Integrated Rules Professional JSON-to-EDI Contents

See JSON-to-EDI API Mapping.

The Consolidated 837p Implementation Guide page 53 and 54 discusses this in further detail.

Submitter (1000A)

Receiver (1000B)

Subscriber

Subscriber Hierarchical Level (2000B)

Subscriber Information (2310BA)

Payer Information (2010BB)

Other Subscriber Information (2320)

Other Subscriber Name (2330A)

Patient Hierarchical Level (2000C)

Patient Name (2010CA)

Property and Casualty (2010CA)

Provider ID

Provider Contact Information – 2010AA

Pay-To Address Name – 2010AB

Pay-To Plan Name – 2010AC

Claim Information (2300)

Claim Information (CLM)

Claim Date Information (DTP)

Claim Supplemental (PWK)*

Contract Information (CN)

Patient Amount Paid*

File Information (K3)*

Claim Note (NTE)

Ambulance Transport Information (CR)

Spinal Manipulation Service Information (CR)

Ambulance Certification (CRC)

Patient Vision Information (CRC)

Homebound Indicator (CRC)

EPSDT Referral (CRC)

Health Care Code Information (HI)

Anesthesia Related Procedure (HI)

Condition Information (HI)

Claim Pricing Information (HCP)

Ambulance Pick Up Location (2310E)

Ambulance Drop Off Location (2310F)

Service Facility Location (2310C)

Other Payer (2330B)

Other Payer Referring Provider (2330C)

Other Payer Rendering Provider (2330D)

Other Payer Service Facility Location (2330E)

Other Payer Supervising Provider (2330F)

Other Payer Billing Provider (2330G)

LX – 1

DTP – 8 Service

REF Provider Control – 10

AMT Sales Tax – 11

AMT Postage – 12

K3 File Information 13

NTE Third Party 14

QTY Ambulance 15

QTY Obstetric Anesthesia – 9

CRC Hospice – 6

CRC Durable – 7

SV – 2

PWK – 3

CR102 & CR301 (Ambulance) – 4

CR301 – 5

DTP 8

REF 10 – MISC Number References

HCP 18

Durable Medical Equipment (DME) Service

Drug Identification (2410)

Line Adjudication Information

Line Adjustment Information

Form Identification Code

Supporting Documentation

Other Providers (2420A-2420F)

Ambulance Pick Up Location (2420G)

Ambulance Drop Off Location (2420H)

Professional Claims v3 API JSON-to-EDI mapping

FieldDescriptionConstraints
controlNumber



Transaction Set Control Number 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 Change Healthcare 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)R
  organizationName


NM103


1000A


Organization name for the submitter, you can use organization or last name.
NM102 = 02 (Non-Person Entity)
1/60 R


  lastName


NM103


1000A


Last name for the submitter, you can use organization or last name.
NM102 = 01(Person)
1/60 R


  firstName

NM104

1000A

Submitter first name.
NM102 = 01(Person)
1/35

  middleName

NM105

1000A

Submitter middle name or initial.
NM102 = 01(Person)
1/25

  taxId

NM108

1000A

Electronic Transmitter Identification Number (ETIN) 46.1/2 R

  contactInformation (Object)
    namePER021000ASubmitter 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)
The insurance company that underwrites the insurance policy.R

  organizationName

NM103

1000B

Organization name for the entity underwriting the insurance policy.1/60 R

  taxId

NM108

1000B

Electronic Transmitter Identification Number (ETIN) 46.1/2 R

See the 837p Implementation Guide page 116 and the Professional Claims V3 OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
paymentResponsibilityLevelCode


SBR01


2000B


Code that identifies payer's level of responsibility for payment of claim.
Example:
P = Primary S = Secondary
1/1 R


groupNumber

SBR03

2000B

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

subscriberGroupName

SBR04

2000B

The subscriber group name is the plan name.1/60 S

insuranceTypeCode







SBR05







2000B







Code that identifies the type of insurance policy in a specific insurance program.
Information is specific only to Medicare plans.
Refer to the ASC X12
Consolidated 270/271 Guide bottom of page 117.
1/3 S







  pregnancyIndicator

PAT09

See Desc.

Subscriber 2000B or Patient 2000C.
1/10 S

See the 837p Implementation Guide page 116 through 127 and the Professional Claims V3 OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
subscriber (Object)The person who has the insurance policy.R
  memberIdNM1092010BAThe subscriber’s insurance member ID.2/80 R
  ssn

REF02

2010BA

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

  firstName

NM104

2010BA

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

  middleNameNM1052010BASubscribers middle name.1/25
  dateOfBirth



DMG02



2010BA



The subscriber’s birth date as specified on their policy.
Format: YYYYMMDD
Required when subscriber is the patient.
1/35 S



  gender


DMG03


2010BA


The subscriber’s gender as specified on their policy.
Required when subscriber is the patient.
1/1 S


  address (Object)
    address1

N301

2010BA

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

    address2N3022010BASubscriber’s address line 2.1/35
    city

N401

2010BA

Subscriber’s city.
Required when subscriber is the patient.
1/60 S

    state

N402

2010BA

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

    postalCode

N403

2010BA

Subscriber’s postal code.
Required when subscriber is the patient.
3/15 S

    countryCodeN4042010ABCountry Code.1/35
    countrySubDivisionCodeN4042010ABCountry Sub Division Code.1/35

Destination Payer's information for the claim. See the 837p Implementation Guide page 133 and the Professional Claims V3 OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
tradingPartnerName


NM103


2010BB


Organization Name.
NM101=PR (Payer)
MN102 = 2 (Non-Person Entity)
1/60 R


tradingPartnerServiceId

NM109

2010BB

Code that identifies party or other code.
NM108 = PI (Payer Identification)
2/80

payerAddress (Object)
  address1N3012010BBAddress Information.1/55
  address2N3022010BBAdditional Address Information.1/55
  cityN4012010BBCity Name.2/30
  stateN4022010BBState Name.2/2
  postalCodeN4032010BBPayer Postal Zone or Zip code.3/15
  countryCodeN4042010BBCountry Code.1/35
  countrySubDivisionCodeN4042010BBCountry sub division code.1/35
  payerIdentificationNumber

REF02

2010BB

Payer identification Number.
REF01=2U
1/50

  employerIdentificationNumber

REF02

2010BB

Employer’s Identification Number.
REF01 = EI
1/50

  claimOfficeNumberREF022010BBClaim Office Number.
REF01 = FY
1/50
  naic


REF02


2010BB


National Association of Insurance Commissioners (NAIC) code.
REF01=NF
1/50


  commercialNumber

REF02

2010BB

Provider Commercial Number.
REF01 = G2
1/50

  locationNumberREF022010BBLocation Number.
REF01 = LU
1/50

See the 837p Implementation Guide page 116 through 18 and page 297 and the Professional Claims V3 OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
otherSubscriberInformation
(Array of objects)
The person who has the insurance policy.S

  paymentResponsibilityLevelCode



SBR01



2320



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



  individualRelationshipCode



SBR02



2320



Code, which describes the relationship between two individuals or entities.
Example:
01 = Spouse
2/2 R



  insuranceGroupOrPolicyNumber


SBR03


2320


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

  otherInsuredGroupNameSBR042320Plan name.1/60
  insuranceTypeCode




SBR05




2320




Code that identifies the insurance policy type within a specific insurance program.
See annotation in OpenAPI Spec.
1/3




  claimFilingIndicatorCode



SBR09



2320



Identifies the claim type.
Example:
13 = Point of Service
See annotation in OpenAPI Spec.
1/2 R



  claimLevelAdjustments (Array)S
    adjustmentGroupCode



CAS01



2320



Identifies the category of payment adjustment.
Ex: CO = Contractual Obligations
1/2



    adjustmentdetails (Array)
    adjustmentReasonCode



See Desc.



2320



Describes the detailed reason for the adjustment. CAS02, CAS05, CAS08, CAS11, CAS14, CAS171/5



    adjustmentAmount


See Desc.


2320


Amount of the adjustment.
CAS03, CAS06, CAS09, CAS12, CAS15, CAS18
1/18


    adjustmentQuantity


See Desc.


2320


Units of service adjusted.
CAS04, CAS07, CAS10, CAS13, CAS16, CAS19
1/15


AMT — Patient Amount Paid
  payerPaidAmount



AMT02



2320



Coordination of Benefits (COB) Payer Paid amount that Medicaid actually paid.1/18



  nonCoveredChargeAmount


AMT02


2320


Monetary Amount — COB Non-Covered Amount.1/18


  remainingPatientLiability







AMT02







2320







Monetary Amount — Remaining Patient Liability.
Check the Consolidated 837 Guide for further details and requirements.
Use the search term, "remaining patient liability" for Loop 2320.
1/18 S






OI — Other Insurance Coverage Information
  benefitsAssignmentCertificationIndicator




OI03




2320




This element answers the question of whether the insured authorized remitting payment directly to the provider.1/1




  patientSignatureGeneratedForPatient







OI04







2320







R when a signature is executed on the patient’s behalf under state/federal law.
Example:
P = Signature generated by provider because the patient was not physically present for services.
1/1







  releaseOfInformationCode





OI06





2320





Code that shows that the provider has on file a signed statement by the patient authorizing release of medical data to other organizations.1/1





MOA — Medicare Outpatient Adjudication
  reimbursementRate

MOA01

2320

Percentage expressed as a decimal.1/10

  hcpcsPayableAmount




MOA02




2320




The claim's Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.1/18




  claimPaymentRemarkCode




MOA03
MOA04
MOA05
MOA06
MOA07
2320




Reference information for a Transaction Set or specified by the Reference Identification Qualifier.1/50




  endStageRenalDiseasePaymentAmount

MOA08

2320

End Stage Renal Disease (ESRD) payment amount.1/18

  nonPayableProfessionalComponentBilledAmount


MOA09


2320


The professional component amount billed but not payable.1/18


NameElementLoopDescriptionC/R
otherSubscriberName (Object)The insurance policy subscriber.R
  otherInsuredQualifier


NM102


2330A


Entity type.
Example:
1 = Person
2 = Non-Person Entity
1/1


  otherInsuredLastName

NM103

2330A

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

  otherInsuredFirstName

NM104

2330A

The subscriber’s first name as specified on their policy.1/35R

  otherInsuredMiddleNameNM1052330ASubscribers middle name.1/25 S
  otherInsuredNameSuffix

NM107

2330A

Use when needed to identify patient.1/10 S

  otherInsuredIdentifierTypeCode


NM108


2330A


Type of identification.
Example:
MI = Member Identification Number
1/2 R


  otherInsuredIdentifier

NM109

2330A

Code that identifies a party or other code.2/80 S

  otherInsuredAddress (Object)
    address1


N301


2330A


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


    address2

N302

2330A

Subscriber’s address line 2.1/35 S

    city


N401


2330A


Subscriber’s city.
Required when the subscriber is the patient.
1/60 S


    state


N402


2330A


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


    postalCode


N403


2330A


Subscriber’s postal code.
Required when the subscriber is the patient.
3/15 S


    countryCodeN4042330ACountry Code.1/35 S
    countrySubDivisionCodeN4042330ACountry Sub Division code.1/35 S
    otherInsuredAdditionalIdentifierREF022330ASocial Security Number.
REF01 = SY
1/50 S

📘

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 holder.S
  lastName



NM103



2010CA



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


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




DMG02




2010CA




Dependent’s birth date.
R when the dependent is the patient.
Required if patient is a dependent of subscriber and cannot be uniquely identified.
1/35 See Desc.




  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 See Desc.




  ssn

REF02

2010CA

Dependent social security number.
REF01 = SY
1/50

  relationshipToSubscriberCode





PAT01





2000C





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





NameElementLoopDescriptionC/R
relationshipToSubscriberCode





PAT01





2000C





Patient’s relation to the insured person, value of PAT01.
Example:
01 = Spouse
Required if patient is a dependent of subscriber and cannot be uniquely identified.
1/50 See Desc.





  pregnancyIndicator

PAT09

See Desc.
Subscriber 2000B or Patient 2000C.1/10

NameElementLoopDescriptionC/R
dependent (Object)S
  lastName



NM103



2010CA



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



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




DMG02




2010CA




Dependent’s birth date.
Format: YYYYMMDD
Required if patient is a dependent of subscriber and cannot be uniquely identified.
1/35 See Desc




  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 See Desc.




  ssn

REF02

2010CA

Dependent's social security number.
REF01 = SY
1/50

  contactInformation
(Object)
Property and Casualty Patient Contact Information.S
    namePER022010CAProvider contact name.1/60 S
    phoneNumber

PER04

2010CA

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

NameElementLoopDescriptionC/R
contactInformation (Object)

2010CA

Property and Casualty Patient Contact Information.S

  namePER022010CAProvider contact name.1/60
  phoneNumber

PER04

2010CA

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

  faxNumber

PER04

2010CA

Provider fax number.
PER03 = FX
1/256 S

  emailPER042010CASubmitter email address.
PER03 = EM
1/256 S
  validContactPER042010CABoolean.S

NameElementLoopDescriptionC/R
providers (Object)R
  providerType





NM101





See Desc.




Provider type, send what is within quotes:
“BillingProvider” (Loop 2010AA),
“ReferringProvider” (Loop 2310A),
“RenderingProvider” (Loop 2310B),
“OrderingProvider” (Loop 2420E) or
“SupervisingProvider” (Loop 2310D)
R





  npi

NM109

Relative

National Provider Identification value.
NM108 = XX
2/80 S

NameElementLoopDescriptionC/R
Billing Provider Tax ID
employerId



REF02



Relative



Provider tax identification number.
REF01 = EI (Employer ID)
1/50 R



ssn





REF02





Relative





Provider's Social Security Number.
REF01 = SY
(Social Security Number).
If provider listed does not have a Tax ID send SSN.
1/50
See Desc.




Billing Provider Secondary ID
commercialNumber


REF02


Relative


Provider commercial number.
REF01 = G2
(Provider Commercial Number)
1/50 S


locationNumber

REF02

Relative

Provider location number.
REF01 = LU (Location Number)
1/50 S

Billing & Referring Provider UPIN/License
stateLicenseNumber



REF02



See Desc.


State license number.
REF01 = 0B
Billing Provider (2010AA) Referring Provider (2310A)
1/50 S



providerUpinNumber



REF02



See Desc.


Provider UPIN number.
REF01 = 1G
Billing Provider (2010AA) Referring Provider (2310A)
1/50 S



taxonomyCode



PRV03



See Desc.


Health care provider taxonomy code.
Referring Provider ()
Rendering Provider (2310B)
1/50 R



NameElementLoopDescriptionC/R
organizationName

NM103

2010AA

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

lastName

NM103

2010AA

Provider last name, you 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 1.1/35 R
  address2N3022010AAProvider’s address line 2.1/35
  cityN4012010AAProvider’s city.1/60 R
  stateN4022010AAProvider’s state.1/35 S
  postalCodeN4032010AAProvider’s postal code.3/15 S
  countryCodeN4042010AACountry code.1/35 S
  countrySubDivisionCodeN4042010AACountry Sub Division code.1/35 S
contactInformation (Object)S
  namePER022010AAProvider contact name.1/60 S
  faxNumberPER042010AAProvider fax number.
PER03 = FX
1/256 S
  phoneNumberPER042010AAProvider contact phone number.
PER03 = TE
1/256 S

NameElementLoopDescriptionC/R
payToAddress (Object)S
  address1N3012010ABPay-To address’s address line 1.1/35 R
  address2N3022010ABPay-To address’s address line 2.1/35 S
  cityN4012010ABPay-To address’s city.1/60 R
  stateN4022010ABPay-To address’s state.1/35 S
  postalCodeN4032010ABPay-To address’s postal code.3/15 S
  countryCodeN4042010ABPay-To country code.1/35 S
  countrySubDivisionCodeN4042010ABPay-To country code.1/35 S

NameElementLoopDescriptionC/R
payToPlan (Object)S
  organizationNameNM1032010ACPay-To Plan organization name.1/60 R
  primaryIdentifierTypeCode




NM108




2010AC




Pay-To Plan identification code qualifier.
PI = Payer Identification
XV = Centers for Medicare and Medicaid Service PlanID
1/2 R




  primaryIdentifier
NM109
2010AC
Pay-To Plan Primary Identifier.
2/80
R
📝 REF01 and REF02 required for REF segment.
  secondaryIdentifierTypeCode




REF01




2010AC




Pay-To Plan Reference Identification Qualifier.
2U = Payer Identification Number
FY = Claim Office Number
NF = NAIC code
2/3




  secondaryIdentifierREF022010ACPay-To Plan Secondary Identifier.1/50
  taxIdentificationNumber



REF02



2010AC



Pay-To Plan Tax Identification Number.
REF01 = EI
(Employer’s Identification Number)
1/50



  address (Object)
    address1
N301
2010AC
Pay-To Plan address line 1.
1/35
R
    address2N3022010ACPay-To Plan address line 2.1/35 S
    cityN4012010ACPay-To Plan city.1/60 R
    stateN4022010ACPay-To Plan state.1/35 S
    postalCodeN4032010ACPay-To Plan postal code.3/15 S
    countryCodeN4042010ACPay-To country code.1/35 S
    countrySubDivisionCodeN4042010ACPay-To country code.1/35 S

NameElementLoopDescriptionC/R
claimInformation
(Object)

A series of required data fields comprising the core information for the claim.R


  claimFilingCode

SBR09

2000B

Subscriber claim filing code.
Example:
12 = PPO
1/2 R

  propertyCasualtyClaimNumber



REF02




2010CA




(Under Patient Name loop) Patient property and casualty claim number.
REF01 = Y4
(Agency Claim Number)
1/50 R




  patientWeight


PAT08


See Desc.
Patient weight.
Subscriber 2300B
or Patient 2000C
1/10


  patientControlNumber


CLM01


2300


Identifier to track a claim from creation by provider through payment.1/38
R
  claimChargeAmountCLM022300Total claim charge amount.1/18 R
  placeOfServiceCode

CLM05-01
2300

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

  claimFrequencyCode

CLM05-03
2300

Code that defines the frequency of the claim.1/1 R

  signatureIndicator

CLM06

2300

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

  planParticipationCode





CLM07





2300





Code that states if the provider accepted assignment.
A = Assigned
B = Assignment accepted only on clinical lab services
C = Not Assigned
1/1 R





  benefitsAssignmentCertificationIndicator




CLM08




2300




Code that indicates the insured or authorized person agrees benefits will be assigned to the provider.
Yes = Y, No = N
1/1 R




  releaseInformationCode







CLM09







2300







Code that indicates if the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
Informed = I, Yes = Y
1/1 R







NameElementLoopDescriptionC/R
patientControlNumber


CLM01


2300


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


claimChargeAmountCLM022300Total claim charge amount.1/18 R
placeOfServiceCode


CLM05-01

2300


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


claimFrequencyCode

CLM05-03
2300

Code specifying the frequency of the claim.1/1 R

signatureIndicator


CLM06


2300


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


planParticipationCode






CLM07






2300






Code, which indicates if the provider accepts the assignment.
A = Assigned
B = Assignment accepted on clinical lab services only,
C = Not Assigned
1/1 R






benefitsAssignmentCertificationIndicator




CLM08




2300




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




releaseInformationCode







CLM09







2300







Code that indicates if the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
Informed = I
Yes = Y
1/1 R







patientSignatureSourceCodeCLM102300CLM10=PBoolean
relatedCausesCode



CLM11



2300



CLM11 Allowed Values are:
'AA' Auto Accident
'EM' Employment
'OA' Other Accident
2/3



patientAmountPaidATM022300ATM01=F51/18
autoAccidentStateCode






CLM11-04





2300






Required when the CLM11-01 or CLM11-02 element contains the Auto Accident (AA) value, which identifies the state or province where the accident occurred.
If not required, do not send.
2/2 S






autoAccidentCountryCode





CLM11-05




2300





Required when the CLM11-01 or CLM11-02 element has the Auto Accident (AA) value and the accident happened in a country other than the US or Canada.2/3 S





specialProgramCode













CLM12













2300













Required if services are rendered under some circumstances in Medicaid.
If not required, do not send.
Codes are as follows:
02: Physically Handicapped Children's Program
03: Special Federal Funding
05: Disability
09: Second Opinion or Surgery.
All listed codes apply only to Medicaid claims.
2/3 S













delayReasonCode





CLM20





2300





Required if claim is submitted late beyond contracted date of filing.
If not required, do not send.

See Implementation Guide page 165.
1/2 S





homeBoundIndicator







CRC02







2300







Required for Medicare claims when an independent lab provides an EKG tracing or obtains a specimen from a homebound or institutionalized patient.
CRC01 = 75
CRC02 = Y
CRC03 = IH
Boolean S







fileInformation










K301










2300










Consult the Consolidated 837 Guide before using this segment.
Its requirements are significant and you should avoid it unless absolutely necessary.
The K3 segment is used only to meet an unexpected data requirement of a legislative authority.
1/80 S










fileInformationList

K301

2300

K301, use when there is more than one fileInformation.List[String]
S

DTP = Date or Time or Period

NameElementLoopDescriptionC/R
Date Format: YYYYMMDD
symptomDateDTP032300Date of first symptom. DTP01=4311/35
initialTreatmentDate

DTP03

2300

Date of initial treatment.
DTP01=454
1/35

lastSeenDate

DTP03

2300

Date of the last visit or consultation.
DTP01=304
1/35

acuteManifestationDate


DTP03


2300


Date of symptoms of a chronic condition.
DTP01=453
1/35


accidentDate

DTP03

2300

Date of the accident.
DTP01=439
1/35

lastMenstrualPeriodDate

DTP03

2300

Date of last menstruation.
DTP01=484
1/35

lastXRayDate

DTP03

2300

Date of last x-ray.
DTP01=455
1/35

hearingAndVisionPrescriptionDate


DTP03


2300


Hearing and vision prescription date.
DTP01=471
1/35


disabilityBeginDate


DTP03


2300


Initial disability start date.
DTP01=360
1/35


disabilityEndDate

DTP03

2300

End of disability date.
DTP01=361
1/35

lastWorkedDate

DTP03

2300

Date last worked.
DTP01=297
1/35

authorizedReturnToWorkDate

DTP03

2300

Date authorized to return to work.
DTP01=296
1/35

admissionDate

DTP03

2300

Date admitted to the hospital.
DTP01=435
1/35

dischargeDate

DTP03

2300

Date discharged from the hospital.
DTP01=096
1/35

assumedAndRelinquishedCareBeginDate




DTP03




2300




Date of assumed care.
Used to indicate the date that the provider filing this claim assumed care from another provider for post-operative care.
DTP01=090
1/35




assumedAndRelinquishedCareEndDate




DTP03




2300




Relinquished care date.
The date the provider for the claim assigned post-operative care to another provider.
DTP01=091
1/35




repricerReceivedDate


DTP03


2300


Date when a repricer passed the claim onto the payer.
DTP01=050
1/35


firstContactDate



DTP03



2300



Date the patient first consulted the provider for their condition.
DTP01=444
1/35



See the 837p Consolidated Guide page 184 through 187 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
claimSupplementalInformation (Object)S
  claimNumber


REF02


2300


Claim ID number for clearing houses.
REF01=D9
1/50 R


  reportInformation (Object)
    attachmentReportTypeCode


PWK01


2300


Code that describes the attachment contents.
Example:
08 = Plan of Treatment
2/2 R


     attachmentTransmissionCode


PWK02


2300


Code that describes how the attachment is sent.
Example:
EL = electronic only.
1/2 R


     attachmentControlNumber



PWK06



2300



Identifies an electronic attachment. The ACN appears in the 275's TRN02 field for an attachment.2/80 S


REFREF01 selection is required.
referralNumber



REF02



2300



Number assigned by the payer or Utilization Management Organization (UMO).
REF01=9F
1/50



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






cliaNumber


REF02


2300


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

repricedClaimNumber


REF02


2300


The repriced claim number is completed by the repricer.
REF01=9A
1/50 S

adjustedRepricedClaimNumber


REF02


2300


Claim number for an adjusted repriced claim number.
REF01=9C
1/50 S

investigationalDeviceExemptionNumber


REF02


2300


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

mammographyCertificationNumber

REF02

2300

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


REF02


2300


Medical record number of the patient.
REF01=EA
1/50 S

demoProjectIdentifier




REF02




2300




Claim identifier for atypical claims from content, purpose, and/or payment, for a demonstration or special project or clinical trial.
REF01=P4
1/50 S




carePlanOversightNumber




REF02




2300




The number of the home health agency or hospice providing Medicare covered patient services for the period during which CPO services were furnished.
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
See annotation in OpenAPI Spec.
1/50 S


See the 837p Consolidated Guide page 188 and 189 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
claimContractInformation (Object)
  contractTypeCode

CN101

2300

Code that identifies a contract type.
Ex: 02 = Per Diem
2/2 R

  contractAmountCN1022300Contract amount.1/18 S
  contractPercentageCN1032300Allowance or charge percent.1/6 S
  contractCodeCN1042300Contract code.1/50 S
  termsDiscountPercentage




CN105




2300




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




  contractVersionIdentifier

CN106

2300

Additional identifier that identifies number for the contract.1/30 S

NameElementLoopDescriptionC/R
patientAmountPaid

AMT02

2300

Amount paid by the patient.
AMT01=F5
1/18

NameElementLoopDescriptionC/R
fileInformation


K301


2300


Data in fixed format agreed upon by the sender and receiver.
Comma separated values.
1/80


NameElementLoopDescriptionC/R
claimNote (Object)Claim Notes/Claim Information.
  additionalInformation


NTE02


2300


Description to clarify the related data elements and their content.
NTE01=ADD
1/80


  certificationNarrative

NTE02

2300

NTE01=CER
Valid only for Professional Claims.
1/80

  goalRehabOrDischargePlans


NTE02


2300


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


  diagnosisDescription

NTE02

2300

Diagnosis description.
NTE01=DGN
1/80

  thirdPartOrgNotes


NTE02


2300


Third-party organization notes.
NTE01=TPO
Valid only for Professional Claims.
1/80


NameElementLoopDescriptionC/R
ambulanceTransportInformation
(Object)
S

  patientWeightInPounds

CR102

2300

Numeric value of weight.
CR101=LB
1/10 R

  ambulanceTransportReasonCodeCR1042300Ambulance Transport Reason Code.1/1 R
  transportDistanceInMiles

CR106

2300

Distance traveled during transport.
CR105=DH (Miles)
1/15 R

  roundTripPurposeDescription

CR109

2300

The purpose of the round trip.

1/80
S
  stretcherPurposeDescription


CR110


2300


The purpose for the usage of a stretcher during the ambulance service.1/80 S


NameElementLoopDescriptionC/R
spinalManipulationServiceInformation
(Object)
S

  patientConditionCode

CR208

2300

Code that provides the label describing patient’s condition.1/1 R

  patientConditionDescription1

CR210

2300

Description of the patient’s condition.1/80 S

  patientConditionDescription2

CR211

2300

Additional description of the patient’s condition.1/80 S

NameElementLoopDescriptionC/R
ambulanceCertification (Array)








Required if two specific conditions exist: when the claim includes ambulance services, AND if the claim reports conditionCodes in one or more loop elements in CRC03 to CRC07.
If the transaction does not require this segment, do not send.
S








  certificationConditionIndicator






CRC02






2300






Code that indicates a Yes or No condition or response.
Y: indicates the condition codes in CRC03 to CRC07 apply.
N: indicates the codes in CRC03 to CRC07 do not apply.
CRC01=07
1/1






  conditionCodes






CRC03
CRC04
CRC05
CRC06
CRC07


2300






Code that labels a condition.
Use CRC03 first, then CRC04-07, as necessary. Ambulance condition code example:
01 = Patient admitted to hospital.
You can apply codes for CRC03 to CRC04-CRC07 as needed.
2/3






  sequenceOrder


2300


Provide each field to which it belongs.
Example:
1 is CRC03
2 is CRC04
  conditionCode

2300

Value of the condition code goes in this field.

NameElementLoopDescriptionC/R
patientVisionInformation (Object)
  codeCategory



CRC01



2300



Qualifies CRC03 to CRC07.
E1: Spectacle Lenses
E2: Contact Lenses
E3: Spectacle Frames
2/2



  certificationConditionIndicator






CRC02






2300






Code that indicates a Yes or No condition or response.
Y: indicates the condition code in CRC03 to CRC07 apply.
N: indicates the conditional codes in CRC03 to CRC07 do not apply.
CRC01=07
1/1






  conditionCodes





CRC03





2300





Code that indicates the reason for the replacement.
Use CRC03 1st, then CRC04 to CRC07 as necessary.
Condition code.
Example:
L2 = Replacement Due to Loss or Theft
L3 = Replacement Due to Breakage or Damage
2/3





  sequenceOrder


2300


Provide which field it belongs to.
Example:
1 would be CRC03
2 would be CRC04
  conditionCode2300Value of the condition code.

NameElementLoopDescriptionC/R
homeBoundIndicator







CRC02







2300







R for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.
Possible values:
Y (Yes) or N (No)
CRC01=75 (Functional Limitations)
CRC03=IH (Independent at Home)
1/1







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




CRC02




2300




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




  conditionIndicators



CRC03
CRC04
CRC05

2300



Condition indicator.
Example:
ST = New Services Requested
Use CRC04 and CRC05 if more codes are necessary.
2/3



NameElementLoopDescriptionC/R
healthCareCodeInformation
(Object)
For sending health care codes with dates and quantities.S

  sequenceOrder2300Use sequenceOrder for the values
  diagnosisTypeCode

HI01-01
HI02-01
2300

Health care diagnosis code qualifier

1/3 R

  diagnosisCode

HI01-02
HI02-02
2300

Diagnosis code value.
Maps to HealthCareDiagnosisCode HI02-02
1/30
R

NameElementLoopDescriptionC/R
anesthesiaRelatedSurgicalProcedure (Array)







HI01-02







2300







Procedure code value.
HI01-01=BP, HI02-01=BO
Required for claims billing or reporting anesthesiology services, the provider knows the surgical code, and that claim adjudication relies on correct provision of the code.
1/30 S







NameElementLoopDescriptionC/R
conditionInformation (Array)


Array of conditionCodes. This can repeat.
Needed when the claim includes patient's condition information.
S


  conditionCodes



HI02-02



2300



Code that indicates a condition.
Use CRC03 first, then CRC04-07 as needed.
Ambulance condition code example:
01 = Patient was admitted to a hospital.
2/3 R



  sequenceOrder2300Ex: sequenceOrder = 1 for HI01-011/2 R
  conditionCode

HI01-02

2300

Value of the condition code.
Example:
HI01-01=BG (Condition)
1/30 R

See the 837p Implementation Guide page 254 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
claimPricingRepricingInformation
(Object)





2300






Pricing/repricing information about a claim or a line item.
Required when the repricer considers it necessary.
Completed by the repricer.
Providers do not complete this segment.
S






  pricingMethodologyCode




HCP01




2300




Pricing Methodology Code specifies the pricing method to price or reprice the claim.
At least one instance of HCP01 or HCP13 is required.
2/2 R




  repricedAllowedAmount





HCP02





2300





Monetary Amount, Repriced Allowed Amount.
Beyond the standard codes in the X12 TR3, your partner agreement defines code use.
HCP02 is the allowed amount.
1/18 R





  repricedSavingAmount

HCP03

2300

Monetary Amount Savings.
Completed by the repricer.
1/18 S

  repricingOrganizationIdentifier


HCP04


2300


Reference Identification Repricing organization identification number.1/50 S

  repricingPerDiemOrFlatRateAmong

HCP05

2300

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

  repricedApprovedAmbulatoryPatientGroupCode

HCP06

2300

Reference Identification Approved DRG code.1/50 S
  repricedApprovedAmbulatoryPatientGroupAmount

HCP07

2300

Monetary Amount Approved DRG amount.1/18 S
  rejectReasonCode





HCP13





2300





Reject Reason Code Code is assigned by the issuer to identify the reason for the claim rejection.
Example:
T4 = Payer Name/Identifier Missing.
2/2 S





  policyComplianceCode



HCP14



2300



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



  exceptionCode



HCP15



2300



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



NameElementLoopDescriptionC/R
ambulancePickUpLocation (Object)LocationS
  address1N3012310EFirst line of facility address information.1/55
  address2N3022310ESecond line of facility address information.1/55
  cityN4012310ECity in which the facility is located.2/30
  stateN4022310EState in which the facility is located.2/2
  postalCodeN4032310EDisplays the postal code.3/15
  countryCodeN4042310ECountry code.1/35
  countrySubDivisionCodeN4042310ECountry Sub Division code.1/35

NameElementLoopDescriptionC/R
ambulanceDropOffLocation (Object)S
  address1N3012310FFirst line of facility address information.1/55
  address2N3022310FSecond line of facility address information.1/55
  cityN4012310FCity in which the facility is located.2/30
  stateN4022310FState in which the facility is located.2/2
  postalCodeN4032310FDisplays the postal code.3/15
  countryCodeN4042310FCountry code.1/35
  countrySubDivisionCodeN4042310FCountry Sub Division code.1/35

NameElementLoopDescriptionC/R
serviceFacilityLocation (Object)

Required when the service location is different from the billing provider's.S

  organizationName

NM103

2310C

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

  npi





NM109





2310C





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





  address (Object)R
    address1N3012310C1st line, facility address information.1/55
    address2N3022310C2nd line, facility address information.1/55
    cityN4012310CCity in which the facility is located.2/30
    stateN4022310CState in which the facility is located.2/2
    postalCodeN4032310CDisplays the postal code.3/15
    countryCodeN4042310Ccountry code.1/35 S
    countrySubDivisionCodeN4042310CCountry Sub Division code.1/35

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 Identification Number
1/2

  otherPayerIdentifier

NM109

2330B

Code that identifies a party or other code.2/80

  otherPayerAddress (Object)
    address1

N301

2330B

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

    address2N3022330BPayer’s address line 2.1/35
    city


N401


2330B


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


N402


2330B


Payer’s state.
Required when other is payer for the patient.
1/35
See Desc.
    postalCode


N403


2330B


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


    countryCodeN4042330BCountry code.1/35 S
    countrySubDivisionCodeN4042330BCountry Sub Division code.1/35 S
otherPayerAdjudicationOrPaymentDate


DTP03


2330B


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


otherPayerSecondaryIdentifierREF022330B1/50 S
  qualifier

REF01

2330B

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

  identifierREF022330BValue of the ID.1/50 R
  otherPayerClaimAdjustmentIndicator


REF02


2330B


Other Payer Claim Adjustment Indicator.
REF01=T4 Signal Code
1/50 S


  otherPayerClaimControlNumber

REF02

2330B

Other payer claims control number.
REF01=F8
1/50 S

See the 837p Implementation Guide page 334 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
otherPayerReferringProvider (Object)


2330C


NM101=DN (Referring Provider)
NM102=1 (Person)
Array[Other Payer Referring Provider]
S


  otherPayerReferringProviderIdentifier


2330C


NM101 = P3 (Primary Care Provider)
NM102=1 (Person) Array[ReferenceIdentification]
1/50 R

  ReferenceIdentification (Object)


2330C


Reference ID as specified by the transaction set or by the Ref01 qualifier.R


    qualifier




REF01




2330C




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




    identifier

REF02

2330C

REF01 ID/number.

1/50 R

See the 837p Implementation Guide page 338 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
otherPayerRenderingProvider
(Object)
2330D


Supplies the full name of an individual or organization.S


  entityTypeQualifier



2330D



NM102



NM101=82
(Rendering Provider)
NM102= 1 (Person)
or 2 (Non-Person Entity)
R



  otherPayerRenderingProviderSecondary (Object)REF012330DR
    otherPayerRenderingProviderSecondaryIdentifier

REF01

2330D

Array
[ReferenceIdentification]
1/1 R
    referenceIdentification




2330D




REF02




Reference ID as specified by the transaction set or by the Ref01 qualifier.1/50 R



      qualifier






REF01






2330D






Type of ID.
REF01=0B/1G/G2:
OB: State License Number
1G: Provider UPIN No.
G2: Provider Commercial Number
LU: Location Number
2/3 R





      identifier

REF02

2330D

REF01 ID/number.

1/50 R

See the 837p Implementation Guide page 342 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
otherPayerServiceFacilityLocation
(Object)
2330E

S

  otherPayerServiceFacilityLocationSecondaryIdentifier




Reference ID as specified by the transaction set or by the Reference Identification Qualifier.1/50 R



    qualifier





REF01





2330E





Type of ID.
REF01=0B/G2/LU:
OB: State License No.
G2: Provider Commercial No.
LU: Location Number
2/3 R





    identifier

REF02

2330E

REF01 ID/number.

1/50 R

See the 837p Implementation Guide page 345 for more information.

NameElementLoopDescriptionC/R
otherPayerSupervisingProvider
(Object)
2330F

NM101 = 98

S

  otherPayerSupervisingProviderIdentifier



REF02



2330F



Reference ID as specified by the transaction set or by the Reference Identification Qualifier.1/50 R



    qualifier





REF01





2330F





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





    identifier

REF02

2330F

REF01 ID/number.

1/50 R

See the 837p Implementation Guide page 349 and the Professional Claims OpenAPI Spec for more details.

NameElementLoopDescriptionC/R
otherPayerBillingProvider
(Object)
2330G

NM101=85 (Billing Provider)
NM102 = 1 (Person) or NM102 = 2 (Non-Person Entity)
S

  entityTypeQualifier

NM102

2330G

Code qualifying the entity type.R

  otherPayerBillingProvider2330GR
    qualifier

REF01

2330G

Type of ID.
REF01 = LU (Location Number)
2/3 R

    identifier

REF02

2330G

REF01 ID/number.

1/50 R

📘

NOTE

This section describes line-level information reporting that may be required if it differs or adds further detail to information provided at the claim level. The general rule for all objects in this category is, If not required by this implementation guide, do not send in the 837P Implementation Guide. It does not rule out their use by the submitter. They also do not require or allow the receiver of the submission to reject it if this information is provided. Senders can use these data fields at their discretion (Consolidated 837P 005010X222A2, page 46).

NameElementLoopDescriptionC/R
serviceLines(Array of objects)

SV101

2400

Contains information that is supplementary to claim-level information.S

assignedNumber

LX01

2400

Number assigned for differentiation within a transaction set.1/6 S

NameElementLoopDescriptionC/R
serviceDate





DTP03





2400





Service date or date range, format YYYYMMDD.
DateTimeQualifier always 472
DTP01=472
Service DTP02=D8
Date expressed in format
1/35 R





NameElementLoopDescriptionC/R
providerControlNumber



REF02



2400



Reference information as defined for a transaction set or as noted by the reference indication qualifier.
REF01=6R
1/50 R



NameElementLoopDescriptionC/R
salesTaxAmount



AMT02



2400



Required when sales tax applies to the service line and the submitter reports that information to the receiver.
If not required in the transaction, do not send.
Value of AMT01=T Tax
1/18 S



NameElementLoopDescriptionC/R
postageClaimedAmount










AMT02










2400










Postage Claimed Amount.
When reporting this attribute (AMT02), the amount reported in lineItemChargeAmount (SV102) for the Service Line must include the amount reported in the postageClaimedAmount field.
Also required when service line charge (SV102) includes a postage amount, which is claimed in this service line.
If postage is not involved in the transaction, it is not required.
Value of AMT01=F4 Postage Claimed
1/18 S










See the 837p Implementation Guide page 209 for more information.

NameElementLoopDescriptionC/R
fileInformation


K301


2300


Data in fixed format agreed upon by the sender and receiver.
Comma separated values.
1/80 R


NameElementLoopDescriptionC/R
thirdPartyOrganizationNotes

NTE02

2400

Description to clarify data elements and content.
NTE01=TPO
1/80 R

additionalNotes


NTE02


2400


Additional description of related data elements and content.
NTE01=ADD
1/80 R


goalRehabOrDischargePlans


NTE02


2400


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


NameElementLoopDescriptionC/R
ambulancePatientCount



QTY02



2400



Number of patients in the ambulance.
Required when more than one patient is transported in the same vehicle.
QTY01=PT Patients.
If not required, do not send.
1/15 S



NameElementLoopDescriptionC/R
obstetricAnesthesiaAdditionalUnits



QTY02



2400



The number of units reported by an anesthesia provider to reflect additional services complexity.
QTY01=FL nits
1/15 S


NameElementLoopDescriptionC/R
hospiceEmployeeIndicator





CRC02





2400





CRC02 is a Certification Condition Code Applies indicator.
“Y” value indicates the condition codes in CRC03 through CRC07 elements apply
“N” value states those codes do not apply
CRC01=07 Hospice
CRC03=65 Open
1/1 S




NameElementLoopDescriptionC/R
conditionIndicatorDurableMedicalEquipment
(Object)
S

  certificationConditionIndicator










CRC02










2400










CRC02 is a Certification Condition Code Applies indicator.
“Y” value states that the condition codes in CRC03 through CRC07 apply
“N” value states that those codes do not apply
Value of CRC01=09 = Durable Medical Equipment Certification.
1/1 R










  conditionIndicator


CRC03


2400


Code that states a condition.
01 = Patient admitted to hospital
12 = Patient confined to bed/chair
2/3 R


  conditionIndicatorCode

CRC04

2400

Second code, use CRC03 list.

2/3 S

Specifies details for each service line in the claim. See the 837p Implementation Guide page 353 through 360 and the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
professionalService (Object)Specify service line item details.R
  compositeMedicalProcedureIdentifier

SV101

2400

Identify a procedure by standard codes and modifiers.2/2 R

  procedureIdentifier


SV101-01


2400


Code that identifies the type/source of the descriptive number used in the Product/Service ID.2/2 R


  procedureCode

SV101-02

2400

The number for a product or service1/48
R
  procedureModifiers


SV101-03
to
SV101-06
2400


Improves the reporting accuracy of the associated procedure code.

2/2 S


  description

SV101-07

2400

Description to clarify related data elements and their content.1/80 S
  lineItemChargeAmount

SV102

2400

The total charge amount for this service line.1/18
R
  measurementUnit





SV103





2400





Unit or Basis for Measurement.
It specifies the units for a reported value or for a taken measurement.
Example:
MJ = Minutes
2/2 R





  serviceUnitCount




SV104




2400




Number of units.
Maximum length is eight digits excluding the decimal.
Max digits allowed to right of the decimal is three.
1/8 R




  placeOfServiceCode


SV105


2400


Code that states where service was performed or maybe performed.1/2


  compositeDiagnosisCodePointers
(Object)
    diagnosisCodePointers

SV107

2400

Diagnosis code for a service line.1/2 R

    emergencyIndicator







SV109







2400







SV109 is the emergency-related indicator.
“Y” value indicates provided service was emergency related
“N” value indicates the service was not emergency related.
1/1 S







    epsdtIndicator





SV111





2400





SV111 is early/ periodic screening for diagnosis and treatment of children with EPSDT involvement.
“Y” indicates EPSDT involvement
“N” denotes no involvement
1/1 S





    familyPlanningIndicator





SV112





2400





SV112 is the family planning involvement indicator.
“Y” value indicates family planning services involvement
“N” indicates no family planning services
1/1 S





    copayStatusCode



SV115



2400



Code stating if co-payment requirements were met on a line-by-line basis.
0 = Copay exempt
1/1 S



Claim supplemental information. See the 837p Implementation Guide page 184 and the Professional Claims OpenAPI Spec for further details.

NameElementLoopDescriptionC/R
serviceLineSupplementalInformation (Array)S
attachmentReportTypeCode



PWK01




2300




Code for the title, or contents of a document, report or supporting document.
CT=Certification
2/2 R




     attachmentTransmissionCode



PWK02



2300



Code value for the attachment delivery method.
Example:
BM = By mail
1/2 R



attachmentControlNumber










PWK06










2300










PWK06 describes the attached electronic documentation.
The PWK06 value is held in the TRN of the electronic attachment.
Requires PWK05=AC
(Attachment Control Number)
2/50
S









durableMedicalEquipmentCertificateOfMedicalNecessity
(Object)
S

  attachmentTransmissionCode






PWK02






2300






Code that defines the timing, transmission method or format by which reports are sent.
PWK01=CT
1/2 R






NameElementLoopDescriptionC/R
ambulanceTransportInformation
(Object)
S

  patientWeightInPoundsCR1022300Patient weight in pounds CR101=LB.1/10 S
  ambulanceTransportReasonCode



CR104



2300



Code that shows the reason for ambulance transport.
Example:
E: Patient Transferred to Rehabilitation Facility
1/1 R



  transportDistanceInMiles

CR106

2300

Distance traveled during transport, in miles. CR105=DH1/15 R
  roundTripPurposeDescription

CR109

2300

The purpose for the round-trip ambulance service.1/80 S

  stretcherPurposeDescription

CR110

2300

The purpose for usage of a stretcher during ambulance service.1/80 S

NameElementLoopDescriptionC/R
durableMedicalEquipmentCertification
(Object)


Provide information about a doctor's certification for durable medical equipment.S



  certificationTypeCode



CR301



2400



Code that indicates the certification type.
I = Initial
R = Renewal
S = Revised
1/1 R



  durableMedicalEquipmentDurationInMonthsCR3032400Months used, CR302=MO1/15 R

Service Line date information for various possible treatment elements. See the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
serviceLineDateInformation
(Object)
Date format: YYYYMMDD
DTP02=D8
S

  prescriptionDate

DTP03

2400

Prescription date.
DTP01=471
1/35
S
  certificationRevisionOrRecertificationDate

DTP03

2400

Required when CR301 = R or S.
DTP01=607
1/35
S
  beginTherapyDate










DTP03










2400










Begin therapy date.
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity
(DMERC CMN)
DMERC Information Form (DIF)
or Oxygen Therapy Certification is included on this service line.
DTP01=463
1/35
S









  lastCertificationDate





DTP03





2400





The date the ordering physician signed the CMN or an Oxygen Therapy Certification or the date the supplier signed the DMERC Information Form (DIF). DTP01=4611/35
S




  treatmentOrTherapyDate






DTP03






2400






Date last seen.
Required when a claim involves physician services, differs from the date listed at claim level, and will impact the payer’s adjudication process.
DTP01=304
1/35
S





  hemoglobinTestDate







DTP03







2400







Test date of the most recent Hemoglobin or Hematocrit tests, or for both.
Required on initial EPO claims service lines for dialysis patients when test results are billed or reported.
DTP01=738
1/35
S






  serumCreatineTestDate






DTP03






2400






Date of most recent serum creatine test.
R on initial EPO claims service lines for dialysis patients when test results are billed or reported.
DTP01=739
1/35
S





  shippedDate


DTP03


2400


Shipped date.
R when billing or reporting shipped products.
DTP01=011
1/35
S

  lastXRayDate






DTP03






2400






Date of the last x-ray.
Required when claim involves spinal manipulation and an x-ray was taken, and differs from information at the claim level (Loop ID-2300).
DTP01=455
1/35
S





  initialTreatmentDate









DTP03









2400









Initial treatment date.
Required when the Initial Treatment Date impacts adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, or speech language pathology, and when it differs from the claim level report.
DTP01=454
1/35
R








NameElementLoopDescriptionC/R
serviceLineReferenceInformation
(Object)
S

  repricedLineItemReferenceNumber

REF02

2400

Repriced line item reference number. REF01=9B1/50
S
  adjustedRepricedLineItemReferenceNumber

REF02

2400

Adjusted Repriced Line Item Reference Number. REF01=9D1/50
S
  payerIdentificationNumber

REF02

2400

Payer Identification Number.

1/50
S
  mammographyCertificationNumber

REF02

2400

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


REF02


2400


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

  referringCliaNumber

REF02

2400

Referring CLIA Facility
Certification Number. REF01=F4
1/50
S
  immunizationBatchNumber

REF02

2400

Immunization Batch Number.
REF01=BT
1/50
S
  referralNumber


REF02


2400


Number assigned by the payer or Utilization Management Organization (UMO).
REF01=9F
1/50
S

See the 837p Implementation Guide page 254 and the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
linePricingRepricingInformation (Object)


Pricing or repricing information about a health care claim or line item.S



  pricingMethodologyCode



HCP01



2400



Pricing Methodology Code.
It specifies the method by which a claim or line item is priced or repriced.
2/2 R



  repricedAllowedAmount





HCP02





2400





Monetary Amount Repriced Allowed Amount. Beyond the standard codes in the X12 TR3, your partner agreement defines code use.1/18 R





  repricedSavingAmount


HCP03


2400


Monetary Amount Savings amount.
Completed by the repricer only.
1/18 S


  repricedOrganizationIdentifier


HCP04


2400


Reference Identification Repricing organization identification number.1/50


  flatRateAmount


HCP05


2400


Pricing rate associated with per diem or 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





Code denoting the type/source of the descriptive number used in Product/Service ID (234).
Example:
WK = Advanced Billing Concepts (ABC) Codes
2/2 S





  repricedApprovedHCPCSCode



HCP10



2400



Repriced Approved HCPCS Code.
HCP10 is the approved procedure code.
1/48 S



  measurementUnitCode




HCP11




2400




Unit or Basis for Measurement Code.
It specifies the units for a reported value or for a taken measurement.
2/2
S



  repricedApprovedServiceUnitCount

HCP12

2400

Quantity of service units or inpatient days.1/50 S

  rejectReasonCode





HCP13





2400





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





  policyComplianceCode




HCP14




2400




Policy Compliance Code.
It specifies if policy compliance is followed.
Example:
1 = Procedure
Followed (Compliance)
1/2 S




  exceptionCode




HCP15




2400




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




See the 837p Implementation Guide page 361 and the Professional Claims OpenAPI Spec for more information. Segment is situational, all fields are required if the object is in use for the claim.

NameElementLoopDescriptionC/R
durableMedicalEquipmentService (Object)







Required for reporting both rental and purchase costs of durable medical equipment, such as a wheelchair.
You won't use this if singly reporting only the purchase or rental price.
2/2 S







days


SV503


2400


Describes the length of time the equipment will be needed.1/15 R


rentalPriceSV5042400DME rental cost.1/18 R
purchasePriceSV5052400DME purchase cost.1/18 R
frequencyCode


SV506


2400


Describes the billing interval for the equipment.
4 = Monthly
1/1 R


Required in a number of different situations. See the 837p Implementation Guide page 425 and the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
drugIdentification
(Object)
Drug Identification

S

  serviceIdQualifier

LIN02

2410

Code that identifies the type/source of the descriptive number in Product/Service ID.2/2 R

  nationalDrugCode

LIN03

2410

Number that identifies a product or service.1/48
R
CTPDrug Quantity
nationalDrugUnitCount

CTP04

2410

Numeric value of quantity.

1/15
R
measurementUnitCode


CTP05-01

2410


Code specifying a value's measurement units or how a measurement is taken.
Example:
GR(Gram)
2/2


REF

Prescription or Compound Drug Association Number.R

linkSequenceNumber





REF01





2410





Defined for a Transaction Set or as specified by the Reference Identification Qualifier.
REF01 = VY (Link Sequence Number)
Used when a drug is provided without a prescription.
1/50 S





pharmacyPrescriptionNumber


REF01


2410


Defined for a Transaction Set or by the Reference Identification Qualifier.
REF01 = XZ (Pharmacy Prescription Number)
1/50
S

See the 837p Implementation Guide page 483 and the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
lineAdjudicationInformation
(Array of objects)
Line Adjudication InformationS
  otherPayerPrimaryIdentifier

SVD01

2430

Payer identification code.

2/80
R
  serviceLinePaidAmount

SVD02

2430

Service line paid amount.

1/18
R
  serviceIdQualifier




SVD03-01




2430




Product/Service ID Qualifier Code.
Identifies the type/source of the descriptive number in 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 related to service performance, as defined by trading partners.
2/2
S





  sequenceOrder

SVD03-03 to
SVD03-06
2430

Example:
sequenceOrder=1
for SVD03-03
  procedureModifiers




SV101-03 to SV101-06



2430




Improves reporting accuracy of an associated procedure code.
Example:
Loop 2430; SVD03-03
2/2
S



  procedureCodeDescription

SVD03-07

2430

Description of the medical procedure.1/80
S
  paidServiceUnitCount




SVD05




2430




Number of paid units in the remittance advice.
When paid units are not in remittance advice, use the original billed units.
1/15
R



  bundledOrUnbundledLineNumber





SVD06





2430





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





  adjudicationOrPaymentDate



DTP03



2430



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


  remainingPatientLiability













AMT02













2430













Amount of remaining patient liability after adjudication.
This segment only used in provider-submitted claims. Required if the Other Payer (in Element SVD01 of the current loop) has adjudicated the claim with line-level content, and the provider can also do so.
AMT01=EAF (Amount Owed)
1/18
S












See the 837p Implementation Guide page 487 and the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
claimAdjustmentInformation (Array)Repeats five timesS
adjustmentGroupCodeCAS01



2430



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



adjustmentInformation (Array)Repeats 6 times
  sequenceOrder

2430

Example:
sequenceOrder=1
value for adjustmentReasonCode is for CAS02.
  adjustmentReasonCode


See Desc.

2430


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


  adjustmentAmount

See
Desc
2430

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

See
Desc
2430

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

Loop ID-2440 allows providers to attach standardized supplemental information to the claim when required to do so by the payer.

See the 837p Implementation Guide page 495 and the Professional Claims OpenAPI Spec for more information.

NameElementLoopDescriptionC/R
formIdentification (Array)
formTypeCode




LQ01




2440




Correct values:
AS = Form Type Code
UT = Centers for Medicare and Medicaid Services (CMS)
Durable Medical Equipment Regional Carrier (DMERC)
Certificate of Medical Necessity (CMN) Forms.
1/3




formIdentifierLQ022440Industry Code1/30

Use the FRM segment to answer specific questions on the form identified in the LQ segment. FRM01 indicates the question being answered.

See the 837p Implementation Guide page 497 and the Professional Claims OpenAPI Spec for more information.

Answers can take one of 4 forms:
FRM02 for Yes/No questions
FRM03 for text/uncodified answers
FRM04 for answers which use dates
FRM05 for answers in percentages
For each FRM01 (question) use a remaining FRM element, choosing the element with the appropriate format. Use one FRM segment for each question/answer pair.

NameElementLoopDescriptionC/R
supportingDocumentation (Array)S
questionNumberFRM01

2440

FRM01 is the question number on a questionnaire or codified form.1/20
S
questionResponseCode


FRM02


2440


Code that indicates a Yes or No condition or response.
N = No
W = Not Applicable
Y = Yes
1/1
S

questionResponse

FRM03

2440

Text/uncodified answers.

1/50
S
questionResponseAsDateFRM04

2440

Answers that use dates.

8/8
S
questionResponseAsPercent


FRM05


2440


Answers that are in percentage.
Percentage is in decimal format.
Example:
2% = 0.2
1/6
S

For REF02, provide one of the following:
stateLicenseNumber (0B)
providerUpinNumber (1G)
commercialNumber (G2)
locationNumber (LU)

NameElementLoopDescriptionC/R
Other provider types include:
renderingProvider
purchaseServiceProvider
supervisingProvider
orderingProvider
referringProvider
NM101





See Desc.





Loops are:
82 = renderingProvider (2420A)
QB = purchaseServiceProvider (2420B)
DQ = supervisingProvider (2420D)
DK = orderingProvider (2420E)
DN = referringProvider (2420F)
2/3 S





organizationName

NM103

1000A

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

NM103

1000A

Provider last name, you can use organization or last name.1/60
R
firstName

NM104

1000A

Provider first name.

1/35
S
middleName

NM105

1000A

Middle initial.

1/25
S
npi

NM109

National Provider Identification value.
NM108 = XX
2/80
S
taxonomyCode


PRV03


See Desc.

Health care provider taxonomy code.
Referring Provider (2310AA)
Rendering Provider (2310B)
1/50
R

stateLicenseNumber



REF02



See Desc.


State license number.
REF01 = 0B
Billing Provider (2010AA)
Referring Provider (2310A)
1/50
S


providerUpinNumber


REF02


See Desc.

Provider UPIN number.
REF01 = 1G
Billing Provider (2010AA)
Referring Provider (2310A)
1/50
S

commercialNumber

REF02

relative

Provider commercial number.
REF01 = G2 (Provider Commercial Number)
1/50
S
locationNumber

REF02

Provider location number.
REF01 = LU
1/50
S
otherIdentifier


REF04-02

Payer identification number.
Do not use with REF01=0B/1G or REF04-01=2U
1/50
S

This is required when the ambulance pick-up location for this service line differs from the ambulance pick-up location provided in Loop ID-2310E.

NameElementLoopDescriptionC/R
ambulancePickUpLocation (Object)LocationS
  address1N3012420GFirst line of facility address information.1/55 R
  address2N3022420GSecond line of facility address information.1/55 S
  cityN4012420GCity in which the facility is located.2/30 R
  stateN4022420GState in which the facility is located.2/2 S
  postalCodeN4032420GDisplays the postal code.3/15 S
  countryCodeN4042420GCountry code.1/35 S
  countrySubDivisionCodeN4042420GCountry Sub Division code.1/35 S

NameElementLoopDescriptionC/R
ambulanceDropOffLocation (Object)S
  address1N3012420HFirst line of facility address information.1/55 R
  address2N3022420HSecond line of facility address information.1/55 S
  cityN4012420HCity in which the facility is located.2/30 R
  stateN4022420HState in which the facility is located.2/2 S
  postalCodeN4032420HDisplays the postal code.3/15 S
  countryCodeN4042420HCountry code.1/35 S
  countrySubDivisionCodeN4042420HCountry Sub Division code.1/35 S

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