Integrated Rules Professional 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 837p Implementation Guide, p. 53-54, discusses this in further detail.

Table of Mappings Tables

Transaction Header (Request)

Submitter (1000A)

Receiver (1000B)

Subscriber

Subscriber Hierarchical Level (2000B)

Subscriber Information (2310BA)

Payer Information (2010BB)

Other Subscriber Information (2320)

Other Subscriber Name (2330A)

Dependent (2010CA)

Patient Hierarchical Level (2000C)

Patient Name (2010CA)

Property and Casualty (2010CA)

Providers

Provider ID

Provider Contact Information – 2010AA

Pay-To Address Name – 2010AB

Pay-To Plan Name – 2010AC

Claims

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 Payers (2330B-G)

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)

Service Lines (2400)

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 (2430)

Line Adjudication Information

Line Adjustment Information

Form Identification (2440)

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 Mappings

FieldDescriptionConstraints
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)R
  organizationName


NM103


1000A


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


  lastName


NM103


1000A


Last name for the submitter.
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 OpenAPI spec for more information.

NameElementLoopDescriptionC/R
paymentResponsibilityLevelCode


SBR01


2000B


Code that identifies payer's level
of responsibility for payment of claim.
Ex: 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 116-127, and the OpenAPI spec for more information.

NameElementLoopDescriptionC/R
subscriber (Object)The person that 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 middle1/25
  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 21/35
    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 Code1/35
    countrySubDivisionCodeN4042010ABCountry Sub Division Code1/35

Destination Payer's information for the claim. See the 837p Implementation Guide, Page 133, and the 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 Code1/35
  countrySubDivisionCodeN4042010BBCountry sub division Code1/35
  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=FY1/50
  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=LU1/50

See the 837p Implementation Guide, Page 116-18 and Page 297, and the OpenAPI spec for more information.

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

  paymentResponsibilityLevelCode



SBR01



2320



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



  individualRelationshipCode



SBR02



2320



Code that describes the
relationship between two
individuals or entities.
Ex: 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.
Ex: 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, CAS17
1/5



    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.
It's the amount that
Medicaid actually paid.
1/18



  nonCoveredChargeAmount


AMT02


2320


Monetary Amount -
Coordination of Benefits
(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.
Ex: 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.
Ex: 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.
Ex: 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 Code1/35 S
    countrySubDivisionCodeN4042330ACountry Sub Division Code1/35 S
    otherInsuredAdditionalIdentifierREF022330ASocial Security Number REF01=SY1/50 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 holderS
  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.
Ex: 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.
Ex: 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 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 = EM1/256 S
  validContactPER042010CABooleanS

NameElementLoopDescriptionC/R
providers (Object)R
  providerType





NM101





See
Desc




Provider type, send what is in 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.
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
  cityN4012010AAProvider’s city1/60 R
  stateN4022010AAProvider’s state1/35 S
  postalCodeN4032010AAProvider’s postal code3/15 S
  countryCodeN4042010AACountry Code1/35 S
  countrySubDivisionCodeN4042010AACountry Sub Division Code1/35 S
contactInformation (Object)S
  namePER022010AAProvider contact name.1/60 S
  faxNumberPER042010AAProvider fax number. PER03=FX1/256 S
  phoneNumberPER042010AAProvider contact phone number. PER03=TE1/256 S

NameElementLoopDescriptionC/R
payToAddress (Object)S
  address1N3012010ABPay-To address’s address line 11/35 R
  address2N3022010ABPay-To address’s address line 21/35 S
  cityN4012010ABPay-To address’s city1/60 R
  stateN4022010ABPay-To address’s state1/35 S
  postalCodeN4032010ABPay-To address’s postal code3/15 S
  countryCodeN4042010ABPay-To countryCode1/35 S
  countrySubDivisionCodeN4042010ABPay-To countryCode1/35 S

NameElementLoopDescriptionC/R
payToPlan (Object)S
  organizationNameNM1032010ACPay-To Plan organization name1/60 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
NOTE: - 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 21/35 S
    cityN4012010ACPay-To Plan city1/60 R
    stateN4022010ACPay-To Plan state1/35 S
    postalCodeN4032010ACPay-To Plan postal code3/15 S
    countryCodeN4042010ACPay-To Country Code1/35 S
    countrySubDivisionCodeN4042010ACPay-To Country Code1/35 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.
Ex: 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 that 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, don't 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, don't send.
See page 165 in Imp. Guide.
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 184-87, and the 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.
Ex: 08 = Plan of Treatment
2/2 R


     attachmentTransmissionCode


PWK02


2300


Code that describes
how the attachment is sent.
Ex: 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) number.
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 188-89, and the 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 Code1/1 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-CRC07. If the
transaction doesn't 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 don't 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;
e.g. 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 CRC04-07 as necessary.
Condition Code Ex:
L2 = Replacement Due to Loss or Theft;
L3 = Replacement Due to Breakage or Damage.
2/3





  sequenceOrder


2300


Provide which field it belongs;
e.g. 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 value: 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 - CRC07 apply;
N = condition codes in CRC03 - CRC07 do not apply.
CRC01=ZZ
1/1




  conditionIndicators



CRC03
CRC04
CRC05

2300



Condition indicator.
Ex: 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.
Ex: HI01-01=BG (Condition)
1/30 R

See the 837p Implementation Guide, Page 254, and the OpenAPI spec for more information.

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.
Ex: T4 = Payer Name/Identifier
Missing.
2/2 S





  policyComplianceCode



HCP14



2300



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



  exceptionCode



HCP15



2300



Code citing the exception
reason for consideration
of out-of-network services.
Ex: 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 Code1/35
  countrySubDivisionCodeN4042310ECountry Sub Division Code1/35

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 Code1/35
  countrySubDivisionCodeN4042310FCountry Sub Division Code1/35

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
    countryCodeN4042310CcountryCode1/35 S
    countrySubDivisionCodeN4042310CCountry Sub Division Code1/35

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.
Ex: 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 21/35
    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


    countryCodeN4042330BcountryCode1/35 S
    countrySubDivisionCodeN4042330BCountry Sub Division Code1/35 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 OpenAPI spec for more information.

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 OpenAPI spec for more information.

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 OpenAPI spec for more information.

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 OpenAPI spec for more information.

NameElementLoopDescriptionC/R
otherPayerBillingProvider
(Object)
2330G

NM101=85 (Billing Provider)
NM102 = 1 (Person) or 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 doesn't rule out their use by the submitter. They also don't 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, P. 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 isn't involved in the transaction,
it is not required.
Value of AMT01=F4 Postage Claimed
1/18 S










See the 837p Implementation Guide, pp. 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.
A “Y” value indicates the condition codes
in CRC03 through CRC07 elements apply;
an “N” value states those codes don't 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.
A “Y” value states that the
condition codes in CRC03
through CRC07 apply;
an “N” value states
that those codes don't 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, pp. 353-60, and the 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 service
1/48
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.
Ex: MJ = Minutes
2/2 R





  serviceUnitCount




SV104




2400




Number of units.
Max length is 8 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.
A “Y” value indicates
provided service was
emergency related;
an “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.
A “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, pp. 184, and the 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 doc.
CT=Certification
2/2 R




     attachmentTransmissionCode



PWK02



2300



Code value for the
attachment delivery
method.
Ex: 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=LB1/10 S
  ambulanceTransportReasonCode



CR104



2300



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



  transportDistanceInMiles

CR106

2300

Distance traveled during
transport, in miles. CR105=DH
1/15 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 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=461
1/35
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=9B
1/50
S
  adjustedRepricedLineItemReferenceNumber

REF02

2400

Adjusted Repriced Line Item
Reference Number. REF01=9D
1/50
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, pp. 254, and the OpenAPI spec for further details.

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).
Ex: 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.
Ex: T4 Payer Name
or Identifier Missing.
2/2 S





  policyComplianceCode




HCP14




2400




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




  exceptionCode




HCP15




2400




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




See the 837p Implementation Guide, pp. 361, and the OpenAPI spec for further details. 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, pp. 425, and the OpenAPI spec for further details.

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.
Ex: 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, pp. 483, and the OpenAPI spec for further details.

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

Ex: sequenceOrder=1
for SVD03-03
  procedureModifiers




SV101-03 to
SV101-06



2430




Improves reporting
accuracy of an
associated
procedure code.
Ex: 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 aren't 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, pp. 487, and the OpenAPI spec for further details.

NameElementLoopDescriptionC/R
claimAdjustmentInformation (Array)Repeats 5 timesS
adjustmentGroupCodeCAS01



2430



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



adjustmentInformation (Array)Repeats 6 times
  sequenceOrder

2430

Ex: 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, pp. 495, and the OpenAPI spec for further details.

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, pp. 497, and the OpenAPI spec for further details.

Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers 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.
Ex: 2% = 0.2
1/6
S

For REF02, one of the stateLicenseNumber (0B), providerUpinNumber (1G), commercialNumber (G2) or locationNumber (LU) must be provided.

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
(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 Code1/35 S
  countrySubDivisionCodeN4042420GCountry Sub Division Code1/35 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 Code1/35 S
  countrySubDivisionCodeN4042420HCountry Sub Division Code1/35 S
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