/18 S
  fileInformation


K301


2300


Array. Data in fixed format
agreed upon by the sender
and the receiver
1/80


  billingNote


NTE02


2300


Billing comments or
special instructions.
NTE01=ADD
1/80


NameElementLoopDescriptionC/R
claimNote (Object)Information providing informational context for the claimS
  allergies

NTE02

2300

Allergies information.
NTE01=ALGClaims
1/80
S
  goalRehabOrDischargePlans


NTE02


2300


Description goals,
rehabilitation potential,
or discharge plans. NTE01=DCP
1/80
S

  diagnosisDescription

NTE02

2300

Diagnosis description.
NTE01=DGN
1/80
S
  dme


NTE02


2300


Durable Medical Equipment (DME)
and Supplies.
NTE01=DME Claims
1/80
S

  medications

NTE02

2300

Medications notes.
NTE01=MEDClaims
1/80
S
  nutritionalRequirements

NTE02

2300

Nutritional Requirements
NTE01=NTRClaims
1/80
S
  ordersForDisciplinesAndTreatments

NTE02

2300

Orders for Disciplines and Treatments
NTE01=ODTClaims
1/80
S
  functionalLimitsOrReasonHomebound

NTE02

2300

Functional Limitations,
Reason Homebound, or Both
NTE01=RHBClaims
1/80
S

  reasonsPatientLeavesHome

NTE02

2300

Reasons Patient Leaves Home
NTE01=RLHClaims *
1/80
S
  timesAndReasonsPatientNotAtHome


NTE02


2300


Times and Reasons Patient
Not at Home SET
NTE01=RNHClaims
1/80
S

  unusualHomeOrSocialEnv

NTE02

2300

Unusual Home, Social Environment,
or Both NTE01=SETClaims
1/80
S
  safetyMeasuresNTE022300Safety Measures NTE01=SFMClaims1/80 S
  supplementalPlanOfTreatment

NTE02

2300

Supplementary Plan of Treatment
NTE01=SPTClaims
1/80
S
  updatedInformation

NTE02

2300

Updated Information
NTE01=UPIClaims
1/80
S

NameElementLoopDescriptionC/R
epsdtReferral (Object)Early & Periodic Screening, Diagnosis, and Treatment (EPSDT)S

  responseCode






CRC02






2300






Response to the question:
Was an EPSDT referral given to patient?
Y = indicates the condition codes
in CRC03-CRC07 apply
N = indicates the condition codes
in CRC03-CRC07 do not apply
CRC01=ZZ
1/1
R





  conditionIndicators


CRC03
CRC04
CRC05

2300



Condition indicator.
Ex: ST = New Services Requested.
Use CRC04 and CRC05 if a second
code is necessary.
2/3
R


DTP = Date or Time or Period

NameElementLoopDescriptionC/R
claimDateInformation (Object)Date Format: YYYYMMDDR
  statementBeginDateDTP032300DTP01=4341/35 R
  statementEndDateDTP032300DTP01=4341/35 R
  dischargeHour


DTP03


2300


Time of discharge.
DTP01=096, DTP02=TM
Format: CCYYMMDDHHMM
1/35
R

  repricerReceivedDateDTP03

2300

Date when the repricer
forwarded the claim to the payer
DTP01=050
1/35 S

  admissionDateAndHour

DTP03

2300

Start of Care date.
DTP02=DT; Format CCYYMMDDHHMM.
1/35
S

Institutional Claim Code in the TR3.

NameElementLoopDescriptionC/R
claimCodeInformation
(Object)
Some of the medical coding for the claim

R

  admissionTypeCode<br><br>CL101

2300

Priority of the admission
or visit
1/1
R
  admissionSourceCode

CL102

2300

Code indicating the source
of the admission.
1/1
S
  patientStatusCode

CL103

2300

Code indicating patient status as of
“statement covers through" date.
1/2
R

NameElementLoopDescriptionC/R
claimContractInformation (Object)




















R for the claim submission when the submitter
is contractually bound to supply this data
on adjudicated claims.
Use the CN1 segment for claims not
meeting HIPAA use.
See the 837i X12 implementation guide,
Page 160, for more info.
S






  contractTypeCode

CN101

2300

Code identifying a contract type.
Example: 02 = Per Diem
2/2
R
  contractAmount

CN102

2300

Contract amount.

1/18
S
  contractPercentage

CN103

2300

Allowance or charge percent.

1/6
S
  contractCode

CN104

2300

Contract code.

1/50
S
  termsDiscountPercentage


CN105


2300


Terms discount percentage, stated as %,
available to purchaser if an invoice is paid
on or before the terms discount due date.
1/6
S

  contractVersionIdentifier

CN106

2300

Additional identifying number
for the contract.
1/30
S

NameElementLoopDescriptionC/R
claimSupplementalInformation
(Object)
Provides references to all attachment
documents for the claim
S

  reportInformation (Object)
    attachmentReportTypeCode

PWK01

2300

Code indicating document title or contents,
report, or supporting item.
Example: 08 = Plan of Treatment
2/2 R

    attachmentTransmissionCode


PWK02


2300


Code defining timing, transmission method
or format by which reports are to be sent.
Example: BM = By mail.
1/2 R


    attachmentControlNumber

PWK06

2300

Code identifying a party or other code.
R when PWK02 = BM, EL, EM, FX or FT
2/80
S

UMO = Utilization Management Organization

NameElementLoopDescriptionC/R
claimSupplementalInformation
(Object)
Additional claim information.
REF01 selection is R.
S

  priorAuthorizationNumber


REF02


2300


Pre-auth number assigned by payer
or UMO to authorize a service before
it is performed. REF01=G1
1/50
S

  referralNumber

REF02

2300

Number assigned by the payer
or UMO. REF01=9F
1/50
S
  claimControlNumber






REF02






2300






The number assigned by the payer
to identify a claim.
The number is usually referred to as
an Internal Control Number (ICN),
Claim Control Number (CCN), or a
Document Control Number (DCN).
REF01=F8
1/50
S





  cliaNumber


REF02


2300


Clinical Laboratory Improvement
Amendment (CLIA) number.
REF01=X4
1/50
S

  repricedClaimNumber


REF02


2300


Repriced claim number
completed by the repricer.
REF01=9A
1/50
S

  adjustedRepricedClaimRefNumber


REF02


2300


Adjusted repriced
claim reference number
from the repricer. REF01=9C
1/50
S

  investigationalDeviceExemptionNumber

REF02

2300

FDA investigational device
exemption (ID) number. REF01=LX
1/50
S
  claimNumber

REF02

2300

Clearinghouse Claim ID number
REF01=D9
1/50
S
  mammographyCertificationNumber

REF02

2300

Mammography certification number.
REF01=EW
1/50
S
  medicalRecordNumber

REF02

2300

Patient's medical record number.
REF01=EA
1/50
S
  demoProjectIdentifier



REF02



2300



Identify atypical claims in
content, purpose, or payment,
demonstration or special project,
or clinical trial. REF01=P4
1/50
S


  carePlanOversightNumber


REF02


2300


Phone of home health agency/hospice
providing Medicare patient services
for the service period. REF01=1J
1/50
S

  medicareCrossoverReferenceId

REF02

2300

Medicare crossover ID.
REF01=F5
1/50
S
  serviceAuthorizationExceptionCode

REF02

2300

Service authorization
exception code. REF01=4N
1/50
S
  autoAccidentState

REF02

2300

Auto accident state or province code.
REF01=LU
1/50
S
  peerReviewAuthorizationNumber

REF02

2300

Preauth. number assigned by the payer
or UMO to authorize services. REF01=G4
1/50
S

HI – Health Care Information Codes. Used to supply information related to the delivery of health care. This is an array of up to 12 records, that ties the claim to one or more sets of industry code lists that set the standards by which information is reported for the claim.

NameElementLoopDescriptionC/R
conditionCodesListArray size is 2
  conditionCodes

2300

Array of 12 Value of the National Uniform
Billing Committee (NUBC) code.
R

HI01-02 to
HI12-02
2300

Value of the condition code. Min 1,
max 12 HI01-01=BG to HI12-01=BG
1/30

NameElementLoopDescriptionC/R
principalDiagnosis (Object)2300Principal diagnosisR
  qualifierCodeHI01-012300Principal diagnosis code.1/3 R
  principalDiagnosisCodeHI01-022300Value of the diagnosis code.1/30 R
  presentOnAdmissionIndicator


HI01-09


2300


Identifies the diagnosis onset
as it relates to the reported diagnosis.
U = Unknown W = Not Applicable Y = Yes
1/1 S


NameElementLoopDescriptionC/R
admittingDiagnosis
(Object)
2300

Admitting diagnosis when the claim
includes inpatient admission
S

  qualifierCodeHI01-012300Admitting diagnosis code.1/3 R
  admittingDiagnosisCode

HI01-02

2300

Value of the admitting
diagnosis code.
1/30
R

Required when a claim involves outpatient visits.

NameElementLoopDescriptionC/R
patientReasonForVisit
(Object)
2300

Patient’s reason for the visit.

S

  qualifierCode








HI01-01
HI02-01
HI03-01






2300








Identifies an Industry code list.
APR = International Classification
of Diseases
Clinical Modification (ICD-10-CM)
Patient’s Reason for Visit
PR = International Classification
of Diseases
Clinical Modification (ICD-9-CM)
Patient’s Reason for Visit
1/3 R








  patientReasonForVisitCode


HI01-02
HI02-02
HI03-02
2300


Reason for visit code.


1/30
R

NameElementLoopDescriptionC/R
externalCauseOfInjury
(Object)
External Cause of Injury

S

  qualifierCode

HI01-01 to
HI0012-01
2300

Industry code. 12 segments

1/3

  externalCauseOfInjury

HI01-02 to
HI012-02
2300

External cause of injury value.
12 segments
1/30

  presentOnAdmissionIndicator






HI01-09 to
HI012-09





2300






Present on admission indicator.
12 segments
Y = onset before hospital admission
N = onset did NOT occur prior to
admission to the hospital
U = Unknown if onset occurred before
or after hospital admission.
1/1
S





NameElementLoopDescriptionC/R
diagnosisRelatedGroupInformation
(Object)
Diagnosis Related Group (DRG)

S

  drugRelatedGroupCodeHI01-022300Related drug group code.1/30

NameElementLoopDescriptionC/R
otherDiagnosisInformationList
(Object)
Other Diagnosis Information
segment repeat 2 times
S

  otherDiagnosisInformation (Array)2300Array size up to 12
    qualifierCode

HI01-1 to
HI012-1
2300

Industry code.

1/3
R
    otherDiagnosisCode

HI01-2 to
HI012-2
2300

Other diagnosis code value.

1/30
R
    presentOnAdmissionIndicator







HI01-9 to
HI012-9






2300







Present on admission indicator.
12 segments
Y = onset before hospital admission
N = onset NOT before hospital
admission
U = Unknown if onset occurred
before or after hospital
admission
1/1 S







NameElementLoopDescriptionC/R
principalProcedureInformation
(Object)

Principal Procedure Information
When a procedure is performed for
an inpatient claim.
S


  qualifierCode



HI01-01



2300



Industry code.
BR = International classification of diseases,
clinical modification (ICD-9-CM)
CAH = Advanced Billing Concepts (ABC)
1/3



  principalProcedureCode

HI01-02

2300

Value of the industry Code.

1/30
R
  principalProcedureDateTime

HI01-03

2300

Principal procedure performed
date and time qualifier. D8 = MMDDYYCC
2/3 R

  principalProcedureDate
HI01-04

2300

Date the principal procedure
was performed. Format: MMDDYYCC
1/38
R

NameElementLoopDescriptionC/R
  otherProcedureInformationList
(Object)
Segment repeat: 2

S

    otherProcedureInformationArray size up to 12 R
    qualifierCode



HI01-01 to
HI012-01


2300



Industry Code BQ = International
classification of diseases
clinical modification (ICD-9-CM),
other procedure codes
1/3
R


    procedureCode
HI01-02 to
HI012-02
2300

Industry Code value.

1/30
R
    procedureDateTime


HI01-03 to
HI012-3

2300


Principal procedure performed
date and time qualifier.
D8 = MMDDYYCC
2/3
R

    procedureDate


HI01-04 to
HI012-04

2300


Date the principal procedure
was performed.
Format: MMDDYYCC
1/38
R

NameElementLoopDescriptionC/R
occurrenceSpanInformationList
(Object)
2300

Segment repeat: 2

S

  occurrenceSpanInformation

2300

Occurrence Span Information Array
size up to 12
R

    occurrenceSpanCode

HI01-02 to
HI012-02
2300

Industry Code.
BI = Occurrence Span
1/3
R
    occurrenceSpanCodeStartDate

HI01-04 to
HI012-04
2300

Date Time Period Format Qualifier
Format: MMDDYYCC
2/3
R
    occurrenceSpanCodeEndDate

HI01-04 to
HI012-04
2300

Date Time Period Format Qualifier
Format: MMDDYYCC
1/35
R

NameElementLoopDescriptionC/R
occurrenceInformationList
(Object)
Segment repeat: 2

S

  occurrenceInformation

Occurrence Information Array
size up to 12
R

    occurrenceSpanCode

HI01-02 to
HI012-02
2300

Industry Code.
BI = Occurrence Span
1/3
R
    occurrenceSpanCodeStartDate

HI01-04 to
HI012-04
2300

Date Time Period
Format Qualifier
2/3
R
    occurrenceSpanCodeEndDate

HI01-04 to
HI012-04
2300

Occurrence span code date
Format: MMDDYYCC
1/35 R

Required when a Value Code applies to the claim.

NameElementLoopDescriptionC/R
valueInformationList
(Object)
Segment repeat: 2

S

  valueInformationValue Information Array up to 12R
    valueCode

HI01-02 to
HI012-02
2300

Industry Code.

1/30
R
    valueCodeAmount

HI01-05 to
HI012-05
2300

Monetary Amount.

1/18
R

Required when Home Health Agencies need to report Plan of Treatment information
under various payer contracts.

NameElementLoopDescriptionC/R
treatmentCodeInformationList
(Object)
Segment repeat: 2

S

  treatmentCodeInformationArray up to 12
    treatmentCode

HI01-02 to
HI12-02
2300

Value of the treatment code.

1/30
R

NameElementLoopDescriptionC/R
claimPricingInformation
(Object)


Pricing/repricing information about
a health care claim or line item
from the repricer.
Specific to Payer in loop 2010BB.
S



  pricingMethodologyCode



HCP01



2300



Pricing Methodology.
Code for pricing methodology used to price
or reprice the claim or line item.
2/2
R


  repricedAllowedAmount

HCP02

2300

Monetary Amount.
Repriced Allowed Amount
1/18
R
  repricedSavingAmount


HCP03


2300


Monetary Savings amount.
Completed by the repricer only.
Specific to Payer in loop 2010-BB.
1/18
S

  repricedOrgIdentifier


HCP04


2300


Reference Identification.
Repricing organization identification
number.
1/50
S

  repricedPerDiem

HCP05

2300

Pricing rate associated with
per diem or flat rate repricing.
1/9 S

  repricedApprovedDRGCode

HCP06

2300

Reference information for a transaction set,
or by the Reference Identification Qualifier.
1/50
S
  repricedApprovedAmount

HCP07

2300

Monetary Amount Approved DRG amount.

1/18
S
  repricedApprovedRevenueCode

HCP08

2300

Completed only by repricer.
Revenue Code Approved revenue code.
1/48
S
  repricedApprovedServiceUnitCode


HCP11


2300


Unit or Basis for Measurement Code.
Specifies the value units
or method of taking a measurement.
2/2
S

  repricedApprovedServiceUnitCount

HCP12

2300

# of service units or inpatient days.

1/50
S
  rejectReasonCode



HCP13



2300



Reject Reason Code assigned by issuer.
Identifies the reason for rejection.
Example: T4 Payer Name or
Identifier Missing.
2/2
S


  policyComplianceCode



HCP14



2300



Policy Compliance Code
specifying policy compliance.
Example: 1 = Procedure Followed
(Compliance)
1/2
S


  exceptionCode



HCP15



2300



Code specifying the exception
reason for consideration of
out-of-network health care services.
Example: 2 = Emergency Care
1/2
S


NameElementLoopDescriptionC/R
serviceFacilityLocation
(Object)
S
  organizationName
NM103

2310E

Service facility organization name
or individual last name
1/60
R
  facilityPrimaryIdentifier





NM109



2310C



Lab or Facility primary identifier.
R when the service location
to be identified has an NPI
and is not a component/subcomponent
of the Billing Provider entity.
NM108 = XX
2/80
S




  address (Object)S
    address1

N301

2310E

First line of facility
address information.
1/55
R
    address2

N302

2310E

Second line of facility
address information.
1/55
S
    city

N401

2310E

City in which the facility
is located.
2/30
R
    state

N402

2310E

State in which the facility
is located. R in US/CA
2/2
R
    postalCodeN403

2310E

Displays the postal code. R in US/CA

3/15
R
    countryCodeN404

2310E

Pay-to countryCode

1/35
S
    countrySubDivisionCodeN404

2310E

Pay-to countryCode

1/35
S

At least one of SV201 or SV202 is required. This object also is required when a tax or surcharge applies to the reported service; the submitter must report that information to the receiver. All service lines in the claim provide a lineItemChargeAmount attribute (SV203). The sum of all service lines' lineItemChargeAmount values must equal the claimChargeAmount in the Claim Information object.

NameElementLoopDescriptionC/R
serviceLines (Object)R
  assignedNumber



LX01



2400



Service Line Number.
The number assigned
for differentiation within
a transaction set.
1/6
R


  serviceTaxAmount

AMT02

2400

Service Tax Amount AMT01=GT

1/18
S
  facilityTaxAmount

AMT02

2400

Facility Tax Amount AMT01=N8

1/18
S
  thirdPartyOrganizationNotes



NTE02



2400



Third Party Organization Notes.
Required when the
repricer sends more information
to the payer. NTE01=TPO
1/80
S


  institutionalService
(Object)
SV2 - Institutional Service Line

R

    serviceLineRevenueCode


SV201


2400


National Uniform Billing Committee
(NUBC) revenue code identifying
a medical product or service.
1/48
R

    compositeMedicalProcedureIdentifier
(Object)



Required for outpatient claims
if a procedure code exists
for this line item; or for an
inpatient claim if an HCPCS
or HIPPS code exists for the item.
S




      procedureIdentifier






SV202
-01





2400






Code identifying the type/source
of the descriptive number used
in product/service ID.
Example: HC = Health Care
Financing Administration
Common Procedural Coding
System (HCPCS) codes.
2/2
R





      procedureCode

SV202
-02
2400

Identifying number for
the product/service.
2/2
R
      procedureModifiers







SV202
-03
SV202
-04
SV202
-05
SV202
-06
2400







Identifies special circumstances
related to service performance,
defined by trading partners.
Array up to 4 values.




2/2
S






      description


SV202
-07

2400


Description of the procedure.
Required if SV202-02 value
is a non-specific procedure code.
1/80
S

    lineItemChargeAmount







SV203







2400







Submitted service line item
amount. The total charge
amount for the service line.
All service line charge
amounts in this field
must equal the total
claim charge amount
in Loop 2300 CLM02.
1/18
R






    serviceUnitCount

SV205

2400

Service unit count. If a decimal,
the fractional digits limit is 3.
1/8
R
    lineItemDeniedChargeAmount

SV207

2400

Non-covered service amount.

1/18
S
  serviceLineSupplementalInformation
(Object)
Line Supplemental
Information in TR3
S

    attachmentReportTypeCode


PWK01


2400


Code indicating the doc type,
report or supporting item.
Example: 06 = Initial Assessment
2/2
R

    attachmentTransmissionCode



PWK02



2400



Code defining timing,
transmission method or
format for sending reports.
Example: BM = By Mail
1/2
R


    attachmentControlNumber


PWK06


2400


Attachment Control Number.
Identifies attached electronic
documentation. PWK05=AC
2/50
S

  serviceLineDateInformation
(Object)
Service Date

S

    serviceDate



DTP03



2400



Date, time, or range of dates,
times, or dates and times.
DTP01=472 Service
DTP02=D8 Date
1/35
S


    beginServiceDate


DTP03


2400


Date, time, or range of dates,
times, or dates and times.
DTP01=472 DTP02=RD8
1/35
S

    endServiceDate


DTP03


2400


Date, time, or range of dates,
times, or dates and times.
DTP01=472 and DTP02=RD8
1/35
S

  serviceLineReferenceInformation
(Object)
Reference Information

S

    providerControlNumber

REF02

2400

Provider control number.
REF01=6R (Provider Control number)
1/50
R
    repricedLineItemRefNumber


REF02


2400


Repriced line item
reference number
REF01=9B
1/50
R

    adjustedRepricedLineItemRefNumber


REF02


2400


Adjusted Repriced Line Item
Reference Number
REF01=9D
1/50
S

  linePricingInformation
(Object)
Health Care Line
Pricing/Repricing Information
S

    pricingMethodologyCode


HCP01


2400


Pricing Methodology Code.
The pricing/repricing method for
the claim/line item.
2/2
R

    repricedAllowedAmount

HCP02

2400

Monetary Amount Allowed amount.

1/18
R
    repricedSavingAmount

HCP03

2400

Monetary Amount Savings amount.

1/18
S
    repricedOrganizationIdentifier

HCP04

2400

Reference Identification.
Repricing organization ID number.
1/50
S
    flatRateAmount

HCP05

2400

Pricing rate associated with
per diem/flat rate repricing.
1/9
S
    apgCode

HCP06

2400

Reference Identification
Approved DRG code.
1/50
S
    apgAmount

HCP07

2400

Monetary Amount
Approved DRG amount.
1/18
S
    serviceIdQualifier





HCP09





2400





Product/Service ID Qualifier Code.
It identifies the type/source
of the number used in the
Product/Service ID (234).
Ex: ER = Jurisdiction Specific
Procedure and Supply Codes
2/2
S




    repricedApprovedHCPCSCode

HCP10

2400

Product/Service ID
Approved procedure code.
1/48
S
    measurementUnitCode

HCP11

2400

Unit/Basis Measurement Code
DA = Days UN = Unit
2/2
S
    repricedApprovedServiceUnitCount

HCP12

2400

Quantity Approved
service units or inpatient days.
1/15
S
    rejectReasonCode


HCP13


2400


Reject Reason Code rejection message,
returned from the third-party
organization.
2/2
S

    policyComplianceCode

HCP14

2400

Policy Compliance Code.
Specifies policy compliance.
1/2 S

    exceptionCode



HCP15



2400



Exception Code showing the reason
for consideration of out-of-network
health care services.
Example: 2 = Emergency Care
1/2
S


Loop 2410 contains compound drug components, quantities and prices.

NameElementLoopDescriptionC/R
drugIdentification
(Object)
Drug Identification (LIN)

S

  serviceIdQualifier


LIN02


2410


Product/Service ID
Qualifier Code defining the
Product/Service ID value.
2/2
R

  nationalDrugCode


LIN03


2410


Product/Service ID.
Identifying number for a
product or service
1/48
R

  nationalDrugUnitCount

CTP04

2410

Numeric value of quantity.

1/15
R
  measurementUnitCode




CTP05
-01



2410




Composite Unit of Measure.
A code specifying the units
representing a value,
or a measurement.
Example: ME = Milligram
2/2
R



Prescription or Compound Drug
Association Number (Ref)
  linkSequenceNumber








REF02








2410








Reference Identification
Link sequence number.
A provider-assigned value,
unique to the claim.
It enables the receiver to
assemble a drug
compound.
REF01=VY (Link Sequence
Number)
1/50
S







  pharmacyPrescriptionNumber


REF02


2410


Reference Identification.
Pharmacy prescription
number. REF01=XZ
1/50
R

NameElementLoopDescriptionC/R
lineAdjustmentInformation
(Object)
Line Adjudication Information

S

  otherPayerPrimaryIdentifier

SVD01

2430

Payer identification code.

2/80
R
  serviceLinePaidAmount


SVD02


2430


Service line paid amount.
This value is the final line-level
payment, minus payer adjustments.
1/18
R

  serviceIdQualifier



SVD03-01



2430



Product/Service ID Qualifier Code.
It identifies the descriptive
number type/source used in the
Product/Service ID (234).
2/2
R


  procedureCode

SVD03-02

2430

Product/Service ID Number
for a product or service.
1/48
R
  procedureModifiers



SVD03-03 to
SVD03-06


2430



Procedure Modifier.
Identifies special circumstances
about service performance,
as defined by trading partners
2/2
S


  procedureCodeDescription

SVD03-07

2430

Procedure description.

1/80
S
  paidServiceUnitCount




SVD05




2430




Paid service unit count.
Number of paid units from
the remittance advice.
When paid units are not present,
use the original billed units.
1/15 R




  bundledOrUnbundledLineNumber




SVD06




2430




Bundled Line Number.
Used for service line bundling.
It references the LX Assigned
Number of the service line
where the service line was bundled.
1/6
S



  remainingPatientLiability


AMT02


2430


Amount of remaining
patient liability.
AMT01=EAF (Amount Owed)
1/18
S

  claimPaidDate



DTP03



2430



Adjudication or payment date.
DT01=573 (Date Claim Paid)
DTP02=D8 (Date as CCYYMMDD)
Dubbed Remittance Date in TR3.
1/35
R


NameElementLoopDescriptionC/R
claimAdjustmentInformation
(Array)
Repeats 5 times

S

  adjustmentGroupCode



CAS01



2430



Claim Adjustment Group Code.
It identifies the general category
of payment adjustment.
Example: CO = Contractual Obligations
1/2 R



adjustmentdetails (Array)Repeats 6 times
  adjustmentReasonCode


S


2430


Claim Adjustment Reason Code.
Describes the reason for the adjustment.
CAS02/CAS05/CAS08/CAS11/CAS14
1/5 S


  adjustmentAmount

S

2430

Monetary amount of the adjustment.
CAS03/CAS06/CAS09/CAS12/CAS15
1/18 R

  adjustmentQuantity

S

2430

Quantity of units of service being adjusted.
CAS04/CAS07/CAS10/CAS13/CAS16
1/15 S

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