4010 5010 Transactional Comparison Documents

4010A1 270 Member Eligibility Inquiry
Element Description ID Min. Usage Loop Loop Values

Identifier Max. Reg. Repeat
ISA INTERCHANGE 1 R
CONTROL HEADER
1 ISA01 Authorization Information ID 2 - 2 R 00, 03
Qualifier
2 ISA02 Authorization Information AN 10 - 10 R
3 ISA03 Security Information ID 2-2 R 00, 01

Qualifier
4 ISA04 Security Information AN 10 - 10 R
5 ISA05 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29,
30, 33, ZZ
6 ISA06 Interchange Sender ID AN 15-15 R
7 ISA07 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29,
30, 33, ZZ
8 ISA08 Interchange Receiver ID AN 15-15 R
9 ISA09 Interchange Date DT 6-6 R YYMMDD
10 ISA10 Interchange Time TM 4-4 R HHMM
11 ISA11 Interchange Control ID 1-1 R U

Standards ID
12 1 ISA12 Interchange Control ID 5-5 R 401
Version Number
13 ISA13 Interchange Control N0 9-9 R
Number
14 ISA14 Acknowledgement ID 1-1 R 0, 1
Requested
15 ISA15 Usage Indicator ID 1-1 R P, T
16 ISA16 Component Element 1-1 R

Separator
GS FUNCTIONAL GROUP 1 R
HEADER
17 1 GS01 Functional Identifier ID 2-2 R HB, HS
Code
18 GS02 Application Sender's AN 2 - 15 R
Code
19 GS03 Application Receiver's AN 2 - 15 R
Code
20 GS04 Date DT 8-8 R CCYYMMDD
21 GS05 Time TM 4-8 R HHMM
22 GS06 Group Control Number N0 1-9 R
23 GS07 Responsible Agency ID 1-2 R X

Code
24 1 GS08 Version/ Release/ AN 1 - 12 R 004010X092
Industry Identifier Code
ST TRANSACTION SET 1 R
HEADER
25 ST01 Transaction Set Identifier ID 3-3 R 270
Code
26 ST02 Transaction Set Control AN 4-9 R
Number
27 1
BHT BEGINNING OF 1 R
HIERARCHICAL
TRANSACTION
28 BHT01 Hierarchical Structure ID 4-4 R 22
Code
29 1 BHT02 Transaction Set Purpose ID 2-2 R 01, 13, 36
Code
30 BHT03 Reference Identification AN 1 - 30 S
31 BHT04 Date DT 8-8 R CCYYMMDD
32 BHT05 Time TM 4-8 R
33 1 BHT06 Transaction Type Code ID 2-2 S RT, RU
HL INFORMATION 1 R 2000A >1

SOURCE LEVEL
34 HL01 Hierarchical ID Number AN 1 - 12 R
35 HL02 Hierarchical Parent ID AN 1 - 12 N/U

Number
36 HL03 Hierarchical Level Code ID 1-2 R 20
37 HL04 Hierarchical Child Code ID 1-1 R 1
NM1 INFORMATION 1 R 2100A 1

SOURCE NAME
38 NM101 Entity Identifier Code ID 2-3 R 2B, 36, GP, P5, PR
39 NM102 Entity Type Qualifier ID 1-1 R 1, 2
40 1 NM103 Name Last or AN 1 - 35 S

Organization Name
41 1 NM104 Name First AN 1 - 25 S
42 NM105 Name Middle AN 1 - 25 S
43 NM106 Name Prefix AN 1 - 10 N/U
44 NM107 Name Suffix AN 1 - 10 S
45 NM108 Identification Code ID 1-2 R 24, 46, FI, NI, PI, XV, XX
Qualifier
46 NM109 Identification Code AN 2 - 80 R
47 NM110 Entity Relationship Code ID 2-2 N/U
48 NM111 Entity Identifier Code ID 2-3 N/U
49 1
HL INFORMATION 1 R 2000B >1

RECEIVER LEVEL
51 HL02 Hierarchical Parent ID AN 1 - 12 R

Number
NM1 INFORMATION 1 R 2100B 1

RECEIVER NAME
54 NM101 Entity Identifier Code ID 2-3 R 1P, 2B, 36, 80, FA, GP,
P5, PR
55 NM102 Entity Type Qualifier ID 1-1 R 1, 2

Organization Name
61 NM108 Identification Code ID 1-2 R 24, 34, FI, PI, PP, SV,
Qualifier XV, XX
65 1
REF INFORMATION 9 S 2100B
RECEIVER
ADDITIONAL
IDENTIFICATION
66 REF01 Reference Identification ID 2-3 R 0B, 1C, 1D, 1J, 4A, CT,
Qualifier EL, EO, HPI, JD, N5, N7,
Q4, SY, TJ
67 1 REF02 Reference Identification AN 1 - 30 R
68 REF03 Description AN 1 - 80 S
69 REF04 REFERENCE N/U

IDENTIFIER
N3 INFORMATION 1 S 2100B
RECEIVER ADDRESS
70 N301 Address Information AN 1 - 55 R
71 N302 Address Information AN 1 - 55 S
RECEIVER CITY/
STATE/ ZIPCODE
72 N401 City Name AN 2 - 30 R
73 N402 State or Province Code ID 2-2 R
74 N403 Postal Code ID 3 - 15 R
75 N404 Country Code ID 2-3 S
76 N405 Location Qualifier ID 1-2 N/U
77 N406 Location Qualifier AN 1 - 30 N/U
78
PER INFORMATION 3 S 2100B

RECEIVER CONTACT
INFORMATION
79 1 PER01 Contact Function Code ID 2-2 R IC
80 1 PER02 Name AN 1 - 60 S
81 1 PER03 Communication Number ID 2-2 S ED, EM, FX, TE

Qualifier
82 1 PER04 Communication Number AN 1 - 80 S
83 1 PER05 Communication Number ID 2-2 S ED, EM, EX, FX, TE

Qualifier
84 1 PER06 Communication Number AN 1 - 80 S AAABBBCCCC
85 1 PER07 Communication Number ID 2-2 S ED, EM, EX, FX, TE
Qualifier
86 1 PER08 Communication Number AN 1 - 80 S AAABBBCCCC
87 1 PER09 Contact Inquiry AN 1 - 20 N/U

Reference
PRV INFORMATION 1 S 2100B

RECEIVER PROVIDER
INFORMATION
88 PRV01 Provider Code ID 1-3 R AD, AT, BI, CO, CV, H,
HH, LA, OT, P1, P2, PC,
PE, R, RF, SB, SK, SU
89 1 PRV02 Reference Identification ID 2-3 R ZZ

Qualifier
90 1 PRV03 Reference Identification AN 1 - 30 R
91 PRV04 State or Province Code ID 2-2 N/U
92 PRV05 PROVIDER SPECIALTY N/U

INFORMATION
93 PRV06 Provider Organization ID 3-3 N/U

Code
HL SUBSCRIBER LEVEL 1 R 2000C >1

Number
97 HL04 Hierarchical Child Code ID 1-1 R 0, 1
TRN SUBSCRIBER TRACE 2 S 2000C

NUMBER
98 TRN01 Trace Type Code ID 1-2 R 1
99 1 TRN02 Reference Identification AN 1 - 30 R
100 TRN03 Originating Company AN 10 - 10 R

Identifier
101 1 TRN04 Reference Identification AN 1 - 30 S
NM1 SUBSCRIBER NAME 1 R 2100C 1
102 NM101 Entity Identifier Code ID 2-3 R IL
103 NM102 Entity Type Qualifier ID 1-1 R 1

Organization Name
109 1 NM108 Identification Code ID 1-2 S MI, ZZ

Qualifier
110 NM109 Identification Code AN 2 - 80 S
113 1
REF SUBSCRIBER 9 S 2100C

ADDITIONAL
IDENTIFICATION
114 1 REF01 Reference Identification ID 2-3 R 18, 1L, 1W, 3H, 49, 6P,
Qualifier
A6, CT, EA, EJ
116 REF03 Description AN 1 - 80 N/U

IDENTIFIER
N3 SUBSCRIBER 1 S 2100C
ADDRESS
N4 SUBSCRIBER CITY/ 1 S 2100C

STATE/ ZIPE CODE
120 N401 City Name AN 2 - 30 S
121 N402 State or Province Name ID 2-2 S
122 N403 Postal Code ID 3 - 15 S

126 1
PRV PROVIDER 1 S 2100C

INFORMATION
127 1 PRV01 Provider Code ID 1-3 R AD, AT, BI, CO, CV, H,
128 1 PRV02 Reference Identification ID 2-3 R 9K, D3, EI, HPI, SY, TJ,
Qualifier
ZZ

INFORMATION

Code
DMG SUBSCRIBER 1 S 2100C

DEMOGRAPHIC
INFORMATION
133 DMG01 Date Time Period Format ID 2-3 S D8
Qualifier
134 DMG02 Date Time Period AN 1 - 35 S
135 DMG03 Gender Code ID 1-1 S F, M
136 DMG04 Marital Status Code ID 1-1 N/U
137 1 DMG05 Race or Ethnicity Code ID 1-1 N/U
138 DMG06 Citizenship Status Code ID 1-2 N/U
139 DMG07 Country Code ID 2-3 N/U
140 DMG08 Basis of Verification ID 1-2 N/U

Code
141 DMG09 Quantity R 1 - 15 N/U
142 1
143 1
INS SUBSCRIBER 1 S 2100C

RELATIONSHIP
144 INS01 Yes/No Condition or ID 1-1 R Y
Response Code
145 INS02 Individual Relationsgip ID 2-2 R 18
Code
146 INS03 Maintenance Type Code ID 3-3 N/U
147 INS04 Maintenance Reason ID 2-3 N/U

Code
148 INS05 Benefit Status Code ID 1-1 N/U
149 1 INS06 Medicare Plan Code ID 1-1 N/U
150 INS07 Consolidated Omnibus ID 1-2 N/U

Budget Reconcilliation
Act (COBRA) Qualifying
151 INS08 Employment Status ID 2-2 N/U

Code
152 INS09 Student Status Code ID 1-1 N/U
153 INS10 Yes/No Condition or ID 1-1 N/U

Response Code
154 INS11 Date Time Period Format ID 2-3 N/U
Qualifier
155 INS12 Date Time Period AN 1 - 35 N/U
156 INS13 Confidentiality Code ID 1-1 N/U
157 INS14 City Name AN 2 - 30 N/U
158 INS15 State or Province Code ID 2-2 N/U
159 INS16 Country Code ID 2-3 N/U
160 INS17 Number N0 1-9 R
1
1
1
1
1
1
DTP SUBSCRIBER DATE 2 S 2100C
161 1 DTP01 Date/Time Qualifier ID 3-3 R 102, 307, 435, 472
162 DTP02 Date Time Period Format ID 2-3 R D8, RD8

Qualifier
163 DTP03 Date Time Period AN 1 - 35 R CCYYMMDD,
CCYYMMDD
CCYYMMDD
EQ SUBSCRIBER 1 S 2110C 99
ELIGIBILITY/BENEFIT
INQUIRY
INFORMATION
164 1 EQ01 Service Type Code ID 1-2 S 1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12,13, 14, 15, 16, 17,
18, 19, 20, 21, 22, 23,
24, 25, 26, 27, 28, 30,
32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43,
44, 45, 46, 47, 48, 49,
50, 51, 52, 53, 54, 55,
56, 57, 58, 59, 60, 61,
62, 63, 64, 65, 66, 67,
68, 69, 70, 71, 72, 73,
74, 75, 76, 77, 78, 79,
80, 81, 82, 83, 84, 85,
86, 87, 88, 89, 90, 91,
92, 93, 94, 95, 96, 97,
98, 99, A0, A1, A2, A3,
A4, A5, A6, A7, A8, A9,
AA, AB, AC, AD, AE, AF,
AG, AH, AI , AJ, AK, AL,
AM, AN ,AO, AQ, AR,
BA,BB, BC, BD, BE, BF,
BG, BH, BI, BJ, BK, BL,
BM, BN, BP, BQ, BR, BS
165 EQ02 COMPOSITE MEDICAL S

PROCEDURE
IDENTIFIER
166 EQ02 -1 Product/Service ID ID 2-2 R AD, CJ, HC, ID, IV, N4,
Qualifier ZZ
167 EQ02 -2 Product/Service ID AN 1 - 48 R
168 EQ02 -3 Procedure Modifier AN 2-2 S
172 EQ02 -7 Description AN 1 - 80 N/U
173 1
174 1 EQ03 Coverage Level Code ID 3-3 S CHD, DEP, ECH,
EMP, ESP, FAM,
IND, SPC, SPO
175 1 EQ04 Insurance Type Code ID 1-3 S AP, C1, CO, GP,
HM, HN, IP, MA,
MB, MC, PR, PS,
SP, WC
176 1
177 1
178 1
179 1
180 1
AMT SUBSCRIBER SPEND 1 S 2110C

DOWN AMOUNT
181 AMT01 Amount Qualifier Code ID 1-3 R R
182 AMT02 Monetary Amount R 1 - 18 N/U
183 AMT03 Credit/Debit Flag Code ID 1-1 N/U
III SUBSCRIBER 10 S 2110C

ELIGIBILITY/ BENEFIT
ADDITIONAL INQUIRY
INFORMATION
184 1 III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ

185 1 III02 Industry Code AN 1 - 30 R If Ill01 = BK or
BF: use
diagnosis code
from code
source 131; If III01
= ZZ: 11, 12, 21, 22, 23,
24, 25, 26, 31, 32, 33,
34, 41, 42, 50, 51, 52,
53, 54, 55, 56, 60, 61,
62, 65, 71, 72, 81, 99
186 III03 Code Category ID 2-2 N/U
187 III04 Free-Form Message Text AN 1-264 N/U
188 III05 Quantity R 1 - 15 N/U
189 III06 COMPOSITE UNIT OF N/U

MEASURE
190 III07 Surface/Layer/Position ID 2-2 N/U
Code
Code
Code
REF SUBSRIBER 1 S 2110C

ADDITIONAL
INFORMATION
193 REF01 Reference Identification ID 2-3 R 9F,G1
Qualifier

IDENTIFIER
DTP SUBSCRIBER 1 S 2110C

ELIGIBILITY/BENEFIT
DATE
197 1 DTP01 Date/Time Qualifier ID 3-3 R 307, 435, 472

Qualifier
199 1 DTP03 Date Time Period AN 1 - 35 R
HL DEPENDENT LEVEL 1 S 2000D >1


Number
TRN DEPENDENT TRACE 2 S 2000D

NUMBER
204 TRN01 Trace Type Code ID 1-2 R 1

Identifier
NM1 DEPENDENT NAME 1 R 2100D 1
208 NM101 Entity Identifier Code ID 2-3 R 3

Organization Name
215 NM108 Identification Code ID 1-2 N/U

Qualifier
216 NM109 Identification Code AN 2 - 80 N/U
219 1
REF DEPENDENT 9 S 2100D

ADDITIONAL
IDENTIFICATION
220 1 REF01 Reference Identification ID 2-3 R 18, 1L, 1W, 49, 6P, A6,
Qualifier CT, EA, EJ, F6, CJ,
HC, ID, IV, N4,
ZZ

IDENTIFIER
N3 DEPENDENT 1 S 2100D
ADDRESS
CITY/STATE/ZIP CODE
227 N402 State or Provine Code ID 2-2 S
232
PRV PROVIDER 1 S 2100D

INFORMATION
233 1 PRV01 Provider Code ID 1-3 R AD, AT, BI, CO, CV, H,
234 1 PRV02 Reference Identification ID 2-3 R 9K, D3, EI, HPI, SY, TJ,
Qualifier ZZ
237 PRV05 PROVIDER N/U

SPECIALITY
INFORMATION
Code
DMG DEPENDENT 1 S 2100D

DEMOGRAPHIC
INFORMATION
239 DMG01 Date Time Period Format ID 2-3 S D8
Qualifier
240 DMG02 Date Time Period AN 1 - 35 S CCYYMMDD
241 DMG03 Gender Code ID 1-1 S F, M
243 DMG05 Race or Ethnicity Code ID 1-1 N/U

Code
248 1
249 1
INS DEPENDENT 1 S 2100D

RELATIONSHIP
250 INS01 Yes/No Condition or ID 1-1 R N
Response Code
251 INS02 Individual Relationship ID 2-2 R 01, 19, 34
Code
252 INS03 Maintenance Type Code ID 3-3 N/U
253 INS04 Maintenance Reason ID 2-3 N/U

Code
255 INS06 Medicare Plan Code ID 1-1 N/U


Code
258 INS09 Student Status Code ID 1-1 N/U
259 INS10 Yes/No Condition or ID 1-1 N/U

Response Code
Qualifier
266 INS17 Number N0 1-9 S

1
1
1
1
1
1
DTP DEPENDENT DATE 2 S 2100D
267 1 DTP01 Date/Time Qualifier ID 3-3 R 102, 307, 435, 472

Qualifier
269 DTP03 Date Time Period AN 1 - 35 R CCYYMMDD,
CCYYMMDD
CCYYMMDD
EQ DEPENDENT 1 R 2110D 99
INQUIRY
INFORMATION
270 1 EQ01 Service Type Code ID 1-2 S 1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12, 13, 14, 15, 16, 17,
18, 19, 20, 21, 22, 23,
24, 25, 26, 27, 28, 30,
32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43,
44, 45, 46, 47, 48, 49,
50, 51, 52, 53, 54, 55,
56, 57, 58, 59, 60, 61,
62, 63, 64, 65, 66, 67,
68, 69, 70, 71, 72, 73,
74, 75, 76, 77, 78, 79,
80, 81, 82, 83, 84, 85,
86, 87, 88, 89, 90, 91,
92, 93, 94, 95, 96, 97,
98, 99, A0, A1, A2, A3,
A4, A5, A6, A7, A8, A9,
AA, AB, AC, AD, AE, AF,
AG, AH, AI , AJ, AK, AL,
AM, AN ,AO, AQ, AR,
BA,BB, BC, BD, BE, BF,
BG, BH, BI, BJ, BK, BL,
BM, BN, BP, BQ, BR, BS
271 EQ02 COMPOSITE MEDICAL S

PROCEDURE
IDENTIFIER
272 EQ02 -1 Product/Service ID ID 2-2 R AD, CJ, HC, ID, IV, N4,
Qualifier ZZ
273 EQ02 -2 Product/Service ID AN 1 - 48 R
274 EQ02 -3 Procdeure Modifier AN 2-2 S
278 EQ02 -7 Description AN 1 - 80 N/U
279 1
280 1 EQ03 Coverage Level Code ID 3-3 S CHD, DEP, ECH,

EMP, ESP, FAM,
IND, SPC, SPO
281 1 EQ04 Insurance Type Code ID 1-3 S AP, C1, CO, GP,
HM, IP, OT, PR,
PS, SP, WC
282 1
283 1
284 1
285 1
286 1
III DEPENDENT 10 S 2110D

ADDITIONAL INQUIRY
INFORMATION
287 1 III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ

288 1 III02 Industry Code AN 1 - 30 R If Ill01 = BK or
BF, use
diagnosis code
from code
source 131; If
III01 = ZZ: 11, 12,
21, 22, 23, 24, 25, 26,
31, 32, 33, 34, 41, 42,
50, 51, 52, 53, 54, 55,
56, 60, 61, 62, 65, 71,
72, 81, 99
289 III03 Code Category ID 2-2 N/U

MEASURE
Code
Code
Code

ADDITIONAL
INFORMATION
296 REF01 Reference Identification ID 2-3 R 9F,G1
Qualifier

IDENTIFIER
DTP DEPENDENT 1 S 2110D

DATE
300 1 DTP01 Date/Time Qualifier ID 3-3 R 307,435,472
Qualifier
302 1 DTP03 Date Time Period AN 1 - 35 R CCYYMMDD,
CCYYMMDD
CCYYMMDD
SE TRANSACTION SET 1 R
TRAILER
303 SE01 Number of Included N0 1 - 10 R
Segments
304 SE02 Transaction Set Control AN 4-9 R
Number
GE FUNCTIONAL GROUP
TRAILER
305 GE01 Number of Transaction N0 1-6 R
Sets Included
306 GE02 Group Control Number N0 1- 9 R Must=GS06
IEA INTERCHANGE 1 R
CONTROL TRAILER
307 IEA01 Number of Included N0 1-5 R
Functional Groups
308 IEA02 Interchange Control N0 9-9 R
Number
5010 270 Member Eligibility Response
Element Description ID Min. Usage Loop Loop Values

ISA INTERCHANGE 1 R
CONTROL HEADER
ISA01 Authorization Information ID 2 - 2 R 00, 03
Qualifier
ISA02 Authorization Information AN 10 - 10 R
ISA03 Security Information ID 2-2 R 00, 01

Qualifier
ISA04 Security Information AN 10 - 10 R
ISA05 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15-15 R
ISA07 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15-15 R
ISA09 Interchange Date DT 6-6 R YYMMDD
ISA10 Interchange Time TM 4-4 R HHMM
ISA11 Repetition Seperator 1-1 R
ISA12 Interchange Control ID 5-5 R 501

Version Number
ISA13 Interchange Control N0 9-9 R
Number
ISA14 Acknowledgement ID 1-1 R 0, 1
Requested
ISA15 Interchange Usage ID 1-1 R P, T
Indicator
ISA16 Component Element 1-1 R
Separator
HEADER
GS01 Functional Identifier ID 2-2 R
Code
GS02 Application Sender's AN 2 - 15 R
Code
GS03 Application Receiver's AN 2 - 15 R
Code
GS04 Date DT 8-8 R CCYYMMDD
GS05 Time TM 4-8 R HHMM
GS06 Group Control Number N0 1-9 R
GS07 Responsible Agency ID 1-2 R X

Code
GS08 Version/Release/ AN 1 - 12 R 005010X279
HEADER
ST01 Transaction Set Identifier ID 3-3 R 270
Code
ST02 Transaction Set Control AN 4-9 R
Number
ST03 Implementation AN 1 - 35 R 005010X279
Convention Reference
HIERARCHICAL
TRANSACTION
BHT01 Hierarchical Structure ID 4-4 R 22
Code
BHT02 Transaction Set Purpose ID 2-2 R 01,13
Code
BHT03 Reference Identification AN 1 - 50 S
BHT04 Transaction Set Creation DT 8-8 R CCYYMMDD

Date
BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 S RT

SOURCE LEVEL
HL01 Hierarchical ID Number AN 1 - 12 R
HL02 Hierarchical Parent ID AN 1 - 12 N/U

Number
HL03 Hierarchical Level Code ID 1-2 R 20
HL04 Hierarchical Child Code ID 1-1 R 1

SOURCE NAME
NM101 Entity Identifier Code ID 2-3 R 2B, 36, GP, P5, PR
NM102 Entity Type Qualifier ID 1-1 R 1, 2
NM103 Name Last or AN 1 - 60 R

Organization Name
NM104 Name First AN 1 - 35 S
NM105 Name Middle AN 1 - 25 S
NM106 Name Prefix AN 1 - 10 N/U
NM107 Name Suffix AN 1 - 10 S
NM108 Identification Code ID 1-2 R 24, 46, FI, NI, PI, XV, XX
Qualifier
NM109 Identification Code AN 2 - 80 R
NM110 Entity Relationship Code ID 2-2 N/U
NM111 Entity Identifier Code ID 2-3 N/U
NM112 Name Last or AN 1 - 60 N/U

Organization Name

RECEIVER LEVEL
HL02 Hierarchical Parent ID AN 1 - 12 R

Number

RECEIVER NAME
NM101 Entity Identifier Code ID 2-3 R 1P, 2B, 36, 80, FA, GP, P5, PR
NM102 Entity Type Qualifier ID 1-1 R 1, 2

Organization Name
NM108 Identification Code ID 1-2 R 24, 34, FI, PI, PP, SV, XV, XX
Qualifier

Organization Name
RECEIVER
ADDITIONAL
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 0B, 1C, 1D, 1J, 4A, CT, EL, EO,
Qualifier HPI, JD, N5, N7, Q4, SY, TJ
REF02 Reference Identification AN 1 - 50 R
REF03 Description AN 1 - 80 S
REF04 REFERENCE N/U

IDENTIFIER
RECEIVER ADDRESS
N301 Address Information AN 1 - 55 R
N302 Address Information AN 1 - 55 S
RECEIVER
CITY/STATE/ ZIP CODE
N401 City Name AN 2 - 30 R
N402 State or Province Code ID 2-2 S
N403 Postal Code ID 3 - 15 S
N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 N/U
N406 Location Qualifier AN 1 - 30 N/U
N407 Country Subdivision ID 1-3 S

Code
RECEIVER PROVIDER
INFORMATION
PRV01 Provider Code ID 1-3 R AD, AT, BI, CO, CV, H, HH, LA,
OT, P1, P2, PC, PE, R, RF, SB,
SK, SU
PRV02 Reference Identification ID 2-3 S PXC

Qualifier
PRV03 Reference Identification AN 1 - 50 S
PRV04 State or Province Code ID 2-2 N/U
PRV05 PROVIDER SPECIALTY N/U

INFORMATION
PRV06 Provider Organization ID 3-3 N/U

Code
HL SUBSCRIBER LEVEL 1 R 2000C >1

Number
HL04 Hierarchical Child Code ID 1-1 R 0, 1

NUMBER
TRN01 Trace Type Code ID 1-2 R 1
TRN02 Reference Identifier AN 1 - 50 R
TRN03 Originating Company AN 10 - 10 R

Identifier
TRN04 Reference Identification AN 1 - 50 S
NM101 Entity Identifier Code ID 2-3 R IL
NM102 Entity Type Qualifier ID 1-1 R 1

NM103 Name Last or AN 1 - 60 S
Organization Name
NM108 Identification Code ID 1-2 S II, MI

Qualifier
NM109 Identification Code AN 2 - 80 S

Organization Name

ADDITIONAL
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 18, 1L, 1W, 3H, 6P, CT, EA, EJ,
Qualifier F6, GH, HJ, IG, N6,
NQ, SY, Y4
REF03 Description AN 1 - 80 N/U
REF04 REFERENCE N/U

IDENTIFIER
ADDRESS
CITY/STATE/ZIP CODE
N402 State or Province Name ID 2-2 S

Code

INFORMATION
OT, P1, P2, PC, PE, R, RF, SK,
SU
PRV02 Reference Identification ID 2-3 S 9K, D3, EI, HPI, PXC, SY, TJ
Qualifier

INFORMATION

Code

DEMOGRAPHIC
INFORMATION
DMG01 Date Time Period Format ID 2-3 S D8
Qualifier
DMG02 Date Time Period AN 1 - 35 S
DMG03 Gender Code ID 1-1 S F, M
DMG04 Marital Status Code ID 1-1 N/U
DMG05 Composite Race or ID 1-1 N/U

Ethnicity Information
DMG06 Citizenship Status Code ID 1-2 N/U
DMG07 Country Code ID 2-3 N/U
DMG08 Basis of Verification ID 1-2 N/U

Code
DMG09 Quantity R 1 - 15 N/U
DMG10 Code List Qualifier Code ID 1-3 N/U
DMG11 Industry Code AN 1 - 30 N/U
INS MULTIPLE BIRTH 1 S 2100C

SEQUENCE NUMBER
INS01 Yes/No Condition or ID 1-1 R Y
Response Code
INS02 Individual Relationsgip ID 2-2 R 18
Code
INS03 Maintenance Type Code ID 3-3 N/U
INS04 Maintenance Reason ID 2-3 N/U

Code
INS05 Benefit Status Code ID 1-1 N/U
INS06 MEDICARE STATUS N/U

CODE
INS07 Consolidated Omnibus ID 1-2 N/U
INS08 Employment Status ID 2-2 N/U

Code
INS09 Student Status Code ID 1-1 N/U
INS10 Yes/No Condition or ID 1-1 N/U

Response Code
INS11 Date Time Period Format ID 2-3 N/U
Qualifier
INS12 Date Time Period AN 1 - 35 N/U
INS13 Confidentiality Code ID 1-1 N/U
INS14 City Name AN 2 - 30 N/U
INS15 State or Province Code ID 2-2 N/U
INS16 Country Code ID 2-3 N/U
INS17 Number N0 1-9 R
HI SUBSCRIBER HEALTH 1 S 2100C

CARE DIAGNOSIS
CODE
HI01 HEALTH CARE CODE R
INFORMATION
HI01 -1 Code List Qualifier Code ID 1-3 R ABK, BK
HI01 -2 Industry Code AN 1 - 30 R
HI01 -3 Date Time Period Format ID 2-3 N/U

Qualifier
HI01 -4 Date Time Period AN 1 - 35 N/U
HI01 -5 Monetary Amount R 1 - 18 N/U
HI01 -6 Quantity R 1 - 15 N/U
HI01 -7 Version Identifier AN 1 - 30 N/U
HI01 -8 Industry Code AN 1 - 30 N/U
HI01 -9 Yes/No Condition or ID 1-1 N/U

Response Code
HI02 HEALTH CARE CODE S
INFORMATION
HI02 -1 Code List Qualifier Code ID 1-3 R ABF, BF

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier


Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code
HI09 HEALTH CARE CODE N/U
INFORMATION
INFORMATION
INFORMATION
INFORMATION
DTP01 Date Time Qualifier ID 3-3 R 102, 291
DTP02 Date Time Period Format ID 2-3 R D8, RD8

Qualifier
DTP03 Date Time Period AN 1 - 35 R CCYYMMDD, CCYYMMDD
CCYYMMDD
EQ SUBSCRIBER 1 S 2110C 99
ELIGIBILITY/BENEFIT
INQUIRY
INFORMATION
EQ01 Service Type Code ID 1-2 S 1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12,13, 14, 15, 16, 17, 18, 19,
20, 21, 22, 23, 24, 25, 26, 27, 28,
30, 32, 33, 34, 35, 36, 37, 38, 39,
40, 41, 42, 43, 44, 45, 46, 47, 48,
49, 50, 51, 52, 53, 54, 55, 56, 57,
58, 59, 60, 61, 62, 63, 64, 65, 66,
67, 68, 69, 70, 71, 72, 73, 74, 75,
76, 77, 78, 79, 80, 81, 82, 83, 84,
85, 86, 87, 88, 89, 90, 91, 92, 93,
94, 95, 96, 97, 98, 99, A0, A1,
A2, A3, A4, A5, A6, A7, A8, A9,
AA, AB, AC, AD, AE, AF, AG,
AH, AI , AJ, AK, AL, AM, AN ,AO,
AQ, AR, B1, B2, B3, BA,BB,
BC, BD, BE, BF, BG, BH, BI, BJ,
BK, BL, BM, BN, BP, BQ, BR,
BS, BT, BU, BV, BW,
BX, BY, BZ, C1, CA,
CB, CC, CD, CE, CF,
CG, CH, CI, CJ, CK,
CL, CM, CN, CO, CP,
CQ, DG, DM, DS, GF,
GN, GY, IC, MH
EQ02 COMPOSITE MEDICAL S

PROCEDURE
IDENTIFIER
EQ02 -1 Product/Service ID ID 2-2 R AD, CJ, HC, ID, IV, N4, ZZ

Qualifier
EQ02 -2 Product/Service ID AN 1 - 48 R
EQ02 -3 Procedure Modifier AN 2-2 S
EQ02 -7 Description AN 1 - 80 N/U
EQ02 -8 Product/Service ID AN 1 - 48 N/U

EQ03 Coverage Level Code ID 3-3 S FAM
EQ04 Insurance Type Code ID 1-3 N/U
EQ05 COMPOSITE S
DIAGNOSIS CODE
POINTER
EQ05 -1 Diagnosis Code Pointer N0 1-2 R
EQ05 -2 Diagnosis Code Pointer N0 1-2 S

DOWN AMOUNT
AMT01 Amount Qualifier Code ID 1-3 R R
AMT02 Monetary Amount R 1 - 18 R
AMT03 Credit/Debit Flag Code ID 1-1 N/U

DOWN TOTAL BILLED
AMOUNT
AMT01 Amount Qualifier Code ID 1-3 R PB
AMT02 Monetary Amount R 1 - 18 R
III SUBSCRIBER 10 S 2110C

ADDITIONAL INQUIRY
INFORMATION
III01 Code List Qualifier Code ID 1-3 R ZZ

III02 Industry Code AN 1 - 30 R 01, 03, 04, 05, 06, 07, 08, 11, 12,
13, 14, 15, 20, 21, 22, 23, 24, 25,
26, 31, 32, 33, 34, 41, 42, 49,
50, 51, 52, 53, 54, 55, 56, 57,
60, 61, 62, 65, 71, 72, 81, 99
III03 Code Category ID 2-2 N/U
III04 Free-Form Message Text AN 1-264 N/U
III05 Quantity R 1 - 15 N/U
III06 COMPOSITE UNIT OF N/U

MEASURE
III07 Surface/Layer/Position ID 2-2 N/U
Code
Code
Code

ADDITIONAL
INFORMATION
REF01 Reference Identification ID 2-3 R 9F, G1
Qualifier
REF04 REFERENCE N/U

IDENTIFIER

ELIGIBILITY/BENEFIT
DATE
DTP01 Date Time Qualifier ID 3-3 R 291

Qualifier
DTP03 Date Time Period Format AN 1 - 35 R CCYYMMDD, CCYYMMDD
CCYYMMDD


Number

NUMBER
TRN01 Trace Type Code ID 1-2 R 1
TRN02 Reference Identification AN 1 - 50 R

Identifier
NM101 Entity Identifier Code ID 2-3 R 3

Organization Name
NM108 Identification Code ID 1-2 N/U

Qualifier
NM109 Identification Code AN 2 - 80 N/U

Organization Name

ADDITIONAL
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 18, 1L, 6P, CT, EA, EJ, F6, GH,
Qualifier
HJ, IF, IG, MRC, N6,
SY, Y4

REF04 REFERENCE N/U

IDENTIFIER
ADDRESS
CITY/STATE/ZIP CODE
N402 State or Provine Code ID 2-2 S

Code

INFORMATION
OT, P1, P2, PC, PE, R, RF, SK,
SU
PRV02 Reference Identification ID 2-3 S 9K, D3, EI, HPI, PXC, SY, TJ
Qualifier
PRV05 PROVIDER N/U

SPECIALITY
INFORMATION
Code

DEMOGRAPHIC
INFORMATION
DMG01 Date Time Period Format ID 2-3 S D8
Qualifier
DMG02 Date Time Period AN 1 - 35 S CCYYMMDD
DMG03 Gender Code ID 1-1 S F, M
DMG05 Composite Race or N/U

Ethnicity Code

Code

RELATIONSHIP
INS01 Yes/No Condition or ID 1-1 R N
Response Code
INS02 Individual Relationship ID 2-2 R 01, 19, 34
Code
INS03 Maintenance Type Code ID 3-3 N/U
INS04 Maintenance Reason ID 2-3 N/U

Code
INS06 MEDICARE STATUS 1-1 N/U

CODE

Code
INS09 Student Status Code ID 1-1 N/U
INS10 Yes/No Condition or ID 1-1 N/U

Response Code
Qualifier
INS17 Number N0 1-9 S

HI DEPENDENT HEALTH 1 S 2100D
CARE DIAGNOSIS
CODE
INFORMATION
HI01 -1 Code List Qualifier Code ID 1-3 R ABK, BK

Qualifier

Response Code

INFORMATION

Qualifier

Response Code
INFORMATION

Qualifier


Response Code

INFORMATION

Qualifier

Response Code
INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code
INFORMATION

Qualifier

Response Code
INFORMATION
INFORMATION
INFORMATION
INFORMATION
DTP01 Date Time Qualifier ID 3-3 R 102, 291

Qualifier
DTP03 Date Time Period AN 1 - 35 R CCYYMMDD, CCYYMMDD
CCYYMMDD
EQ DEPENDENT 1 R 2110D 99
INQUIRY
INFORMATION
EQ01 Service Type Code ID 1-2 S 1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12,13, 14, 15, 16, 17, 18, 19,
20, 21,22,23,24,25,26,
27,28,30,32,33,34,
35,36,37,38,39,40, 41, 42, 43,
44, 45, 46, 47, 48, 49, 50, 51, 52,
53, 54, 55, 56, 57, 58, 59, 60, 61,
62, 63, 64, 65, 66, 67, 68, 69, 70,
71, 72, 73, 74, 75, 76, 77, 78, 79,
80, 81, 82, 83, 84, 85, 86, 87, 88,
89, 90, 91, 92, 93, 94, 95, 96, 97,
98, 99, A0, A1, A2, A3, A4, A5,
A6, A7, A8, A9, AA, AB, AC, AD,
AE, AF, AG, AH, AI , AJ, AK, AL,
AM, AN ,AO, AQ, AR, B1, B2,
B3, BA,BB, BC, BD, BE, BF,
BG, BH, BI, BJ, BK, BL, BM, BN,
BP, BQ, BR, BS, BT, BU,
BV, BW, BX, BY, BZ,
C1, CA, CB, CC, CD,
CE, CF, CG, CH, CI,
CJ, CK, CL, CM,
CN ,CO, CP, CQ, DG,
DM, DS, GF, GN, GY,
IC, MH,
EQ02 COMPOSITE MEDICAL S

PROCEDURE
IDENTIFIER
EQ02 -1 Product/Service ID ID 2-2 R AD, CJ, HC, ID, IV, N4, ZZ
Qualifier
EQ02 -2 Product/Service ID AN 1 - 48 R
EQ02 -3 Procdeure Modifier AN 2-2 S
EQ02 -7 Description AN 1 - 80 N/U
EQ02 -8 Product/Service ID AN 1 - 48 N/U
EQ03 Coverage Level Code ID 3-3 N/U
EQ04 Insurance Type Code ID 1-3 N/U
EQ05 COMPOSITE S
DIAGNOSIS CODE
POINTER
EQ05 -1 Diagnosis Code Pointer N0 1-2 R
III DEPENDENT 10 S 2110D

ADDITIONAL INQUIRY
INFORMATION
III01 Code List Qualifier Code ID 1-3 R ZZ

III02 Industry Code AN 1 - 30 R 01, 03, 04, 05, 06, 07, 08, 11, 12,
13, 14, 15, 20, 21, 22, 23, 24, 25,
26, 31, 32, 33, 34, 41, 42, 49, 50,
51, 52, 53, 54, 55, 56,57, 60, 61,
62, 65, 71, 72, 81, 99
III03 Code Category ID 2-2 N/U

MEASURE
Code
Code
Code

ADDITIONAL
INFORMATION
REF01 Reference Identification ID 2-3 R 9F, G1
Qualifier
REF04 REFRENCE N/U

IDENTIFIER

DATE
DTP01 Date Time Qualifier ID 3-3 R 291
Qualifier
DTP03 Date Time Period AN 1 - 35 R
TRAILER
SE01 Number of Included N0 1 - 10 R
Segments
SE02 Transaction Set Control AN 4-9 R
Number
GE FUNCTIONAL GROUP 1 R
TRAILER
GE01 Number of Transaction N0 1-6 R
Sets Included
GE02 Group Control Number N0 1- 9 R Must=GS06
IEA INTERCHANGE 1 R
CONTROL TRAILER
IEA01 Number of Included N0 1-5 R
Functional Groups
IEA02 Interchange Control N0 9-9 R
Number
4010A1 271 Member Eligibility Response
Element Description ID Min. Usage Loop Loop

ISA INTERCHANGE 1 R
CONTROL HEADER
1 ISA01 Authorization Information ID 2-2 R
Qualifier
3 ISA03 Security Information ID 2-2 R

Qualifier
5 ISA05 Interchange ID Qualifier ID 2-2 R
6 ISA06 Interchange Sender ID AN 15/15 R

8 ISA08 Interchange Receiver ID AN 15/15 R

9 ISA09 Interchange Date DT 6-6 R
10 ISA10 Interchange Time TM 4-4 R
11 ISA11 Interchange Control ID 1-1 R
Standards ID
12 1 ISA12 Interchange Control ID 5-5 R
Version Number
13 ISA13 Interchange Control N0 9-9 R
Number
14 ISA14 Acknowledgement ID 1-1 R
Requested
15 ISA15 Usage Indicator ID 1-1 R
16 ISA16 Component Element 1-1 R

Separator
HEADER
17 1 GS01 Functional Identifier ID 2-2 R
Code
18 GS02 Application Sender's AN 2 - 15 R
Code
19 GS03 Application Receiver's AN 2 - 15 R
Code
20 GS04 Date DT 8-8 R
21 GS05 Time TM 4-8 R
23 GS07 Responsible Agency ID 1-2 R
Code
24 1 GS08 Version/ Release/ AN 1 - 12 R
HEADER
25 ST01 Transaction Set Identifier ID 3-3 R
Code
Number
27 1
HIERARCHICAL
TRANSACTION
28 BHT01 Hierarchical Structure ID 4-4 R
Code
29 1 BHT02 Transaction Set Purpose ID 2-2 R
Code
30 BHT03 Reference Identification AN 1 - 30 S
31 BHT04 Date DT 8-8 R
33 BHT06 Transaction Type Code ID 2-2 N/U

SOURCE LEVEL
35 HL02 Number AN 1 - 12 N/U
36 HL03 Hierarchical Level Code ID 1-2 R
37 HL04 Hierarchical Child Code ID 1-1 R
AAA REQUEST VALIDATION 9 S 2000A
38 AAA01 Yes/No Condition or ID 1-1 R

Response Code
39 AAA02 Agency Qualifier Code ID 2-2 N/U
40 AAA03 Reject Reason Code ID 2-2 R
41 AAA04 Follow-up Action Code ID 1-1 R
SOURCE NAME
42 NM101 Entity Identifier Code ID 2-3 R
43 NM102 Entity Type Qualifier ID 1-1 R

Organization Name
49 NM108 Identification Code ID 1-2 R
Qualifier

53 1
REF INFORMATION 9 S 2100A

SOURCE ADDITIONAL
IDENTIFICATION
54 1 REF01 Reference Identification ID 2-3 R

Qualifier
56 1 REF03 Description AN 1 - 80 S
57 1 REF04 REFERENCE N/U
INDENTIFIER
PER INFORMATION 3 S 2100A

SOURCE CONTACT
INFORMATION
58 PER01 Contact Function Code ID 2-2 R
59 PER02 Name AN 1 - 60 S
60 1 PER03 Communication Number ID 2-2 S
Qualifier
61 PER04 Communication Number AN 1 - 80 S

Qualifier

Qualifier
66 PER09 Contact Inquiry AN 1 - 20 N/U

Reference

Response Code
HL INFORMATION 1 S 2000B >1

RECEIVER LEVEL
Number

RECEIVER NAME

Organization Name
82 NM108 Identification Code ID 1-2 R
Qualifier

86 1
RECEIVER
ADDITIONAL
IDENTIFICATION
Qualifier

IDENTIFIER
AAA INFORMATION 9 S 2100B

RECEIVER REQUEST
VALIDATION
91 AAA01 Yes/ No Condition or ID 1-1 R

Response Code
HL SUBSCRIBER LEVEL 1 S 2000C >1

96 HL02 Number AN 1 - 12 R
NUMBER
99 TRN01 Trace Type Code ID 1-2 R
Identifier

Organization Name
108 NM106 Name Prefix AN 1 - 10 S
110 1 NM108 Identification Code ID 1-2 S
Qualifier

114 1

ADDITIONAL
IDENTIFICATION
Qualifier

IDENTIFIER
ADDRESS
N4 SUBSCRIBER CITY/ 1 S 2100C

STATE/ ZIP CODE

122 N402 State or Province Code ID 2-2 S
125 N405 Location Qualifier ID 1-2 S
126 N406 Location Qualifier AN 1 - 30 S
127
PER SUBSCRIBER 3 S 2100C

CONTACT
INFORMATION
128 1 PER01 Contact Function Code ID 2-2 R
129 1 PER02 Name AN 1 - 60 S
Qualifier

Qualifier

Qualifier

Reference
AAA SUBSCRIBER 9 S 2100C

REQUEST VALIDATION

Response Code
139 1 AAA03 Reject Reason Code ID 2-2 R

DEMOGRAPHIC
INFORMATION
141 DMG01 Date Time Period Format ID 2-3 S
Qualifier
143 DMG03 Gender Code ID 1-1 S

Code
150 1
151 1

REALTIONSHIP
152 INS01 Yes/ No Condition or ID 1-1 R
Response Code
153 INS02 Individual Relationship ID 2-2 R
Code
154 INS03 Maintenance Type Code ID 3-3 S
155 INS04 Maintenance Reason ID 2-3 S

Code


Code
160 INS09 Student Status Code ID 1-1 S
161 INS10 Yes/ No Condition or ID 1-1 S
Response Code
Qualifier
1
1
1
1
1
1

169 1 DTP01 Date/Time Qualifier ID 3-3 R
170 DTP02 Date Time Period Format ID 2-3 R

Qualifier
EB SUBSCRIBER 1 S 2110C >1

INFORMATION
172 1 EB01 Eligibility or Benefit ID 1-2 R

Information
173 EB02 Coverage Level Code ID 3-3 S

174 1 EB03 Service Type Code ID 1-2 S
175 1 EB04 Insurance Type Code ID 3-Jan S
176 EB05 Plan Coverage AN 1 - 50 S

Description
177 EB06 Time Period Qualifier ID 1-2 S
178 EB07 Monetary Amount R 1 - 18 S

179 EB08 Percent R 1 - 10 S
180 1 EB09 Quantity Qualifier ID 2-2 S
181 EB10 Quantity R 1 - 15 S

182 EB11 Yes/No Condition or ID 1-1 S
Response Code
183 1 EB12 Yes/No Condition or ID 1-1 S
Response Code
184 EB13 PROCEDURE S
IDENTIFIER
185 EB13 -1 Product/Service ID ID 2-2 R
Qualifier
186 EB13 -2 Product/Service ID AN 1 - 48 R
187 EB13 -3 Procedure Modifier AN 2-2 S
191 EB13 -7 Description AN 1 - 80 N/U
192 1
193 1
194 1
195 1
196 1
197 1
HSD HEALTH CARE 9 S 2110C

SERVICES DELIVERY
198 HSD01 Quantity Qualifier ID 2-2 S
199 HSD02 Quantity R 1 - 15 S

200 HSD03 Unit or Basis for ID 2-2 S
Measurement Code
201 HSD04 Sample Selection R 1-6 S
Modulus
202 HSD05 Time Period Qualifier ID 1-2 S
203 HSD06 Number of Periods N0 1-3 S

204 HSD07 Ship/Delivery or ID 1-2 S
Calendar Pattern Code
205 HSD08 Ship/Delivery Pattern ID 1-1 S

Time Code

ADDITIONAL
IDENTIFICATION
Qualifier

IDENTIFIER

ELIGIBILITY/BENEFIT
DATE

Qualifier

REQUEST VALIDATION

Response Code
216 AAA04 Follow-up Action code ID 1-1 R

MSG MESSAGE TEXT 10 S 2110C
217 MSG01 Free-Form Message Text AN 1-264 R
218 MSG02 Printer Carriage Control ID 2-2 N/U

Code
219 MSG03 Number N0 1-9 N/U
III SUBSCRIBER 1 S 2115C 10

ADDITIONAL
INFORMATION
220 III01 Code List Quantifier ID 1-3 R

Code
221 1 III02 Industry Code AN 1 - 30 R
222 1 III03 Code Category ID 2-2 N/U


MEASURE
Code
Code
Code
LS LOOP HEADER 1 S 2110C
229 1 LS01 Loop Identifier Code AN 1-6 R
NM1 SUBSCRIBER BENEFIT 1 S 2120C 1

RELATED ENTITY
NAME
230 1 NM101 Entity Identifier Code ID 2-3 R

Organization Name
Qualifier

239 1 NM110 Entity Relationship Code ID 2-2 N/U

241 1
RELATED ENTITY
ADDRESS
N4 SUBSCRIBER BENEFIT 1 S 2110C

RELATED
CITY/STATE/ZIP CODE

250 1
PER SUBSCRIBER BENEFIT 3 S 2120C
RELATED ENTITY
CONTACT
INFORMATION
252 PER02 Name AN 1 - 60 S
253 PER03 Communication Number ID 2-2 S
Qualifier

Qualifier

Qualifier

Reference
PRV SUBSCRIBER BENEFIT 1 S 2120C

RELATED PROVIDER
INFORMATION
260 PRV01 Provider Code ID 1-3 R
261 1 PRV02 Reference Identification ID 2-3 R

Qualifier

INFORMATION

Code
LE LOOP TRAILER 1 S 2110C
266 1 LE01 Loop Identifier Code AN 1-6 R


Number

NUMBER
Identifier

Organization Name
Qualifier

286 1

ADDITIONAL
IDENTIFICATION
Qualifier
IDENTIFIER
ADDRESS
CITY/STATE/ZIP CODE

299 1
PER DEPENDENT 3 S 2100D

CONTACT
INFORMATION
301 1 PER02 Name AN 1 - 60 S
Qualifier

Qualifier

Qualifier

Reference
AAA DEPENDENT REQUEST 9 S 2100D
VALIDATION

Response Code

DEMOGRAPHIC
INFORMATION
313 DMG01 Date Time Period Format ID 2-3 S
Qualifier
315 DMG03 Gender Code ID 1-1 S

Code
322 1
323 1

RELATIONSHIP
324 INS01 Yes/No Condition or ID 1-1 R
Response Code
325 1 INS02 Individual Relationship ID 2-2 R
Code

Code


Code
332 1 INS09 Student Status Code ID 1-1 S
333 1 INS10 Yes/No Condition or ID 1-1 S
Response Code
Qualifier
1
1
1
1
1
1
1

Qualifier
EB DEPENDENT 1 S 2110D >1

ELIGIBILITY/BENEFIT
INFORMATION
344 EB01 Eligibility/ Benefit ID 1-2 R
Information
345 1 EB02 Coverage Level Code ID 3-3 S

346 1 EB03 Service Type Code ID 1-2 S
347 EB04 Insurance Type Code ID 1-3 S
348 EB05 Plan Coverage AN 1 - 50 S

Description
349 EB06 Time Period Qualifier ID 2-2 S
350 EB07 Monetary Amount R 1 - 18 S

351 EB08 Percent R 1 - 10 S
352 1 EB09 Quantity Qualifier ID 2-2 S
353 EB10 Quantity R 1 - 15 S

354 EB11 Yes/No Condition or ID 1-1 S
Response Code
355 1 EB12 Yes/No Condition or ID 1-1 S
Response Code
356 EB13 COMPOSITE MEDICAL S
PROCEDURE
IDENTIFIER
357 1 EB13 -1 Product/Service ID ID 2-2 R

Qualifier
358 EB13 -2 Product/Service ID AN 1 - 48 R

363 EB13 -7 Description AN 1 - 80 N/U
364 1
365 1
366 1
367 1
368 1
369 1
HSD HEALTH CARE 9 S 2110D

SERVICES DELIVERY
370 HSD01 Quantity Qualifier ID 2-2 S
371 HSD02 Quantity R 1 - 15 S

372 HSD03 Unit or Basis for ID 2-2 S
Measurement Code
373 HSD04 Sample Selection R 1-6 S
Modulus
374 HSD05 Time Period Qualifier ID 1-2 S
375 HSD06 Number of Periods N0 1-3 S
376 HSD07 Ship/Delivery or ID 1-2 S
Calendar Pattern Code
377 HSD08 Ship/Delivery Pattern ID 1-1 S

Time Code

ADDITIONAL
IDENTIFICATION
Qualifier

IDENTIFIER

ELIGIBILITY/BENEFIT
DATE

Qualifier

VALIDATION

Response Code
MSG MESSAGE TEXT 10 S 2110D
389 MSG01 Free-Form Message Text AN 1-264 R
390 MSG02 Printer Carriage Control ID 2-2 N/U

Code
391 MSG03 Number N0 1-9 N/U
III DEPENDENT 1 S 2115D 10

ELIGIBILITY/BENEFIT
ADDITIONAL
INFORMATION
392 1 III01 Code List Qualifier Code ID 1-3 R
393 1 III02 Industry Code AN 1 - 30 R
394 1 III03 Code Category ID 2-2 N/U


MEASURE
Code
Code
Code
LS DEPENDENT 1 S 2110D
INFORMATION
401 1 LS01 Loop Identifier Code AN 1-6 R

NM1 DEPENDENT BENEFIT 1 S 2120D 1
RELATED ENTITY
NAME

Organization Name
Qualifier


413 1
N3 DEPENDENT BENEFIT 1 S 2120D

RELATED ENTITY
ADDRESS

RELATED ENTITY
CITY/STATE/ZIP CODE

422
PER DEPENDENT BENEFIT 3 S 2120D

RELATED ENTITY
CONTACT
INFORMATION
424 PER02 Name AN 1 - 60 S
Qualifier

Qualifier

Qualifier
PRV DEPENDENT BENEFIT 1 S 2120D

RELATED PROVIDER
INFORMATION
433 PRV02 Reference Identification ID 2-3 R

Qualifier
434 PRV03 Reference Identification AN 1 - 30 R

INFORMATION

Code
LE LOOP TRAILER 1 S 2110D

438 LE01 Lopp Identifier Code AN 1-6 R
TRAILER
439 SE01 Number of Included N0 1 - 10 R
Segments
Number
GE FUNCTIONAL GROUP
TRAILER
441 GE01 Number of Transaction N0 1-6 R
Sets Included
442 GE02 Group Control Number N0 1-9 R
IEA INTERCHANGE
CONTROL TRAILER
443 IEA01 Number of Included N0 1-5 R
Functional Groups
444 IEA02 Interchange Control N0 9-9 R
Number
igibility Response 5010 271 Member Eligibility Response
Values Element Description ID Min. Usag Loop Loop

Identifier Max. e Repea
Reg. t
ISA INTERCHANGE 1 R
CONTROL HEADER
00, 03 ISA01 Authorization Information ID 2-2 R
Qualifier
00, 01 ISA03 Security Information ID 2-2 R

Qualifier
01, 14, 20, 27, 28, ISA05 Interchange ID Qualifier ID 2-2 R

29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15/15 R
01, 14, 20, 27, 28, ISA07 Interchange ID Qualifier ID 2-2 R

29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15/15 R
YYMMDD ISA09 Interchange Date DT 6-6 R
HHMM ISA10 Interchange Time TM 4-4 R
U ISA11 Repetition Seperator 1-1 R
401 ISA12 Interchange Control ID 5-5 R

Version Number
Number
0, 1 ISA14 Acknowledgement ID 1-1 R
Requested
P, T ISA15 Interchange Usage ID 1-1 R
Indicator
Separator
HEADER
HB, HS GS01 Functional Identifier ID 2-2 R
Code
GS02 Application Sender's AN 2 - 15 R
Code
GS03 Application Receiver's AN 2 - 15 R
Code
CCYYMMDD GS04 Date DT 8-8 R
HHMM GS05 Time TM 4-8 R

X GS07 Responsible Agency ID 1-2 R

Code
004010X092 GS08 Version/Release/ AN 1 - 12 R
HEADER
Code
Number
ST03 Implementation AN 1 - 35 R
HIERARCHICAL
TRANSACTION
22 BHT01 Hierarchical Structure ID 4-4 R
Code
11 BHT02 Transaction Set Purpose ID 2-2 R
Code
BHT03 Reference Identification AN 1 - 50 S
CCYYMMDD BHT04 Date DT 8-8 R
BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 N/U

SOURCE LEVEL
HL02 Number AN 1 - 12 N/U
0, 1 HL04 Hierarchical Child Code ID 1-1 R
N, Y AAA01 Yes/No Condition or ID 1-1 R

Response Code
AAA02 Agency Qualifier Code ID 2-2 N/U
04, 41, 42, 79 AAA03 Reject Reason Code ID 2-2 R
C, N, P, R, S, Y AAA04 Follow-up Action Code ID 1-1 R

SOURCE NAME
2B, 36, GP, P5, PR NM101 Entity Identifier Code ID 2-3 R
1, 2 NM102 Entity Type Qualifier ID 1-1 R

Organization Name
24, 46, FI, NI, PI, NM108 Identification Code ID 1-2 R

XV, XX Qualifier

Organization Name
18, 55
PER PAYER CONTACT 3 S 2100A

INFORMATION
IC PER01 Contact Function Code ID 2-2 R
PER02 Name AN 1 - 60 S
ED, EM, FX, TE PER03 Communication Number ID 2-2 S

Qualifier
AAABBBCCCC PER04 Communication Number AN 1-256 S
ED, EM, EX, FX, TE PER05 Communication Number ID 2-2 S

Qualifier

Qualifier
PER09 Contact Inquiry AN 1 - 20 N/U

Reference

Response Code
04, 41, 42, 79, 80, AAA03 Reject Reason Code ID 2-2 R
T4
C, N, P, R, S, W, X, AAA04 Follow-up Action Code ID 1-1 R
Y
HL INFORMATION 1 S 2000B >1

RECEIVER LEVEL

Number
0,1 HL04 Hierarchical Child Code ID 1-1 R

RECEIVER NAME
1P, 2B, 36, 80, FA, NM101 Entity Identifier Code ID 2-3 R
GP, P5, PR

Organization Name
24, 34, FI, PI, PP, NM108 Identification Code ID 1-2 R

SV, XV, XX Qualifier

Organization Name
RECEIVER
ADDITIONAL
IDENTIFICATION
0B, 1C, 1D, 1J, 4A, REF01 Reference Identification ID 2-3 R
CT, EL, EO, HPI Qualifier
REF04 REFERENCE N/U

IDENTIFIER
AAA INFORMATION 9 S 2100B

RECEIVER
VALIDATION REQUEST
N, Y AAA01 Yes/ No Condition or ID 1-1 R

Response Code
79, 97, T4
C, N, R, S, W, X, Y AAA04 Follow-up Action Code ID 1-1 R

RECEIVER PROVIDER
INFORMATION
PRV01 Provider Code ID 1-3 R
PRV02 Reference Identification ID 2-3 S

Qualifier
PRV05 PROVIDER N/U

SPECIALITY
INFORMATION
Code
HL SUBSCRIBER LEVEL 1 S 2000C >1
HL02 Number AN 1 - 12 R

NUMBER
1, 2 TRN01 Trace Type Code ID 1-2 R

Identifier
IL NM101 Entity Identifier Code ID 2-3 R

Organization Name
MI, ZZ NM108 Identification Code ID 1-2 S

Qualifier

Organization Name

ADDITIONAL
IDENTIFICATION
18, 1L, 1W, 3H, 49, REF01 Reference Identification ID 2-3 R
6P, A6, EA, EJ, F6, Qualifier
GH, HJ, IF, IG, ML,
N6, NQ, Q4, SY
REF04 REFERENCE N/U

IDENTIFIER
ADDRESS
CITY/STATE/ZIP CODE
CY, FI N405 Location Qualifier ID 1-2 N/U

Code
IC
HP, TE, WP
AAABBBCCCC
EX, HP, TE, WP
AAABBBCCCC
EX, HP, TE, WP

REQUEST VALIDATION

Response Code
48, 49, 51, 52, 56,
57, 58, 60, 61, 62,
63, 64, 65, 66,
67, 68, 71, 72, 73,
74, 75, 76, 77, 78

INFORMATION

Qualifier
PRV05 PROVIDER N/U

SPECIALITY
INFORMATION
Code

DEMOGRAPHIC
INFORMATION
D8 DMG01 Date Time Period Format ID 2-3 S
Qualifier
F, M, U DMG03 Gender Code ID 1-1 S
DMG05 ETHNICITY ID 1-1 N/U

INFORMATION

Code
DMG10 Code List Qalifier Code ID 1-3 N/U

RELATIONSHIP
Y INS01 Yes/ No Condition or ID 1-1 R
Response Code
18 INS02 Individual Relationship ID 2-2 R
Code

Code
INS06 MEDICARE STATUS ID 1-1 N/U

CODE

Code
F, N, P INS09 Student Status Code ID 1-1 S
N, Y INS10 Yes/ No Condition or ID 1-1 S

Response Code
Qualifier
HI SUBSCRIBER HEALTH 1 S 2100C

CARE DIAGNOSIS
CODE
INFORMATION
HI01 -1 Code List Qualifier Code ID 1-3 R

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier


Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code
HI09 HEALTH CARE CODE

INFORMATION

INFORMATION

INFORMATION

INFORMATION

102, 152, 291, 307, DTP01 Date Time Qualifier ID 3-3 R
318, 340, 341, 342,
343, 346, 347, 356,
357, 382, 435, 442,
458, 472, 539, 540,
636, 771
D8, RD8 DTP02 Date Time Period Format ID 2-3 R

Qualifier
CCYYMMDD DTP03 Date Time Period AN 1 - 35 R
CCYYMMDD
MPI SUBSCRIBER 1 S 2100C

MILITARY PERSONNEL
INFORMATION
MPI01 Information Status Code ID 1-1 R
MPI02 Employment Status ID 2-2 R

Code
MPI03 Government Service ID 1-1 R

Affiliation Code
MPI04 Description AN 1 - 80 S
MPI05 Military Service Rank ID 2-2 S

Code
MPI06 Date Time Period Format ID 2-3 S

Qualifier
MPI07 Date Time Period AN 1 - 35 S
EB SUBSCRIBER 1 S 2110C >1

INFORMATION
1, 2, 3, 4, 5, 6, 7, 8, EB01 Eligibility or Benefit ID 1-2 R

9, A, B, C, CB, D, E, Information
F, G, H, I, J, K, L, M,
MC, N, O, P, Q, R,
S, T, U, V, W, X, Y
CHD, DEP, ECH, EB02 Coverage Level Code ID 3-3 S

EMP, ESP, FAM,
IND, SPC, SPO
1, 2, 3, 4, 5, 6, 7, 8, EB03 Service Type Code ID 1-2 S
9, 10, 11, 12, 13, 14,
15, 16, 17, 18, 19,
20, 21, 22, 23, 24,
25, 26, 27, 28, 30,
32, 33, 34, 35, 36,
37, 38, 39, 40, 41,
42, 43, 44, 45, 46,
47, 48, 49, 50, 51,
52, 53, 54, 44, 56,
57, 58, 59, 60, 61,
62, 63, 64, 65, 66,
67, 68, 69, 70, 71,
72, 73, 74, 75, 76,
77, 78, 79, 80, 81,
82, 83, 84, 85, 86,
87, 99, 89, 90, 91,
92, 93, 94, 95, 96,
97, 98, 99, A0, A1,
A2, A3, A4, A5, A6,
A7, A8, A9, AA, AB,
AC, AD, AE, AF, AG,
AH, AI, AJ, AK, AL,
AM, AN, AO, AQ,
AR, BA, BB, BC, BD,
BE, BF, BG, BH, BI,
BJ, BK, BL BM, BN,
BP, BQ, BR, BS
12, 13, 14, 15, 16, EB04 Insurance Type Code ID 3-Jan S
41, 42, 43, 47, AP,
C1, CO, CP, D, DB,
EP, FF, GP, HM,
HN, HS, IN, LC, LD,
LI, LT, MA, MB, MC,
MH, MI, MP, OT, PE,
PL, PP, PR, PS, QM,
RP, SP, TF, WC,
WU
EB05 Plan Coverage AN 1 - 50 S

Description
6, 7, 13, 21, 22, 23, EB06 Time Period Qualifier ID 1-2 S
24, 25, 26, 27, 28,
29, 30, 31, 32, 33,
34, 35, 36
EB07 Monetary Amount R 1 - 18 S
EB08 Percentage as Decimal R 1 - 10 S

99, CA, CE, DB, DY, EB09 Quantity Qualifier ID 2-2 S
HS, LA, LE, MN, P6,
QA, S7, S8, VS, YY
EB10 Quantity R 1 - 15 S
N,U,Y EB11 Yes/No Condition or ID 1-1 S

Response Code
N,U,Y EB12 Yes/No Condition or ID 1-1 S
Response Code
EB13 PROCEDURE S
IDENTIFIER
AD, CJ, HC, ID, IV, EB13 -1 Product/Service ID ID 2-2 R
N4, ZZ Qualifier
EB13 -2 Product/Service ID AN 1 - 48 R
EB13 -3 Procedure Modifier AN 2-2 S
EB13 -7 Description AN 1 - 80 N/U
EB13 -8 Product/Service ID AN 1 - 48 S
EB14 COMPOSITE S
DIAGNOSIS CODE
POINTER
EB14 -1 Diagnosis Code Pointer N0 1-2 R
EB14 -2 Diagnosis Code Pointer N0 1-2 S
HSD HEALTH CARE 9 S 2110C

SERVICES DELIVERY
DY, FL, HS, MN, VS HSD01 Quantity Qualifier ID 2-2 S
HSD02 Quantity R 1 - 15 S
DA, MO, VS, WK, HSD03 Unit or Basis for ID 2-2 S

YR Measurement Code
HSD04 Sample Selection R 1-6 S
Modulus
6, 7, 21, 22, 23, 24, HSD05 Time Period Qualifier ID 1-2 S
25, 26, 27, 28, 29,
30, 31, 32, 33, 34,
35
HSD06 Number of Periods N0 1-3 S
1, 2, 3, 4, 5, 6, 7, 8, HSD07 Ship/Delivery or ID 1-2 S
9, A, B, C, D, E, F, Calendar Pattern Code
G, ,H, J, K, L ,M N,
O, P, Q, R, S, SG,
SL, SP, SX, SY, SZ,
T, U, V, W, X, Y
A, B, C, D, E, F, G, Y HSD08 Ship/Delivery Pattern ID 1-1 S

Time Code

ADDITIONAL
IDENTIFICATION
18, 1L, 1W, 49, 6P, REF01 Reference Identification ID 2-3 R
9F, A6, F6, G1, IG, Qualifier
N6, NQ
REF04 REFERENCE N/U

IDENTIFIER

DATE
292, 295, 304, 307,
318, 348, 349, 356,
357, 435, 472, 636

Qualifier
CCYYMMDD DTP03 Date Time Period AN 1 - 35 R
CCYYMMDD

REQUEST VALIDATION

Response Code
57, 60, 61, 62, 63,
69, 70
C, N, R, W, X, Y AAA04 Follow-up Action code ID 1-1 R

MSG MESSAGE TEXT 10 S 2110C
MSG01 Free-Form Message Text AN 1-264 R
MSG02 Printer Carriage Control ID 2-2 N/U

Code
MSG03 Number N0 1-9 N/U
III SUBSCRIBER 1 S 2115C 10

ADDITIONAL
INFORMATION
BF, BK, ZZ III01 Code List Quantifier ID 1-3 S

Code
If III01=ZZ: 11, 12, III02 Industry Code AN 1 - 30 S
21, 22, 23, 24, 25,
26, 31, 32, 33, 34,
41, 42, 50, 51, 52,
53, 54, 55, 56, 60,
61, 62, 65, 71, 72,
81, 99
III03 Code Category ID 2-2 S
III04 Free-Form Message Text AN 1-264 S

MEASURE
Code
Code
Code
LS LOOP HEADER 1 S 2110C
2120 LS01 Loop Identifier Code AN 1-4 R
NM1 SUBSCRIBER BENEFIT 1 S 2120C 23

RELATED ENTITY
NAME
13, 1P, 2B, 36, 73, NM101 Entity Identifier Code ID 2-3 R
FA, GP, IL, LR, P3,
P4, P5, PR, PRP,
SEP, TTP, VN, X3

Organization Name
24, 34, 46, FA, FI, NM108 Identification Code ID 1-2 S

MI, NI, PI, PP, SV, Qualifier
XV, XX, ZZ
NM110 Entity Relationship Code ID 2-2 S

Organization Name

RELATED ENTITY
ADDRESS

RELATED
CITY/STATE/ZIP CODE
RJ N405 Location Qualifier ID 1-2 S
N406 Location Qualifier AN 1 - 30 S

Code
PER SUBSCRIBER BENEFIT 3 S 2120C
RELATED ENTITY
CONTACT
INFORMATION
ED, EM, FX, TE, WP PER03 Communication Number ID 2-2 S

Qualifier

Qualifier

Qualifier

Reference
PRV SUBSCRIBER BENEFIT 1 S 2120C

RELATED PROVIDER
INFORMATION
AD, AT, BI, CO, CV, PRV01 Provider Code ID 1-3 R

H, HH, LA, OT, P1,
P2, PC, PE, R, RF,
SB, SK, SU
9K, D3, EI, PRV02 Reference Identification ID 2-3 S

Qualifier
HPI, SY, TJ,
ZZ

INFORMATION

Code
LE LOOP TRAILER 1 S 2120C
2120 LE01 Loop Identifier Code AN 1-4 R


Number

NUMBER
1, 2 TRN01 Trace Type Code ID 1-2 R

Identifier

Organization Name
MI, ZZ NM108 Identification Code ID 1-2 N/U

Qualifier

Organization Name

ADDITIONAL
IDENTIFICATION
Qualifier
A6, CT, EA, EJ, F6,
CJ, HC, ID, IV,
N4, ZZ
REF04 REFERENCE N/U

IDENTIFIER
ADDRESS
CITY/STATE/ZIP CODE
N407 Country Subdivision ID 1-3

Code
IC
HP, TE, WP
AAABBBCCCC
EX, HP, TE, WP
AAABBBCCCC
HP, TE, WP
AAABBBCCCC
VALIDATION

Response Code
48, 49, 51, 52, 56,
57, 58, 60, 61, 62,
63, 64, 65, 66, 67,
68, 71

INFORMATION

Qualifier

INFORMATION

Code

DEMOGRAPHIC
INFORMATION
D8 DMG01 Date Time Period Format ID 2-3 S
Qualifier
F, M, U DMG03 Gender Code ID 1-1 S
DMG05 COMPOSITE RACE OR 1-1 N/U

ETHNICITY
INFORMATION

Code
DMG10 Code List Qalifier Code ID 1-3 N/U


RELATIONSHIP
N INS01 Yes/No Condition or ID 1-1 R
Response Code
01, 19, 21, 34 INS02 Individual Relationship ID 2-2 R
Code

Code
INS06 MEDICARE STATUS N/U

CODE

Code
F, N, P INS09 Student Status Code ID 1-1 N/U
N, Y INS10 Yes/No Condition or ID 1-1 N/U

Response Code
Qualifier
HI DEPENDENT HEALTH 1 S 2100D

CARE DIAGNOSIS
CODE
INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

Qualifier

Response Code
INFORMATION
HI07 -3 Qualifier ID 2-3 N/U

Response Code

INFORMATION

Qualifier

Response Code

INFORMATION

INFORMATION

INFORMATION
HI12 INFORMATION N/U


318, 340, 341, 342,
343, 346, 347, 382,
435, 442, 458, 472,
539, 540, 636

Qualifier
MPI DEPENDENT MILITARY 1 S 2100D

PERSONNEL
INFORMATION
MPI01 Information Status Code ID 1-1 R
MPI02 Employment Status ID 2-2 R

Code
MPI03 Government Service ID 1-1 R

Affiliation Code
MPI04 Description AN 1 - 80 S
MPI05 Military Service Rank ID 2-2 S

Code
MPI06 Date Time Period Format ID 2-3 S
Qualifier
MPI07 Date Time Period AN 1 - 35 S
EB DEPENDENT 1 2110 >1

ELIGIBILITY/BENEFIT D
INFORMATION
1, 2, 3, 4, 5, 6, 7, 8, EB01 Eligibility or Benefit ID 1-2 R
A, B, C, CB, D, E, F, Information Code
G, H, I, J, K, L, M,
MC, N, O, P, Q, R,
S,T, U, V, W, X, Y
CHD, DEP, ECH, EB02 Coverage Level Code ID 3-3 S

ESP, FAM, IND,
SPC, SPO
1, 2, 3, 4, 5, 6, 7, 8, EB03 Service Type Code ID 1-2 S
9, 10, 11, 12, 13, 14,
15, 16, 17, 18, 19,
20, 21, 22, 23, 24,
25, 26, 27, 28, 29,
30, 32, 33, 34, 35,
36, 37, 38, 39, 40,
41, 42, 43, 44, 45,
46, 47, 48, 49, 50,
51, 52, 53, 54, 55,
56, 57, 58, 59, 60,
61, 62, 63, 64, 65,
66, 67, 68, 69, 70,
71, 72, 73, 74, 75,
76, 77, 78, 79, 80,
81, 82, 83, 84, 85,
86, 87, 88, 89, 90,
91, 92, 93, 94, 95,
96, 97, 98, 99, A0,
A1, A2, A3, A4, A5,
A6, A7, A8, A9, AA,
AB, AC, AD, AE, AF,
AG, AH, AI, AJ, AK,
AL, AM, AN, AO,
AQ, AR, BA, BB, BC,
BD, BE, BF, BG, BH,
BI, BJ, BK, BL, BM,
BN, BP, BQ, BR, BS
12, 13, 14, 15, 16, EB04 Insuarance Type Code ID 1-3 S
41, 42, 43, 47, AP,
C1, CO, CP, D, DB,
EP, FF, GP, HM,
HN, HS, IN, IP, LC,
LD, LI, LT, MA, MB,
MC, MH, MI, MP,
OT, PE, PL, PP, PR,
PS, QM, RP, SP, TF,
WC, WU
EB05 Plan Coverage AN 1 - 50 S

Description
6, 7, 13, 21, 22, 23, EB06 Time Period Qualifier ID 2-2 S
24, 25, 26, 27, 28,
29, 30, 31, 32, 33,
34, 35, 36
EB07 Monetary Amount R 1 - 18 S
EB08 Percentage as Decimal R 1 - 10 S

99, CA, CE, DB, DY, EB09 Quantity Qualifier ID 2-2 S
HS, LA, LE, MN, P6,
S7, S8, VS, YY
EB10 Quantity R 1 - 15 S
N, U, Y EB11 Yes/No Condition or ID 1-1 S

Response Code
N, U, Y EB12 Yes/No Condition or ID 1-1 S
Response Code
EB13 COMPOSITE MEDICAL S
PROCEDURE
IDENTIFIER
AD, CJ, HC, ID, EB13 -1 Product/Service ID ID 2-2 R

Qualifier
ND, ZZ
EB13 -2 Product/Service ID AN 1 - 48 R
EB13 -7 Description AN 1 - 80 N/U
EB13 -8 Product/Service ID AN 1 - 48 S
EB14 COMPOSITE S
DIAGNOSIS CODE
POINTER
EB14 -1 Diagnosis Code Pointer N0 2-2 R
HSD HEALTH CARE 9 2110

SERVICES DELIVERY C
DY, FL, HS, MN, VS HSD01 Quantity Qualifier ID 2-2 S
HSD02 Quantity R 1 - 15 S
DA, MO, VS, WK, HSD03 Unit or Basis for ID 2-2 S

YR Measurement Code
HSD04 Sample Selection R 1-6 S
Modulus
6, 7, 21, 22, 23, 24, HSD05 Time Period Qualifier ID 1-2 S
25, 26, 27, 28, 29,
30, 31, 32, 33, 34,
35
HSD06 Number of Periods N0 1-3 S
1, 2, 3, 4, 5, 6, 7, 8, HSD07 Ship/Delivery or ID 1-2 S

9, A, B, C, D, E, F, Calendar Pattern Code
G, H, I, J, K, L, M, N,
O, P, Q, R, S, SG,
SL, SP, SX, SY, SZ,
T, U, V, W, X, Y
A, B, C, D, E, F, G, Y HSD08 Ship/Delivery Pattern ID 1-1 S

Time Code

ADDITIONAL
IDENTIFICATION
9F, A6, F6, G1, IG, Qualifier
N6, NQ
REF04 REFERENCE N/U

IDENTIFIER

ELIGIBILITY/BENEFIT
DATE
292, 295, 304, 307,
318, 348, 349, 356,
357, 435, 472, 636,
771

Qualifier

VALIDATION

Response Code
56, 57, 60, 61, 62,
63, 69, 70
C, N, R, W, X, Y AAA04 Follow-up Action Code ID 1-1 R
MSG MESSAGE TEXT 10 S 2110D
MSG01 Free-Form Message Text AN 1-264 R
MSG02 Printer Carriage Control ID 2-2 N/U

Code
MSG03 Number N0 1-9 N/U
III DEPENDENT 1 S 2115D 10

ELIGIBILITY/BENEFIT
ADDITIONAL
INFORMATION
BF, BK, ZZ III01 Code List Qualifier Code ID 1-3 S
If III01=ZZ: 11, 12, III02 Industry Code AN 1 - 30 S

21, 22, 23, 24, 25,
26, 31, 32, 33, 34,
41, 42, 50, 51, 52,
53, 54, 55, 56, 60,
61, 62, 65, 71, 72,
81, 99
III03 Code Category ID 2-2 S

MEASURE
Code
Code
Code
LS LOOP HEADER 1 S 2115D
2120 LS01 Loop Identifier Code AN 1-4 R

NM1 DEPENDENT BENEFIT 1 S 2120D 23
RELATED ENTITY
NAME
13, 1P, 2B, 36, 73, NM101 Entity Identifier Code ID 2-3 R
FA, GP, IL, LR, P3,
P4, P5, PR, PRP,
SEP, TTP, VN, X3

Organization Name
24, 34, 46, FA, FI, NM108 Identification Code ID 1-2 S

MI, NI, PI, PP, SV, Qualifier
XV, XX, ZZ
NM110 Entity Relationship Code ID 2-2 S

Organization Name

RELATED ENTITY
ADDRESS

RELATED ENTITY
CITY/STATE/ZIP CODE
RJ N405 Location Qualifier ID 1-2 S

N406 Location Qualifier AN 1 - 30 S

Code
PER DEPENDENT BENEFIT 3 S 2120D

RELATED ENTITY
CONTACT
INFORMATION

Qualifier
ED, EM, EX, FX, TE, PER05 Communication Number ID 2-2 S

WP Qualifier
ED, EM, EX, FX, TE, PER07 Communication Number ID 2-2 S

WP Qualifier

Reference
PRV DEPENDENT BENEFIT 1 S 2120D

RELATED PROVIDER
INFORMATION
AD, AT, BI, CO, CV, PRV01 Provider Code ID 1-3 R
H, HH, LA, OT, P1,
P2, PC, PE, R, RF,
SB, SK, SU
9K, D3, EI, PRV02 Reference Identification ID 2-3 S

Qualifier
HPI, SY, TJ,
ZZ

INFORMATION

Code
LE LOOP TRAILER 1 S
2120 LE01 Lopp Identifier Code AN 1-4 R

TRAILER
SE01 Number of Included N0 1 - 10 R
Segments
Number
GE FUNCTIONAL GROUP 1 R
TRAILER
Sets Included
Must=GS06 GE02 Group Control Number N0 1-9 R
IEA INTERCHANGE 1 R
CONTROL TRAILER
Functional Groups
Number
ber Eligibility Response
Values
00, 03
00, 01
01, 14, 20, 27, 28, 29, 30,

33, ZZ
01, 14, 20, 27, 28, 29, 30,

33, ZZ
YYMMDD
HHMM
501
0, 1
P, T
CCYYMMDD
HHMM
X
005010X279
271
005010X279
22
06, 11
CCYYMMDD
20
0, 1
N, Y
04, 41, 42, 79
C, N, P, R, S, Y
2B, 36, GP, P5, PR
1, 2
24, 46, FI, NI, PI, XV, XX
IC
ED, EM, TE, FX, UR
AAABBBCCCC
ED, EM, TE, FX, EX, UR
AAABBBCCCC
ED, EM, TE, FX, EX, UR

AAABBBCCCC
N, Y
04, 41, 42, 79, 80, T4
C, N, P, R, S, W, X, Y
21
0, 1
1P, 2B, 36, 80, FA, GP, P5,

PR
1, 2
24, 34, FI, PI, PP, SV, XV,

XX
0B, 1C, 1D, 1J, 4A, CT, EL,
EO, HPI, JD, N5, N7,
Q4, SY, TJ
N, Y
46, 47, 48, 50, 51, 79, 97, T4
C, N, R, S, W, X, Y
AD, AT, BI, CO, CV, H, HH,

LA, OT, P1, P2, PC, PE, R,
RF, SB, SK, SU
PXC
22
0, 1
1, 2
IL
II, MI
18, 1L, 1W, 3H, 49, 6P, CT,

EA, EJ, F6, GH, HJ, IF, IG,
N6, NQ, Q4, SY, Y4
CY, FI
N, Y
15, 35, 42, 43, 45, 47, 48,
49, 51, 52, 56, 57, 58, 60,
61, 62, 63, 71, 72, 73, 74,
75, 76, 77, 78
C, N, R, S, W, X, Y

RF, SK, SU
PXC
D8
F, M, U
Y
18
25
F, N, P
N, Y
ABK, BK
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
096, 102, 152, 291, 307,
318, 340, 341, 342, 343,
346, 347, 356, 357, 382,
435, 442, 458, 472, 539,
540, 636, 771
D8, RD8
CCYYMMDD, CCYYMMDD
CCYYMMDD
A, C, L, O, P, S, T
AE, AO, AS, AT, AU, CC,

DD, HD, IR, LX, PE, RE, RM,
RR, RU
A, B, C, D, E, F, G, H, I, J, K,
L, M, N, O, Q, R, S, U, W
A1, A2, A3, B1, B2, C1, C2,

C3, C4, C5, C6, C7, C8, C9,
E1, F1, F2, F3, F4, G1, G4,
L1, L2, L3, L4, L5, L6, M1,
M2, M3, M4, M5, M6, P1, P2,
P3, P4, P5, R1, S1, S2, S3,
S4, S5, S6, S7, S8, S9, SA,
SB, SC, T1, V1, W1
D8, RD8
1, 2, 3, 4, 5, 6, 7, 8, A, B, C,
CB, D, E, F, G, H, I, J, K, L,
M, MC, N, O, P,Q, R, S, T, U,
V, W, X, Y
CHD, DEP, ECH, EMP,

ESP, FAM, IND, SPC, SPO
1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, 12, 13, 14, 15, 16, 17,
18, 19, 20, 21, 22, 23, 24,
25, 26, 27, 28, 30, 32, 33,
34, 35, 36, 37, 38, 39, 40,
41, 42, 43, 44, 45, 46, 47,
48, 49, 50, 51, 52, 53, 54,
44, 56, 57, 58, 59, 60, 61,
62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75,
76, 77, 78, 79, 80, 81, 82,
83, 84, 85, 86, 87, 99, 89,
90, 91, 92, 93, 94, 95, 96,
97, 98, 99, A0, A1, A2, A3,
A4, A5, A6, A7, A8, A9, AA,
AB, AC, AD, AE, AF, AG,
AH, AI, AJ, AK, AL, AM, AN,
AO, AQ, AR, B1, B2,
B3, BA, BB, BC, BD, BE,
BF, BG, BH, BI, BJ, BK, BL
BM, BN, BP, BQ, BR, BS,
BT, BU, BV, BW,
BX, BY, BZ, C1, CA,
CB, CC, CD, CE,
CF, CG, CH, CI, CJ,
CK, CL, CM, CN,
CO, CP, CQ, DG,
DM, DS, GF, GY, IC,
MH,
12, 13, 14, 15, 16, 41, 42,

43, 47, AP, C1, CO, CP, D,
DB, EP, FF, GP, HM, HN,
HS, IN, IP, LC, LD, LI, LT,
MA, MB, MC, MH, MI, MP,
OT, PE, PL, PP, PR, PS,
QM, RP, SP, TF, WC, WU
6, 7, 13, 21, 22, 23, 24, 25,

26, 27, 28, 29, 30, 31, 32,
33, 34, 35, 36
8H, 99, CA, CE, DB, DY,
HS, LA, LE, M2, MN, P6,
QA, S7, S8, VS, YY
N,U,Y
N,U,W,Y
AD, CJ, HC, ID, IV, N4, ZZ
DY, FL, HS, MN, VS
DA, MO, VS, WK, YR
6, 7, 21, 22, 23, 24, 25, 26,

27, 28, 29, 30, 31, 32, 33,
34, 35
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B,
C, D, E, F, G, ,H, J, K, L ,M
N, O, P, Q, R, S, SG, SL, SP,
SX, SY, SZ, T, U, V, W, X, Y
A, B, C, D, E, F, G, Y
18, 1L, 1W, 49, 6P, 9F,

ALS, CLI, F6, FO, G1,
IG, M7, N6, NQ
096, 193, 194, 198, 290,

291, 292, 295, 304, 307,
318, 346, 348, 349, 356,
357, 435, 472, 636, 771
R8, RD8
CCYYMMDD, CCYYMMDD
CCYYMMDD
N, Y
15, 33, 52, 53, 54, 55, 56,

57, 60, 61, 62, 63, 69, 70,
98, AA, AE, AF, AG,
AO, CI, E8, IA, MA
C, N, R, W, X, Y
GR, NI, ZZ
01, 03, 04,
If III01=ZZ:
05, 06, 07, 08, 11, 12,
13, 14, 15, 20, 21, 22,
23, 24, 25, 26, 31, 32, 33,
34, 41, 42, 49, 50, 51, 52,
53, 54, 55, 56, 57, 60, 61,
62, 65, 71, 72, 81, 99
44
2120
13, 1I, 1P, 2B, 36, 73, FA,
GP, GW, I3, IL, LR, OC,
P3, P4, P5, PR, PRP, SEP,
TTP, VN, VY, X3
1, 2
24, 34, 46, FA, FI, II, MI, NI,

PI, PP, SV, XV, XX
01, 02, 27, 41, 48,

65, 72
RJ
IC
ED, EM, FX, TE, UR, WP
AAABBBCCCC
AAABBBCCCC
AAABBBCCCC

RF, SB, SK, SU
PXC
23
1, 2
18, 1L, 49, 6P, CT, EA, EJ,

F6, GH, HJ, IF, IG,
MRC, N6, NQ, Q4,
SY, Y4
N, Y
15, 35, 42, 43, 45, 47, 48,

49, 51, 52, 56, 57, 58, 60,
61, 62, 63, 64, 65, 66, 67,
68, 71, 77
C, N, R, S, W, X, Y

SK, SU
PXC
D8
F, M, U
N
01, 19, 20, 21, 39, 40,

53, G8
1
25
ABK, BK
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
096, 102, 152, 291, 307,
318, 340, 341, 342, 343,
346, 347, 356 357, 382,
435, 442, 458, 472, 539,
540, 636, 771
D8, RD8
CCYYMMDD, CCYYMMDD
CCYYMMDD
A, C, L, O, P, S, T
AE, AO, AS, AT, AU, CC,

DD, HD, IR, LX, PE, RE, RM,
RR, RU
A, B, C, D, E, F, G, H, I, J, K,
L, M, N, O, Q, R, S, U, W
, , , , B2, C1, C2, C3,
D8, RD8
1, 2, 3, 4, 5, 6, 7, 8, A, B, C,
CB, D, E, F, G, H, I, J, K, L,
M, MC, N, O, P, Q, R, S, T,
U, V, W, X, Y
CHD, DEP, ECH, EMP,

ESP, FAM, IND, SPC, SPO
1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, 12, 13, 14, 15, 16, 17,
18, 19, 20, 21, 22, 23, 24,
25, 26, 27, 28,29, 30, 32, 33,
34, 35, 36, 37, 38, 39, 40,
41, 42, 43, 44, 45, 46, 47,
48, 49, 50, 51, 52, 53, 54,55,
56, 57, 58, 59, 60, 61, 62,
63, 64, 65, 66, 67, 68, 69,
70, 71, 72, 73, 74, 75, 76,
77, 78, 79, 80, 81, 82, 83,
84, 85, 86, 87, 99, 89, 90,
91, 92, 93, 94, 95, 96, 97,
98, 99, A0, A1, A2, A3, A4,
A5, A6, A7, A8, A9, AA, AB,
AC, AD, AE, AF, AG, AH, AI,
AJ, AK, AL, AM, AN, AO,
AQ, AR, B1, B2, B3, BA,
BB, BC, BD, BE, BF, BG,
BH, BI, BJ, BK, BL BM, BN,
BP, BQ, BR, BS, BT, BU,
BV, BW, BX, BY,
BZ, C1, CA, CB,
CC, CD, CE, CF,
CG, CH, CI, CJ, CK,
CL, CM, CN, CO,
CP, CQ, DG, DM,
DS, GF, GY, IC, MH,
12, 13, 14, 15, 16, 41, 42,

43, 47, AP, C1, CO, CP, D,
DB, EP, FF, GP, HM, HN,
HS, IN, IP, LC, LD, LI, LT,
MA, MB, MC, MH, MI, MP,
OT, PE, PL, PP, PR, PS,
QM, RP, SP, TF, WC, WU
6, 7, 13, 21, 22, 23, 24, 25,

26, 27, 28, 29, 30, 31, 32,
33, 34, 35, 36
8H, 99, CA, CE, D3, DB,
DY, HS, LA, LE, M2, MN,
P6, QA, S7, S8, VS, YY
N,U,Y
N,U,W,Y
AD, CJ, HC, ID, IV, N4, ZZ
DY, FL, HS, MN, VS
DA, MO, VS, WK, YR
6, 7, 21, 22, 23, 24, 25, 26,

27, 28, 29, 30, 31, 32, 33,
34, 35
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B,
C, D, E, F, G, H, I, J, K, L,
M, N, O, P, Q, R, S, SG, SL,
SP, SX, SY, SZ, T, U, V, W,
X, Y
A, B, C, D, E, F, G, Y
18, 1L, 1W, 49, 6P, 9F,

ALS, CLI, F6, FO, G1,
IG, N6, NQ
096, 193, 194, 198, 290,

291, 292, 295, 304, 307,
318, 346, 348, 349, 356,
357, 435, 472, 636, 771
D8, RD8
CCYYMMDD, CCYYMMDD
CCYYMMDD
N, Y
15, 33, 52, 53, 54, 55, 56,

57, 60, 61, 62, 63, 69, 70,
98, AA, AE, AF, AG,
AO, CI, E8, IA, MA
C, N, R, W, X, Y
GR, NI, ZZ
If III01=ZZ: 01, 03,
04, 05, 06, 07, 08,
11, 12, 13, 14, 15,
20, 21, 22, 23, 24,
25, 26, 31, 32, 33,
34, 41, 42, 49, 50,
51, 52, 53, 54, 55,
56, 57, 60, 61, 62,
65, 71, 72, 81, 99
44
2120
13,1I, 1P, 2B, 36, 73, FA,
GP, GW, I3, IL, LR, OC,
P3, P4, PR, PRP, SEP, TTP,
VN, VY, X3
1, 2
24, 34, 46, FA, FI, II, MI, NI,

PI, PP, SV, XV, XX
01, 02, 27, 41, 48,

65, 72
RJ
IC
AAABBBCCCC
ED, EM, EX, FX, TE, UR,

WP
AAABBBCCCC
ED, EM, EX, FX, TE, UR,

WP
AAABBBCCCC

RF, SB, SK, SU
PXC
2120
4010A1 276 Claim Status Inquiry
ISA INTERCHANGE 1 R 1
CONTROL HEADER
Qualifier
3 ISA03 Security Information Qualifier ID 2-2 R


11 1 ISA11 Interchange Control Standards ID 1-1 R
ID
12 1 ISA12 Interchange Control Version ID 5-5 R
Number
13 ISA13 Interchange Control Number N0 9-9 R
14 ISA14 Acknowledgement Requested ID 1-1 R

16 ISA16 Component Element Separator AN 1-1 R
GS FUNCTIONAL GROUP 1 R >1

HEADER
17 GS01 Functional Identifier Code ID 2-2 R
18 GS02 Application Sender Code AN 2 - 15 R
19 GS03 Application Receiver Code AN 2 - 15 R
23 GS07 Responsible Agency Code ID 1-2 R
24 1 GS08 Version Identifier Code AN 1 - 12 R
ST TRANSACTION 1 R >1
SET HEADER
25 ST01 Transaction Set Identifier Code ID 3-3 R

Number
27 1
BHT BEGINNING OF 1 R 1
HIERARCHICAL
TRANSACTION
28 BHT01 Hierarchical Structure Code ID 4-4 R
29 BHT02 Transaction Set Purpose Code ID 2-2 R
30 1 BHT03 Reference Identification AN 1 - 30 N/U

31 BHT04 Transaction Set Creation Date DT 8-8 R
32 BHT05 Time TM 4-8 N/U

33 BHT06 Transaction Type Code ID 2-2 N/U

SOURCE LEVEL
35 HL02 Hierarchical Parent ID Number AN 1 - 12 N/U

NM1 PAYER NAME 1 R 2100A >1

40 1 NM103 Payer Name AN 1-1 R
41 1 NM104 Name First AN 1 - 25 N/U
42 NM105 Name Middle AN 1 - 25 N/U
43 NM106 Name Prefix AN 1 -10 N/U
44 NM107 Name Suffix AN 1 -10 N/U
45 1 NM108 Identification Code Qualifier ID 1-2 R
46 1 NM109 Payer Identifier AN 1 - 30 R
49 1

INFORMATION
51 1 PER02 Payer Contact Name AN 1 - 60 S
52 1 PER03 Communication Number ID 2-2 R
Qualifier
53 1 PER04 Communication Number AN 1 - 80 R
Qualifier
Qualifier
58 1 PER09 Contact Inquiry Reference AN 1 - 20 N/U

RECEIVER LEVEL
60 HL02 Hierarchical Parent ID Number AN 1 - 12 R

NM1 INFORMATION 1 R 2100B >1

RECEIVER NAME
65 1 NM103 Information Receiver Last AN 1 - 35 R
Name or Organization Name
66 1 NM104 Information Receiver First AN 1 - 25 S
Name
67 NM105 Information Receiver Middle AN 1 - 25 S
Name
68 NM106 Name Prefix AN 1 -10 N/U
69 NM107 Information Receiver Name AN 1 -10 S
Suffix
71 1 NM109 Information Receiver AN 1 - 30 R
Identification Number
74 1
HL SERVICE 1 R 2000C >1

PROVIDER LEVEL

NM1 PROVIDER NAME 1 R 2100C >1

81 1 NM103 Provider Last or Organization AN 1 - 35 R
Name
82 1 NM104 Provider First Name AN 1 - 25 S
83 NM105 Provider Middle Name AN 1 - 25 S
84 NM106 Provider Name Prefix AN 1 -10 S
85 NM107 Provider Name Suffix AN 1 -10 S
86 NM108 Identification Code Qualifier ID 1-2 R
87 1 NM109 Provider Identifier AN 1 - 80 R
90 1
HL SUBSCRIBER LEVEL 1 R 2000D >1


DMG SUBSCRIBER 1 S 2000D

DEMOGRAPHIC
INFORMATION
95 DMG01 Date Time Period Format ID 2-3 R
Qualifier
96 DMG02 Subscriber Birth Date AN 1 - 35 R
97 DMG03 Subscriber Gender Code ID 1-1 R
102 DMG08 Basis of Verification Code ID 1-2 N/U
103 DMG09 Quantity R 1 -15 N/U
104 1
105 1
NM1 SUBSCRIBER NAME 1 R 2100D 1

108 1 NM103 Subscriber Last Name AN 1 - 35 R
109 1 NM104 Subscriber First Name AN 1 - 25 S
110 NM105 Subscriber Middle Name AN 1 - 25 S
111 NM106 Subscriber Name Prefix AN 1 -10 S
112 NM107 Subscriber Name Suffix AN 1 -10 S
114 1 NM109 Subscriber Identifier AN 1 - 80 R
117 1
TRN CLAIM SUBMITTER 1 R 2200D >1

TRACE NUMBER
119 1 TRN02 Trace Number AN 1 - 30 R
120 TRN03 Originating Company Identifier AN 10 - 10 N/U
121 1 TRN04 Reference Identification AN 1 - 30 N/U

REF PAYER CLAIM 1 S 2200D
IDENTIFICATION
NUMBER
122 REF01 Reference Identification ID 2-3 R
Qualifier
123 1 REF02 Payer Claim Control Number AN 1 - 30 R
125 REF04 REFERENCE IDENTIFIER N/U
REF INSTITUTIONAL BILL 1 S 2200D

TYPE IDENTIFICATION

Qualifier
127 1 REF02 Bill Type Identifier AN 1 - 30 R
1
1
REF MEDICAL RECORD 1 S 2200D

IDENTIFICATION
Qualifier
131 1 REF02 Medical Record Number AN 1 - 30 R
132 1 REF03 Description AN 1 - 80 N/U
133 1 REF04 REFERENCE IDENTIFIER N/U
REF GROUP NUMBER 1 S 2200D

Qualifier
135 1 REF02 Group Number AN 1 - 30 R
1
1
1
1
1
1
1
1
AMT CLAIM SUBMITTED 1 S 2200D

CHARGES
138 AMT01 Amount Qualifier Code ID 1-3 R
139 AMT02 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
DTP CLAIM SERVICE DATE 1 S 2200D
141 DTP01 Date Time Qualifier ID 3-3 R

142 1 DTP02 Date Time Period Format ID 2-3 R
Qualifier
143 1 DTP03 Claim Service Period AN 1 -35 R
SVC SERVICE LINE 1 S 2210D >1

INFORMATION
144 SVC01 Composite Medical Procedure R
Identifier
145 1 SVC01-1 Product/Service ID Qualifier ID 2-2 R
146 SVC01-2 Service Identification Code AN 1 - 48 R

147 SVC01-3 Procedure Modifier AN 2-2 S
151 SVC01-7 Description AN 1 -80 N/U
152 1
153 SVC02 Line Item Charge Amount R 1 - 18 R
S9(7)V99
154 SVC03 Monetary Amount R 1 - 18 N/U
155 SVC04 Revenue Code AN 1 - 48 S
156 SVC05 Quanity R 1 - 15 N/U
157 SVC06 Composite Medical Procedure N/U
Identifier
158 SVC07 Quantity R 1 - 15 S
REF SERVICE LINE ITEM 1 S 2210D

IDENTIFICATION
Qualifier
160 1 REF02 Line Item Control Number AN 1 - 30 R
162 REF04 Reference Identifier N/U
DTP SERVICE LINE DATE 1 R 2210D

Qualifier
165 1 DTP03 Service Line Date AN 1 -35 R
HL DEPENDENT LEVEL 1 S 2000E >1


169 HL04 Hierarchical Child Code ID 1-1 N/U
DMG DEPENDENT 1 R 2000E

DEMOGRAPHIC
INFORMATION
Qualifier
171 DMG02 Patient Birth Date AN 1 - 35 R
172 1 DMG03 Patient Gender Code ID 1-1 R
178 DMG09 Quantity R 1 -15 N/U
179 1
180 1
NM1 DEPENDENT NAME 1 R 2100E 1

183 1 NM103 Patient Last Name AN 1 - 35 R
184 1 NM104 Patient First Name AN 1 - 25 S
185 NM105 Patient Middle Name AN 1 - 25 S
186 NM106 Patient Name Prefix AN 1 -10 S
187 NM107 Patient Name Suffix AN 1 -10 S
188 1 NM108 Identification Code Qualifier ID 1-2 S
189 1 NM109 Patient Primary Identifier AN 1 - 80 S
192 1
TRN CLAIM SUBMITTER 1 R 2200E >1

TRACE NUMBER
REF PAYER CLAIM 1 S 2200E

IDENTIFICATION
NUMBER
Qualifier
198 1 REF02 Payer Claim Control Number AN 1 - 30 R
REF INSTITUTIONAL BILL 1 S 2200E

TYPE IDENTIFICATION

Qualifier
202 1 REF02 Bill Type Identifier AN 1 - 30 R
1
1
REF MEDICAL RECORD 1 S 2200E

IDENTIFICATION
Qualifier
1
1
1
1
1
1
1
1
1
1
1
AMT CLAIM SUBMITTED 1 S 2200E

CHARGES
210 AMT02 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
DTP CLAIM SERVICE DATE 1 S 2200E
212 DTP01 Date/Time Qualifier ID 3-3 R

Qualifier
214 1 DTP03 Claim Service Period AN 1 -35 R
SVC SERVICE LINE 1 S 2210E >1

INFORMATION
215 SVC01 COMPOSITE MEDICAL R
PROCEDURE INDENTIFIER
216 1 SVC01-1 Product or Service ID Qualifier ID 2-2 R

222 SVC01-7 Description AN 1 -80 N/U
223 1
S9(7)V99
225 SVC03 Monetary Amount R 1 - 18 N/U
227 SVC05 Quanity R 1 - 15 N/U
228 SVC06 Composite Medical Procedure N/U
Identifier
229 SVC07 Quantity R 1 - 15 S
REF SERVICE LINE ITEM 1 S 2210E

IDENTIFICATION
Qualifier
DTP SERVICE LINE DATE 1 S 2210E

Qualifier
236 1 DTP03 Service Date AN 1 -35 R
TRAILER
237 SE01 Transaction Segment Count N0 1 - 10 R
Number
GE FUNCTIONAL GROUP 1 R 1
TRAILER
239 GE01 Number of Transaction Sets N0 1-6 R
Included
IEA INTERCHANGE 1 R 1
CONTROL TRAILER
241 IEA01 Number of Included Functional N0 1-5 R
Groups
242 IEA02 Interchange Control Number N0 9-9 R
111
us Inquiry 5010 276 Claim Status Inquiry
Values Element Description ID Min. Usage Loop Loop
Identifier Max. Reg. Repea
t
CONTROL HEADER
Qualifier
00, 01 ISA03 Security Information Qualifier ID 2-2 R
01, 14, 20, 27, 28, 29, 30, 33, ISA05 Interchange ID Qualifier ID 2-2 R
ZZ
ZZ
U ISA11 Repetition Seperator AN 1-1 R
401 ISA12 Interchange Control Version ID 5-5 R

Number
ISA13 Interchange Control Number N0 9-9 R
0, 1 ISA14 Acknowledgement Requested ID 1-1 R
P, T ISA15 Usage Indicator ID 1-1 R

ISA16 Component Element Separator AN 1-1 R

HEADER
HR GS01 Functional Identifier Code ID 2-2 R
GS02 Application Sender Code AN 2 - 15 R
GS03 Application Receiver Code AN 2 - 15 R
HHMMSSDD GS05 Time TM 4-8 R
X GS07 Responsible Agency Code ID 1-2 R
004010X093 GS08 Version Identifier Code AN 1 - 12 R
ST TRANSACTION 1 R >1
SET HEADER

Number
ST03 Implementation Convention AN 1 - 35 R
Reference
BHT BEGINNING OF 1 R 1
HIERARCHICAL
TRANSACTION
BHT03 Reference Identification AN 1 - 50 R

CCYYMMDD BHT04 Transaction Set Creation Date DT 8-8 R
BHT05 Time TM 4-8 R

BHT06 Transaction Type Code ID 2-2 N/U
HL INFORMATION 1 R 2000 >1

SOURCE LEVEL A
HL02 Hierarchical Parent ID Number AN 1 - 12 N/U

NM1 PAYER NAME 1 R 2100 >1

A
PR NM101 Entity Identifier Code ID 2-3 R
NM103 Payer Name AN 1 - 60 R
NM104 Name First AN 1 - 35 N/U
NM105 Name Middle AN 1 - 25 N/U
NM106 Name Prefix AN 1 -10 N/U
NM107 Name Suffix AN 1 -10 N/U
21, AD, FI, NI, PI, PP, XV NM108 Identification Code Qualifier ID 1-2 R
NM109 Payer Identifier AN 2 - 80 R
NM112 Last Name ID 1 - 60 N/U
IC
ED, EM, TE
EX
EX, FX
HL INFORMATION 1 R 2000 >1

RECEIVER LEVEL B
HL02 Hierarchical Parent ID Number AN 1 - 12 R

NM1 INFORMATION 1 R 2100 1

RECEIVER NAME B
NM103 Information Receiver Last AN 1 - 60 S
Name or Organization Name
NM104 Information Receiver First AN 1 - 35 S
Name
NM105 Information Receiver Middle AN 1 - 25 S
Name
NM106 Name Prefix AN 1 -10 N/U
NM107 Information Receiver Name AN 1 -10 N/U
Suffix
46, FI, XX NM108 Identification Code Qualifier ID 1-2 R
NM109 Information Receiver AN 2 - 80 R
HL SERVICE 1 R 2000 >1

PROVIDER LEVEL C

NM1 PROVIDER NAME 1 R 2100 2

C
1P NM101 Entity Identifier Code ID 2-3 R
NM103 Provider Last or Organization AN 1 - 60 S
Name
NM104 Provider First Name AN 1 - 35 S
NM105 Provider Middle Name AN 1 - 25 S
NM106 Provider Name Prefix AN 1 -10 N/U
NM107 Provider Name Suffix AN 1 -10 S
FI, SV, XX NM108 Identification Code Qualifier ID 1-2 R
NM109 Provider Identifier AN 2 - 80 R
HL SUBSCRIBER LEVEL 1 R 2000 >1
D

DMG SUBSCRIBER 1 S 2000

DEMOGRAPHIC D
INFORMATION
D8 DMG01 Date Time Period Format Qualifier ID 2-3 R
CCYYMMDD DMG02 Subscriber Birth Date AN 1 - 35 R
F, M, U DMG03 Subscriber Gender Code ID 1-1 S
DMG05 Race or Ethnicity Code ID 1-1 N/U
DMG08 Basis of Verification Code ID 1-2 N/U
DMG09 Quantity R 1 -15 N/U
NM1 SUBSCRIBER NAME 1 R 2100 1

D
IL, QC NM101 Entity Identifier Code ID 2-3 R
NM103 Subscriber Last Name AN 1 - 60 R
NM104 Subscriber First Name AN 1 - 35 S
NM105 Subscriber Middle Name AN 1 - 25 S
NM106 Subscriber Name Prefix AN 1 -10 N/U
NM107 Subscriber Name Suffix AN 1 -10 S
24, MI, ZZ NM108 Identification Code Qualifier ID 1-2 R
NM109 Subscriber Identifier AN 2 - 80 R
TRN CLAIM STATUS 1 S 2200 >1

TRACKING NUMBER D
TRN02 Trace Number AN 1 - 50 R
TRN03 Originating Company Identifier AN 10 - 10 N/U
TRN04 Reference Identifier AN 1 - 50 N/U

REF PAYER CLAIM 1 S 2200
CONTROL NUMBER D
1K REF01 Reference Identification ID 2-3 R

Qualifier
REF02 Payer Claim Control Number AN 1 - 50 R
REF04 Reference Identifier N/U
REF INSTITUTIONAL BILL 1 S 2200

TYPE IDENTIFICATION D
BLT REF01 Reference Identification ID 2-3 R

Qualifier
REF02 Bill Type Identifier AN 1 - 50 R
REF APPLICATION OR 1 S 2200

LOCATION SYSTEM D
IDENTIFIER
REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Application or Location System AN 1 - 50 R
Identifier
EA
Addenda REF GROUP NUMBER 1 S 2200

D
LU REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Group Number AN 1 - 50 R
REF PATIENT CONTROL 1 S 2200

NUMBER D
Qualifier
REF02 Patient Control Number AN 1 - 50 R
REF PHARMACY 1 S 2200
PRESCRIPTION D
NUMBER
Qualifier
REF02 Pharmacy Prescription Number AN 1 - 50 R

REF CLAIM ID FOR 1 S 2200

CLEARINGHOUSES D
AND OTHER
TRANSMISSION
INTERMEDIARIES
Qualifier
REF02 Clearinghouse Trace Number AN 1 - 50 R

AMT CLAIM SUBMITTED 1 S 2200

CHARGES D
T3 AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
DTP CLAIM SERVICE DATE 1 S 2200

D
RD8 DTP02 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDDCCYYMMDD DTP03 Claim Service Period AN 1 -35 R
SVC SERVICE LINE 1 S 2210 >1

INFORMATION D
SVC01 Composite Medical Procedure R
Identifier
AD, CI, HC, ID, IV, N1, N2, N3, SVC01-1 Product Service ID ID 2-2 R
N4, ND,NH, NU, RB
SVC01-2 Service Identification Code AN 1 - 48 R
SVC01-3 Procedure Modifier AN 2-2 S
SVC01-7 Description AN 1 -80 N/U
SVC01-8 Product Service ID AN 1 - 48 N/U
SVC02 Line Item Charge Amount R 1 - 18 R
S9(7)V99
SVC03 Monetary Amount R 1 - 18 N/U
SVC04 Revenue Code AN 1 - 48 S
SVC05 Quanity R 1 - 15 N/U
SVC06 Composite Medical Procedure N/U
Identifier
SVC07 Quantity R 1 - 15 R
REF SERVICE LINE ITEM 1 S 2210

IDENTIFICATION D
FJ REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Line Item Control Number AN 1 - 50 R
DTP SERVICE LINE DATE 1 R 2210

D
Qualifier
HL DEPENDENT LEVEL 1 S 2000 >1

E

HL04 Hierarchical Child Code ID 1-1 N/U
DMG DEPENDENT 1 R 2000

DEMOGRAPHIC E
INFORMATION
D8 DMG01 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDD DMG02 Patient Birth Date AN 1 - 35 R
F, M, U DMG03 Patient Gender Code ID 1-1 S
DMG09 Quantity R 1 -15 N/U
NM1 DEPENDENT NAME 1 R 2100 1

E
QC NM101 Entity Identifier Code ID 2-3 R
NM103 Patient Last Name AN 1 - 60 R
NM104 Patient First Name AN 1 - 35 S
NM105 Patient Middle Name AN 1 - 25 S
NM106 Patient Name Prefix AN 1 -10 N/U
NM107 Patient Name Suffix AN 1 -10 S
MI, ZZ NM108 Identification Code Qualifier ID 1-2 N/U
NM109 Patient Primary Identifier AN 2 - 80 N/U
TRN CLAIM STATUS 1 R 2200 >1

TRACKING NUMBER E
TRN03 Originating Company Identifier AN 10 - 10 N/U
TRN04 Reference Identification AN 1 - 50 N/U

CONTROL NUMBER E

Qualifier
REF INSTITUTIONAL BILL 1 S 2200

TYPE IDENTIFICATION E

Qualifier
REF APPLICATION OR 1 S 2200

LOCATION SYSTEM E
IDENTIFIER
Qualifier
REF02 Application or Location System AN 1 - 50 R
Identifier
REF GROUP NUMBER 1 S 2200

E
Qualifier
REF02 Group Number AN 1 - 50 R
REF PATIENT CONTROL 1 S 2200
NUMBER E
Qualifier
REF PHARMACY 1 S 2200

PRESCRIPTION E
NUMBER
Qualifier
REF02 Pharmacy Prescription Number AN 1 - 50 R

REF CLAIM ID FOR 1 S 2200

CLEARINGHOUSES E
AND OTHER
TRANSMISSION
INTERMEDIARIES
Qualifier

AMT CLAIM SUBMITTED 1 S 2200

CHARGES E
T3 AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
DTP CLAIM SERVICE DATE 1 S 2200

E
Qualifier
SVC SERVICE LINE 1 S 2210 >1

INFORMATION E
SVC01 Composite Medical Procedure R
Identifier
AD, CI, HC, ID, IV, N1, N2, N3, SVC01-1 Product Service ID ID 2-2 R
N4, ND, NH, NU, RB
SVC01-7 Description AN 1 -80 N/U
SVC01-8 Product Service ID AN 1 - 48 N/U
S9(7)V99
SVC03 Monetary Amount R 1 - 18 N/U
SVC05 Quanity R 1 - 15 N/U
SVC06 Composite Medical Procedure N/U
Identifier
SVC07 Quantity R 1 - 15 R
REF SERVICE LINE ITEM 1 S 2210

IDENTIFICATION E
Qualifier

E
Qualifier
CCYYMMDDCCYYMMDD DTP03 Service Line Date AN 1 -35 R
TRAILER
SE01 Transaction Segment Count N0 1 - 10 R
Number
TRAILER
GE01 Number of Transaction Sets N0 1-6 R
Included
Must=GS06 GE02 Group Control Number N0 1-9 R
CONTROL TRAILER
IEA01 Number of Included Functional N0 1-5 R
Groups
IEA02 Interchange Control Number N0 9-9 R
Status Inquiry
Values
00, 03
00, 01
01, 14, 20, 27, 28, 29,

30, 33, ZZ
01, 14, 20, 27, 28, 29,

30, 33, ZZ
YYMMDD
HHMM
501
0, 1
P, T
HR
CCYYMMDD
HHMMSSDD
X
005010X212
276
005010X212
10
13
CCYYMMDD
20
1
PR
2
PI, XV
21
1
41
1, 2
46
19
1
1P
1, 2
FI, SV, XX
22
0, 1
D8
CCYYMMDD
F, M
IL
1, 2
24, II, MI
1
1K
BLT
LU
6P
EJ
XZ
D9
T3
472
D8, RD8
CCYYMMDD,
CCYYMMDD
CCYYMMDD
AD, ER, HC, HP, IV,

N4, NU, WK
FJ
472
D8, RD8
CCYYMMDD,
CCYYMMDD
CCYYMMDD
23
D8
CCYYMMDD
F, M
QC
1
1
1K
BLT
LU
6P
EJ
XZ
D9
T3
472
D8, RD8
CCYYMMDD,
CCYYMMDD
CCYYMMDD
AD, ER, HC, HP, IV,

N4, NU, WK
FJ
472
D8, RD8
CCYYMMDD,
CCYYMMDD
CCYYMMDD
4010A1 277 Claim Status Response
CONTROL HEADER
Qualifier



ID
Number


HEADER
ST TRANSACTION SET 1 R >1

HEADER

Number
27 1
HIERARCHICAL
TRANSACTION
30 BHT03 Originator Application AN 1 -30 R

Transaction Identifier
32 BHT05 Time TM 4-8 N/U

33 BHT06 Transaction Type Code ID 2-2 R

SOURCE LEVEL

NM1 PAYER NAME 1 R 2100A >1

40 1 NM103 Payer Name AN 1 - 35 R
44 NM107 Name Suffix AN 1 - 10 N/U
46 NM109 Payer Identifier AN 2 - 80 R

49 1

INFORMATION
51 PER02 Payer Contact Name AN 1 - 60 S
Qualifier
Qualifier
Qualifier
58 PER09 Contact Inquiry Reference AN 1 - 20 N/U

RECEIVER LEVEL
NM1 INFORMATION 1 R 2100B >1

RECEIVER NAME
65 1 NM103 Information Receiver Last or AN 1 - 35 R
Organization Name
66 1 NM104 Information Receiver First AN 1 - 25 S
Name
67 NM105 Information Receiver Middle AN 1 - 25 S
Name
68 NM106 Information Receiver Name AN 1 - 10 S
Prefix
69 NM107 Information Receiver Name AN 1 - 10 S
Suffix
71 NM109 Information Receiver AN 2 - 80 R

74 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HL SERVICE PROVIDER 1 R 2000C >1

LEVEL

78 1 HL04 Hierarchical Child Code ID 1-1 R
NM1 PROVIDER NAME 1 R 2100C >1

81 1 NM103 Provider Last or Organization AN 1 - 35 R
Name
82 1 NM104 Provider First Name AN 1 - 25 S
83 NM105 Provider Middle Name AN 1 - 25 S
84 NM106 Provider Name Prefix AN 1 - 10 S
85 NM107 Provider Name Suffix AN 1 - 10 S
87 NM109 Provider Identifier AN 2 - 80 R

90 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HL SUBSCRIBER LEVEL 1 R 2000D >1


DMG SUBSCRIBER 1 R 2000D

DEMOGRAPHIC
INFORMATION
95 1 DMG01 Date Time Period Format ID 2-3 R
Qualifier
96 1 DMG02 Subscriber Birth Date AN 1 - 35 R
97 1 DMG03 Subscriber Gender Code ID 1-1 R
98 1 DMG04 Marital Status Code ID 1-1 N/U
100 1 DMG06 Citizenship Status Code ID 1-2 N/U
101 1 DMG07 Country Code ID 2-3 N/U
102 1 DMG08 Basis of Verification Code ID 1-2 N/U
103 1 DMG09 Quantity R 1 - 15 N/U

109 NM106 Subscriber Name Prefix AN 1 - 10 S
110 NM107 Subscriber Name Suffix AN 1 - 10 S
112 NM109 Subscriber Identifier AN 2 - 80 R

115 1
TRN CLAIM SUBMITTER 1 S 2200D >1

TRACE NUMBER

STC CLAIM LEVEL STATUS 1 R 2200D

INFORMATION
120 STC01 HEALTH CARE CLAIM R

STATUS
121 STC01-1 Health Care Claim Status AN 1 - 30 R
Category Code
122 STC01-2 Health Care Claim Status Code AN 1 - 30 R
123 1 STC01-3 Entity Identifier Code ID 2-3 S
124 1
125 STC02 Status Information Effective DT 8-8 R
Date
126 STC03 Action Code ID 1-2 N/U
127 STC04 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
128 STC05 Claim payment Amount R 1 - 18 R
S9(7)V99
129 STC06 Adjudication or Payment Date DT 8-8 S
130 STC07 Payment Method Code ID 3-3 S

131 STC08 Check Issue or EFT Effective DT 8-8 S
Date
132 STC09 Check or EFT Trace Number AN 1 - 16 S
133 STC10 HEALTH CARE CLAIM S
STATUS
134 STC10-1 Health Care Claim Status AN 1 -30 R
Category Code
135 STC10-2 Health Care Claim Status Code AN 1 -30 R
136 STC10-3 Entity Identifier Code AN 2-3 S

137 1
STATUS
139 STC11-1 Health Care Claim Status AN 1 -30 R
Category Code
140 STC11-2 Health Care Claim Status Code AN 1 -30 R
141 STC11-3 Entity Identifier Code ID 2-3 S

142 1
143 STC12 Free-Form Message Text AN 1-264 N/U

IDENTIFICATION
NUMBER
Qualifier
145 1 REF02 Payer Claim Control Number AN 1 -30 R


TYPE IDENTIFICATION

Qualifier
149 1 REF02 Bill Type Identifier AN 1 -30 R
REF MEDICAL RECORD 1 S 2200D

IDENTIFICATION
Qualifier
153 1 REF02 Medical Record Number AN 1 -30 R
1
1
1
1
1
1
1
1
1
1
1
DTP CLAIM SERVICE DATE 1 S 2200D

Qualifier
158 1 DTP03 Claim Service Period AN 1 - 35 R

INFORMATION

166 SVC01-7 Description AN 1 - 80 N/U
S9(7)V99
168 SVC03 Line Item Provider Payment R 1 - 18 R
Amount S9(7)V99
170 SVC05 Quantity R 1 - 15 N/U
171 SVC06 COMPOSITE MEDICAL N/U
172 SVC07 Original Units of Service Count R 1 - 15 S
S9(3)V9
STC SERVICE LINE STATUS 1 S 2220D

INFORMATION
STATUS
Category Code
177 1
Date
180 STC04 Line Item Charge Amount R 1 - 18 S
S9(7)V99
181 STC05 Line Item Provider Payment R 1 - 18 S
Amount S9(7)V99
182 1 STC06 Date DT 8-8 N/U
183 STC07 Payment Method Code ID 3-3 N/U

185 STC09 Check Number AN 1 - 16 N/U
STATUS
Category Code

190 1
Category Code

194 1

IDENTIFICATION
Qualifier
197 1 REF02 Line Item Control Number AN 1 -30 R
DTP SERVICE LINE DATE 1 S 2220D

Qualifier
202 1 DTP03 Service Line Date AN 1 - 35 R


206 HL04 Hierarchical Child Code ID 1-1 N/U
DMG DEPENDENT 1 R 2000E

DEMOGRAPHIC
INFORMATION
Qualifier
208 1 DMG02 Patient Birth Date AN 1 - 35 R
209 1 DMG03 Patient Gender Code ID 1-1 R

219 1 NM104 Patient First Name AN 1 - 25 S
221 NM106 Patient Name Prefix AN 1 - 10 S
222 NM107 Patient Name Suffix AN 1 - 10 S
224 NM109 Patient Primary Identifier AN 2 - 80 S

227 1
TRN CLAIM SUBMITTER 1 R 2200E >1

TRACE NUMBER

STC CLAIM LEVEL STATUS 1 R 2200E

INFORMATION

STATUS
233 1 STC01-1 Health Care Claim Status AN 1 - 30 R
Category Code
236 1
Date
239 STC04 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
240 STC05 Claim Payment Amount R 1 - 18 R
S9(7)V99
241 STC06 Adjudication or Payment Date DT 8-8 S
242 1 STC07 Payment Method Code ID 3-3 S

243 STC08 Check Issue or EFT Effective DT 8-8 S
Date
244 STC09 Check or EFT TraceNumber AN 1 - 16 S
STATUS
Category Code

249 1
STATUS
Category Code

254 1
REF PAYER CLAIM 1 R 2200E

IDENTIFICATION
NUMBER
Qualifier
257 1 REF02 Payer Claim Control Number AN 1 -30 R


TYPE IDENTIFICATION

Qualifier
261 1 REF02 Bill Type Identifier AN 1 -30 R
REF MEDICAL RECORD 1 S 2200E

IDENTIFICATION
Qualifier
265 1 REF02 Medical Record Number AN 1 -30 R
1
1
1
1
1
1
1
1
1
1
1
DTP CLAIM SERVICE DATE 1 S 2200E
268 DTP01 Date/Time Qualifier ID 3-3 R

Qualifier
270 1 DTP03 Claim Service Period AN 1 - 35 R

INFORMATION

278 SVC01-7 Description AN 1 - 80 N/U
279 1
S9(7)V99
281 SVC03 Line Item Provider Payment R 1 - 18 R
Amount S9(7)V99
283 SVC05 Quantity R 1 - 15 N/U
284 SVC06 COMPOSITE MEDICAL N/U
285 SVC07 Original Units of Service Count R 1 - 15 S
S9(3)V9
STC SERVICE LINE STATUS 1 S 2220E

INFORMATION

STATUS
Category Code
290 1
Date
293 STC04 Line Item Charge Amount R 1 - 18 S
S9(7)V99
294 STC05 Line Item Provider Payment R 1 - 18 S
Amount S9(7)V99
296 STC07 Payment Method Code ID 3-3 N/U

298 STC09 Check Number AN 1 - 16 N/U
STATUS
Category Code

303 1
STATUS
Category Code

308 1

IDENTIFICATION
Qualifier
311 1 REF02 Line Item Control Number AN 1 -30 R
DTP SERVICE LINE DATE 1 S 2220E

Qualifier
316 1 DTP03 Service Date AN 1 - 35 R
TRAILER

Number
TRAILER
Included
CONTROL TRAILER
Groups
188
us Response 5010 277 Claim Status Response
Values Element Description ID Min. Usag Loop Loop
Identifier Max. e Repeat
Reg.
CONTROL HEADER
Qualifier

ZZ
ZZ
U ISA11 Repetition Seperator AN 1-1 R

Number

ISA16 Component Element AN 1-1 R
Separator

HEADER
HN GS01 Functional Identifier Code ID 2-2 R
004010X093A1 GS08 Version Identifier Code AN 1 - 12 R
ST TRANSACTION SET 1 R >1

HEADER
Code
Number
Reference
HIERARCHICAL
TRANSACTION
8 BHT02 Transaction Set Purpose ID 2-2 R

Code
BHT03 Originator Application AN 1 - 50 R
Transaction Identifier
CCYYMMDD BHT04 Transaction Set Creation DT 8-8 R
Date
BHT05 Time TM 4-8 R
DG BHT06 Transaction Type Code ID 2-2 R

SOURCE LEVEL
HL02 Hierarchical Parent ID AN 1 - 12 N/U
Number
NM1 PAYER NAME 1 R 2100A 1

NM107 Name Suffix AN 1 - 10 N/U
21, AD, FI, NI, PI, PP, XV NM108 Identification Code Qualifier ID 1-2 R


INFORMATION
PER02 Payer Contact Name AN 1 - 60 S
ED, EM, TE PER03 Communication Number ID 2-2 R
Qualifier
PER04 Communication Number AN 1-256 R
EX PER05 Communication Number ID 2-2 S
Qualifier
PER06 Communication Number AN 1-256 S
EX, FX PER07 Communication Number ID 2-2 S
Qualifier
PER09 Contact Inquiry Reference AN 1 - 20 N/U

RECEIVER LEVEL
Number

RECEIVER NAME
NM103 Information Receiver Last or AN 1 - 60 S
Organization Name
NM104 Information Receiver First AN 1 - 35 S
Name
NM105 Information Receiver Middle AN 1 - 25 S
Name
NM106 Information Receiver Name AN 1 - 10 N/U
Prefix
NM107 Information Receiver Name AN 1 - 10 N/U
Suffix
46, FI, XX NM108 Identification Code Qualifier ID 1-2 R
NM109 Information Receiver AN 2 - 80 R

TRN INFORMATION 1 S 2200B 1

RECEIVER TRACE
IDENTIFIER
TRN01 Referenced Transaction ID 1-2 R
Trace Number
TRN02 Claim Transaction Batch AN 1 - 50 R
Number
TRN03 Originating Company AN 10 - 10 N/U
Identifier
STC INFORMATION >1 R 2200B

RECEIVER STATUS
INFORMATION
STC01 HEALTH CARE CLAIM R
STATUS
STC01-1 Health Care Claim Status AN 1 - 30 R
Category Code
Code
STC01-3 Entity Identifier Code ID 2-3 S
STC01-4 Code List Qualifier Code ID 1-3 N/U
STC02 Status Information Effective DT 8-8 R
Date
STC03 Action Code ID 1-2 N/U
STC04 Monetary Amount R 1 - 18 N/U
STC06 Date DT 8-8 N/U
STC07 Payment Method Code ID 3-3 N/U
STC09 Check Number AN 1 - 16 N/U
STC10 HEALTH CARE CLAIM S
STATUS
Category Code
Code
STATUS
Category Code
Code
STC12 Free-Form Message Text AN 1-264 N/U
HL SERVICE PROVIDER 1 R 2000C >1

LEVEL
Number
NM1 PROVIDER NAME 1 R 2100C 2
1P NM101 Entity Identifier Code ID 2-3 R

NM103 Provider Last or Organization AN 1 - 60 S
Name
NM104 Provider First Name AN 1 - 35 S
NM105 Provider Middle Name AN 1 - 25 S
NM106 Provider Name Prefix AN 1 - 10 N/U
NM107 Provider Name Suffix AN 1 - 10 S
FI, SV, XX NM108 Identification Code Qualifier ID 1-2 R
NM109 Provider Identifier AN 2 - 80 R

TRN PROVIDER OF 1 S 2200C 1

SERVICE TRACE
IDENTIFIER
TRN01 Current Transaction Trace ID 1-2 R
Number
TRN02 Provider of Service AN 1 - 50 R
Information Trace Identifier

Identifier
STC PROVIDER STATUS >1 R 2200C

INFORMATION
STATUS
Category Code
Code
STC02 Status Information Effective DT 8-8 R
Date
STC09 Check Number AN 1 - 16 N/U
STATUS
Category Code
Code
STATUS
Category Code
Code
HL SUBSCRIBER LEVEL 1 S 2000D >1

Number
D8
CCYYMMDD
F, M, U
IL, QC NM101 Entity Identifier Code ID 2-3 R

NM106 Subscriber Name Prefix AN 1 - 10 N/U
NM107 Subscriber Name Suffix AN 1 - 10 S
24, MI, ZZ NM108 Identification Code Qualifier ID 1-2 R
NM109 Subscriber Identifier AN 2 - 80 R

TRN CLAIM STATUS 1 S 2200D >1

TRACKING NUMBER
2 TRN01 Referenced Transaction ID 1-2 R
Trace Number
Identifier
STC CLAIM LEVEL >1 R 2200D

STATUS
INFORMATION
STATUS
Category Code
Code
13, 17, 1E, 1G, 1H, 1I, 1O, 1P, STC01-3 Entity Identifier Code ID 2-3 S
1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X,
1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K,
2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C,
3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K,
3L, 3M, 3N, 3O, 3P, 3Q, 3R,
3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z,
40, 43, 44, 4A, 4B, 4C, 4D, 4E,
4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N,
4O, 4P, 4Q, 4R, 4S, 4U, 4V,
4W, 4X, 4Y, 4Z, 5A, 5B, 5C,
5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K,
5L, 5M, 5N, 5O, 5P, 5Q, 5R,
5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z,
61, 6A, 6B, 6C, 6D, 6E, 6F, 6G,
6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O,
6P, 6Q, 6R, 6S, 6U, 6V, 6W,
6X, 6Y, 71, 72, 73, 74, 77, 7C,
80, 82, 84, 85, 87, 95, CK, CZ,
D2, DD, DJ, DK, DN, DO, DQ,
E1, E2, E7, E9, FA, FD, FE,
G0, G3, GB, GD, GI, GJ, GK,
GM, GY, HF, HH, I3, IJ, IL, IN,
LI, LR, MR, OB, OD, OX, P0,
P2, P3, P4, P6, P7, PT, PV,
PW, QA, QB, QC, QD, QE, QH,
QK, QL, QN, QO, QS, QV, QY,
RC, RW, S4, SJ, SU, T4, TQ,
TT, TU, UH, X3, X4, X5, ZZ
STC01-4 Code List Qualifier Code ID 1-3 S

CCYYMMDD STC02 Status Information Effective DT 8-8 R
Date
STC04 Total Claim Charge Amount R 1 - 18 S
S9(7)V99
STC05 Claim payment Amount R 1 - 18 S
S9(7)V99
CCYYMMDD STC06 Adjudication or Payment Date DT 8-8 S
ACH, BOP, CHK, FWT, NON STC07 Payment Method Code ID 3-3 N/U
CCYYMMDD STC08 Remittance Date DT 8-8 S
STC09 Remittance Trace Number AN 1 - 16 S

STATUS
STC10-1 Health Care Claim Status AN 1 -30 R
Category Code
Code
STC10-3 Entity Identifier Code AN 2-3 S
STC10-4 Code List Qualifier Code ID N/U
STATUS
Category Code
Code
STC11-4 Code List Qualifier Code ID S

CONTROL NUMBER

Qualifier

REF04 REFERENCE IDENTIFIER N/U

TYPE
IDENTIFICATION
Qualifier
EA
REF PATIENT CONTROL 1 S 2200D

NUMBER
Qualifier
REF PHARMACY 1 S 2200D

PRESCRIPTION
NUMBER
Qualifier
REF02 Pharmacy Prescription AN 1 - 50 R
Number
REF VOUCHER 1 S 2200D

IDENTIFIER
Qualifier
REF02 Voucher Identifier AN 1 - 50 R
REF CLAIM 1 S 2200D

IDENTIFICATION
NUMBER FOR
CLEARINGHOUSES
AND OTHER
TRANSMISSION
INTERMEDIARIES

Qualifier

DTP CLAIM SERVICE 1 S 2200D

DATE
Qualifier
CCYYMMDDCCYYMMDD DTP03 Claim Service Period AN 1 - 35 R

INFORMATION
SVC01 COMPOSITE MEDICAL R
AD, CI, HC, ID, IV, N1, N2, N3, SVC01-1 Product/Service ID Qualifier ID 2-2 R
N4, ND,NH, NU, RB

SVC01-7 Description AN 1 - 80 N/U
S9(7)V99
SVC03 Line Item Payment Amount R 1 - 18 R
S9(7)V99
SVC05 Quantity R 1 - 15 N/U
SVC06 COMPOSITE MEDICAL N/U
SVC07 Units of Service Count R 1 - 15 S
S9(3)V9
STC CLAIM LEVEL >1 R 2220D

STATUS
INFORMATION
STATUS
Category Code
Code
1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X,
1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K,
2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C,
3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K,
3L, 3M, 3N, 3O, 3P, 3Q, 3R,
3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z,
40, 43, 44, 4A, 4B, 4C, 4D, 4E,
4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N,
4O, 4P, 4Q, 4R, 4S, 4U, 4V,
4W, 4X, 4Y, 4Z, 5A, 5B, 5C,
5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K,
5L, 5M, 5N, 5O, 5P, 5Q, 5R,
5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z,
61, 6A, 6B, 6C, 6D, 6E, 6F, 6G,
6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O,
6P, 6Q, 6R, 6S, 6U, 6V, 6W,
6X, 6Y, 71, 72, 73, 74, 77, 7C,
80, 82, 84, 85, 87, 95, CK, CZ,
E1, E2, E7, E9, FA, FD, FE,
P2, P3, P4, P6, P7, PT, PV,

Date
STC04 Total Claim Charge Amount R 1 - 18 N/U
S9(7)V99
STC05 Claim payment Amount R 1 - 18 N/U
S9(7)V99
STC06 Adjudication or Payment Date DT 8-8 N/U

STC08 Remittance Date DT 8-8 N/U
STC09 Remittance Trace Number AN 1 - 16 N/U
STATUS
Category Code
Code
Category Code
Code

IDENTIFICATION
Qualifier
DTP SERVICE LINE DATE 1 R 2220D

Qualifier
CCYYMMDDCCYYMMDD DTP03 Service Line Date AN 1 - 35 R

Number
HL04 Hierarchical Child Code ID 1-1 N/U
D8
CCYYMMDD
F, M, U

NM103 Dependent Last Name AN 1 - 60 R
NM104 Dependent First Name AN 1 - 35 S
NM105 Dependent Middle Name AN 1 - 25 S
NM106 Dependent Name Prefix AN 1 - 10 N/U
NM107 Dependent Name Suffix AN 1 - 10 S
NM109 Dependent Identifier AN 2 - 80 N/U

TRN CLAIM STATUS 1 R 2200E >1

TRACKING NUMBER
2 TRN01 Referenced Transaction ID 1-2 R
Trace Number
Identifier
STC CLAIM LEVEL >1 R 2200E

STATUS
INFORMATION
STATUS
Category Code
Code
1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X,
1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K,
2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C,
3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K,
3L, 3M, 3N, 3O, 3P, 3Q, 3R,
3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z,
40, 43, 44, 4A, 4B, 4C, 4D, 4E,
4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N,
4O, 4P, 4Q, 4R, 4S, 4U, 4V,
4W, 4X, 4Y, 4Z, 5A, 5B, 5C,
5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K,
5L, 5M, 5N, 5O, 5P, 5Q, 5R,
5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z,
61, 6A, 6B, 6C, 6D, 6E, 6F, 6G,
6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O,
6P, 6Q, 6R, 6S, 6U, 6V, 6W,
6X, 6Y, 71, 72, 73, 74, 77, 7C,
80, 82, 84, 85, 87, 95, CK, CZ,
E1, E2, E7, E9, FA, FD, FE,
P2, P3, P4, P6, P7, PT, PV,

Date
STC04 Total Claim Charge Amount R 1 - 18 S
S9(7)V99
STC05 Claim payment Amount R 1 - 18 S
S9(7)V99
CCYYMMDD STC06 Adjudication or Payment Date DT 8-8 S
ACH, BOP, CHK, FWT, NON STC07 Payment Method Code ID 3-3 N/U
CCYYMMDD STC08 Remittance Date DT 8-8 S
STC09 Remittance Trace Number AN 1 - 16 S

STATUS
Category Code
Code
STATUS
Category Code
Code
REF PAYER CLAIM 1 S 2200E

CONTROL NUMBER

Qualifier


TYPE
IDENTIFICATION
Qualifier
EA
REF PATIENT CONTROL 1 S 2200E

NUMBER
Qualifier
REF PHARMACY 1 S 2200E

PRESCRIPTION
NUMBER
Qualifier
REF02 Pharmacy Prescription AN 1 - 50 R
Number
REF VOUCHER 1 S 2200E

IDENTIFIER
Qualifier
REF02 Voucher Identifier AN 1 - 50 R
REF CLAIM 1 S 2200E

IDENTIFICATION
NUMBER FOR
CLEARINGHOUSES
AND OTHER
TRANSMISSION
INTERMEDIARIES

Qualifier

DTP CLAIM SERVICE 1 S 2200E

DATE
Qualifier
CCYYMMDDCCYYMMDD DTP03 Claim Service Period AN 1 - 35 R

INFORMATION
SVC01 COMPOSITE MEDICAL R
AD, CI, HC, ID, IV, N1, N2, N3, SVC01-1 Product/Service ID Qualifier ID 2-2 R
N4, ND, NH, NU, RB

SVC01-7 Description AN 1 - 80 N/U
SVC01-8 Product Service ID AN N/U
S9(7)V99
SVC03 Line Item Payment Amount R 1 - 18 R
S9(7)V99
SVC05 Quantity R 1 - 15 N/U
SVC06 COMPOSITE MEDICAL N/U
SVC07 Units of Service Count R 1 - 15 S
S9(3)V9
STC CLAIM LEVEL >1 R 2200E

STATUS
INFORMATION
STATUS
Category Code
Code
1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X,
1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K,
2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C,
3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K,
3L, 3M, 3N, 3O, 3P, 3Q, 3R,
3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z,
40, 43, 44, 4A, 4B, 4C, 4D, 4E,
4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N,
4O, 4P, 4Q, 4R, 4S, 4U, 4V,
4W, 4X, 4Y, 4Z, 5A, 5B, 5C,
5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K,
5L, 5M, 5N, 5O, 5P, 5Q, 5R,
5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z,
61, 6A, 6B, 6C, 6D, 6E, 6F, 6G,
6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O,
6P, 6Q, 6R, 6S, 6U, 6V, 6W,
6X, 6Y, 71, 72, 73, 74, 77, 7C,
80, 82, 84, 85, 87, 95, CK, CZ,
E1, E2, E7, E9, FA, FD, FE,
P2, P3, P4, P6, P7, PT, PV,

Date
STC04 Total Claim Charge Amount R 1 - 18 N/U
S9(7)V99
STC05 Claim payment Amount R 1 - 18 N/U
S9(7)V99
STC06 Adjudication or Payment Date DT 8-8 N/U

STC08 Remittance Date DT 8-8 N/U
STC09 Remittance Trace Number AN 1 - 16 N/U
STATUS
Category Code
Code
STATUS
Category Code
Code

IDENTIFICATION
Qualifier
DTP SERVICE LINE DATE 1 R 2200E

Qualifier
CCYYMMDDCCYYMMDD DTP03 Service Line Date AN 1 - 35 R
TRAILER

Number
TRAILER
Included
GE02 Group Control Number N0 1-9 R
CONTROL TRAILER
Functional Groups
Status Response
Values
00, 03
00, 01
01, 14, 20, 27, 28, 29, 30,

33, ZZ
01, 14, 20, 27, 28, 29, 30,

33, ZZ
YYMMDD
HHMM
501
0, 1
P, T
HR
CCYYMMDD
HHMMSSDD
005010X212
277
005010X212
10
CCYYMMDD
DG
20
1
PR
2
PI, XV
IC
ED, EM, TE, FX
ED, EM, TE, FX, EX
ED, EM, TE, FX, EX

21
0, 1
41
1, 2
46
D0, E
41, AY, PR
CCYYMMDD
D0, E
41, AY, PR
D0, E
41, AY, PR
19
0, 1
1P
1, 2
FI, SV, XX
1
D0, E
1P
CCYYMMDD
D0, E
1P
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4010A1 278 Review Request
5010 278 REVIEW REQUEST
ST Transaction Set Header 1 R 1
ST01 Transaction Set Identifier Code ID 3/3 R
ST02 Transaction Set Control AN 4/9 R

Number
ST03 Implementation Convention AN 1/35 R
Reference
BHT Beginning of R 1
Hierarchical
Transaction
BHT01 Hierarchical Structure Code ID 4/4 R
BHT02 Transaction Set Purpose Code ID 2/2 R
BHT03 Reference Identification AN 1/50 R

BHT04 Date DT 8/8 R
BHT05 Time TM 4/8 R
BHT06 Transaction Type Code ID 2/2 S
UTILIZATION
MANAGEMENT
ORGANIZATION (UMO)
HL LEVEL R 2000A 1
HL01 HIERARCHICAL ID NUMBER AN 1/12

HIERARCHICAL PARENT ID
HL02 NUMBER AN 1/12 N/U
HL03 HIERARCHICAL LEVEL CODE AN 1/2
HL04 HIERARCHICAL CHILD CODE ID 1/1
UTILIZATION
MANAGEMENT
ORGANIZATION (UMO)
NM1 NAME R 2010A 1
NM101 ENTITY IDENTIFIER CODE ID 2/3 R

NM102 ENTITY TYPE QUALIFIER ID 1/1 R
NAME LAST OR
NM103 ORGANIZATION NAME AN 1/60 S
NM104 NAME FIRST AN 1/35 S
NM105 NAME MIDDLE AN 1/25 S
NM106 NAME PREFIX AN 1/10 N/U
NM107 NAME SUFFIX AN 1/10 S
IDENTIFICATION CODE
NM108 QUALIFIER ID 1/2 R
NM109 IDENTIFICATION CODE AN 2/80 R
NM110 ENTITY RELATIONSHIP ID 2/2 N/U
CODE
NM111 ENTITY IDENTIFIER CODE ID 2/3 N/U
NM112 NAME LAST OR AN 1/60 N/U

ORGANIZATION NAME
HL REQUESTER LEVEL R 2000B 1
HL01 HIERARCHICAL ID NUMBER AN 1/12 R
HL02 NUMBER AN 1/12 R
HL03 HIERARCHICAL LEVEL CODE ID 1/2 R
HL04 HIERARCHICAL CHILD CODE ID 1/1 R
NM1 REQUESTER NAME R 2010B 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
REQUESTER
SUPPLEMENTAL
REF IDENTIFICATION S 2010B 8
REFERENCE
REF01 IDENTIFICATION QUALIFIER ID 2/3 R
REFERENCE
REF02 IDENTIFICATION AN 1/50 R
REF03 DESCRIPTION AN 1/80 N/U
REQUESTER
N3 ADDRESS S 2010B 1
N301 ADDRESS INFORMATION AN 1/55 R
N302 ADDRESS INFORMATION AN 1/55 S
REQUESTER CITY,
N4 STATE, ZIP S 2010B 1
N401 CITY NAME AN 2/30 R
N402 STATE OR PROVINCE CODE ID 2/2 S

N403 POSTAL CODE ID 3/15 S
N404 COUNTRY CODE ID 2/3 S
N405 LOCATION QUALIFIER ID 1/2 N/U
N406 LOCATION IDENTIFIER AN 1/30 N/U
N407 COUNTRY SUBDIVISION ID 1/3 S
CODE
REQUESTER
CONTACT
PER INFORMATION S 2010B 1
PER01 CONTACT FUNCTION CODE ID 2/2 R

PER02 NAME AN 1/60 S
COMMUNICATION NUMBER
PER03 QUALIFIER ID 2/2 S
PER04 COMMUNICATION NUMBER AN 1/256 S



PER09 CONTACT INQUIRY AN 1/20 N/U
REFERENCE
REQUESTER
PROVIDER
PRV INFORMATION S 2010B 1
PRV01 PROVIDER CODE ID 1/3 R

REFERENCE
PRV02 IDENTIFICATION QUALIFIER ID 2/3 S
REFERENCE
PRV03 IDENTIFICATION AN 1/50 S
PRV04 STATE OR PROVINCE CODE ID 2/2 N/U
INFORMATION
PRV06 PROVIDER ORGANIZATION ID 3/3 N/U
CODE
HL SUBSCRIBER LEVEL R 2000C 1

HL02 HIERARCHICAL PARENT ID AN 1/12 R
NM1 SUBSCRIBER NAME R 2010C 1

NAME LAST OR
NM106 NAME PREFIX AN 1/10 S
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
SUBSCRIBER
SUPPLEMENTAL
REF IDENTIFICATION S 2010C 9
REFERENCE
REFERENCE
SUBSCRIBER
N3 ADDRESS S 2010C 1
SUBSCRIBER CITY,
N4 STATE, ZIP S 2010C 1
CODE
DMG SUBSCRIBER S 2010C 1

DEMOGRAPHIC
INFORMATION
DMG01 DATE TIME PERIOD FORMAT ID 2/3 R
QUALIFIER
DMG02 DATE TIME PERIOD AN 1/35 R
DMG03 GENDER CODE ID 1/1 S
DMG04 MARITAL STATUS CODE ID 1/1 N/U
DMG05 COMPOSITE RACE OR N/U
ETHNICITY
DMG06 CITIZENSHIP STATUS CODE ID 1/2 N/U
DMG07 COUNTRY CODE ID 2/3 N/U

DMG08 BASIS OF VERIFICATION ID 1/2 N/U
CODE
DMG09 QUANTITY R 1/15 N/U
DMG10 CODE LIST QUALIFIER CODE ID 1/3 N/U
DMG11 INDUSTRY CODE AN 1/30 N/U
INS SUBSCRIBER S 2010C 1

RELATIONSHIP
INS01 YES/NO CONDITION OR ID 1/1 R
RESPONSE CODE
INS02 INDIVIDUAL RELATIONSHIP ID 2/2 R
CODE
INS03 MAINTENANCE TYPE CODE ID 3/3 N/U
INS04 MAINTENANCE REASON ID 2/3 N/U

CODE
INS05 BENEFIT STATUS CODE ID 1/1 N/U
INS06 MEDICARE STATUS CODE N/U
INS07 CONSOLIDATED OMNIBUS ID 1/2 N/U

BUDGET RECONCILATION
ACT (COBRA) QUALIFYING
INS08 EMPLOYMENT STATUS ID 2/2 R
CODE
INS09 STUDENT STATUS CODE ID 1/1 N/U
INS10 YES/NO CONDITION OR ID 1/1 N/U

RESPONSE CODE
INS11 DATE TIME PERIOD FORMAT ID 2/3 N/U
QUALIFIER
INS12 DATE TIEME PERIOD AN 1/35 N/U
INS13 CONFIDENTIALITY CODE ID 1/1 N/U
INS14 CITY NAME A 2/30 N/U

INS15 STATE OR PROVINCE CODE ID 2/2 N/U
INS16 COUNTRY CODE ID 2/3 N/U
INS17 NUMBER N0 1/9 N/U
HL DEPENDENT LEVEL S 2000D 1
NM1 DEPENDENT NAME R 2010D 1

NAME LAST OR
IDENTIFICATION CODE
NM108 QUALIFIER ID 1/2 N/U
NM109 IDENTIFICATION CODE AN 2/80 N/U
CODE

ORGANIZATION NAME
DEPENDENT
SUPPLEMENTAL
REF IDENTIFICATION S 2010D 3
REFERENCE
REFERENCE
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N3 ADDRESS S 2010D 1

DEPENDENT CITY,
N4 STATE, ZIP S 2010D 1



CODE
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DEMOGRAPHIC
INFORMATION
QUALIFIER
ETHNICITY

CODE
INS DEPENDENT S 2010D 1

RELATIONSHIP
RESPONSE CODE
CODE

CODE

INS08 EMPLOYMENT STATUS ID 2/2 N/U
CODE
RESPONSE CODE
QUALIFIER

INS17 NUMBER N0 1/9 S
HL PATIENT LEVEL S 2000E 1
PATIENT EVENT
TRN TRACKING NUMBER S 2000E 2
TRN01 TRACE TYPE CODE ID 1/2 R
PATIENT EVENT TRACKING
TRN02 NUMBER AN 1/50 R
TRACE ASSIGNING ENTITY
TRN03 IDENTIFIER AN 10/10 R
TRN04 ADDITIONAL IDENTIFIER AN 1/50 S
HEALTH CARE
SERVICES REVIEW
UM INFORMATION R 2000E 1
UM01 REQUEST CATEGORY CODE ID 1/2
UM02 CERTIFICATION TYPE CODE ID 1/1
UM03 SERVICE TYPE CODE ID 1/2

HEALTH CARE SERVICE
UM04 LOCATION INFORMATION S
UM04-1 FACILITY CODE VALUE AN 1/2 R
UM04-2 FACILITY CODE QUALIFIER ID 1/2 R

CLAIM FREQUENCY TYPE
UM04-3 CODE ID 1/1 N/U
RELATED CAUSES
UM05 INFORMATION S
UM05-1 RELATED CAUSES CODE ID 2/3 R
UM05-2 RELATED CAUSES CODE ID 2/3 S

UM05-3 RELATED CAUSES CODE ID 2/3 S
UM05-4 STATE OR PROVINCE CODE ID 2/2 S
UM05-5 COUNTRY CODE ID 2/3 S
UM06 LEVEL OF SERVICE CODE ID 1/3 S

CURRENT HEALTH
UM07 CONDITION CODE ID 1/1 S
UM08 PROGNOSIS CODE ID 1/1 S
RELEASE OF INFORMATION
UM09 CODE ID 1/1 S
UM10 DELAY REASON CODE ID 1/2 S
PREVIOUS REVIEW
AUTHORIZATION
REF NUMBER S 2000E 1
REFERENCE
REFERENCE
PREVIOUS REVIEW
ADMINISTRATIVE
REF REFERENCE NUMBER S 2000E 1
REFERENCE
REFERENCE
DTP ACCIDENT DATE S 2000E 1

DTP01 DATE/TIME QUALIFIER ID 3/3 R
DATE TIME PERIOD FORMAT
DTP02 QUALIFIER ID 2/3 R
DTP03 DATE TIME PERIOD AN 1/35 R
LAST MENSTRUAL
DTP DATE S 2000E 1
ESTIMATED DATE OF
DTP BIRTH S 2000E 1
ONSET OF CURRENT
SYMPTOMS OR
DTP ILLNESS DATE S 2000E 1
DTP EVENT DATE S 2000E 1

DTP ADMISSION DATE S 2000E 1

DTP DISCHARGE DATE S 2000E 1

HI PATIENT DIAGNOSIS S 2000E 1

HEALTH CARE CODE
HI01 INFORMATION R
HI01-1 CODE LIST QUALIFIER CODE ID 1/3 R

HI01-2 INDUSTRY CODE AN 1/30 R
HI01-3 QUALIFIER ID 2/3 S
HI01-4 DATE TIME PERIOD AN 1/35 S
HI04-5 MONETARY AMOUNT R 1/18 N/U
HI04-6 QUANTITY R 1/15 N/U
HI04-7 VERSION IDENTIFIER AN 1/30 N/U
HI04-8 INDUSTRY CODE AN 1/30 N/U
YES/NO CONDITION OR
HI04-9 RESPONSE CODE ID 1/1 N/U
HEALTH CARE CODE
HI02 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI03 INFORMATION
HI03-1 CODE LIST QUALIFIER CODE ID 1/3

HI03-2 INDUSTRY CODE AN 1/30
HI03-3 QUALIFIER ID 2/3
HI03-4 DATE TIME PERIOD AN 1/35
I HI03-5 MONETARY AMOUNT R 1/18 N/U
YES/NO CONDITION OR
HEALTH CARE CODE
HI04 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI05 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI06 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI07 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI08 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI09 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI10 INFORMATION
YES/NO CONDITION OR
HEALTH CARE CODE
HI11 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI12 INFORMATION

YES/NO CONDITION OR
HSD HEALTH CARE R 2000E 1

SERVICES DELIVERY
HSD01 QUANTITY QUALIFIER ID 2/2 S
HSD02 QUANTITY QUALIFIER R 1/15 S
HSD03 UNIT OR BASIS FOR ID 2/2 S
MEASUREMENT CODE
HSD04 SAMPLE SELECTION R 1/6 S
MODULUS
HSD05 TIMIE PERIOD QUALIFIER ID 1/2 S
HSD06 NUMBER OF PERIODS N0 1/3 S

HSD07 SHIP/DELIVERY OR ID 1/2 S
CALENDAR PATTERN CODE
HSD08 SHIP/DELIVERY PATTERN ID 1/1 S

TIME CODE
CRC AMBULANCE S 2000E 1

CERTIFICATION
INFORMATION
CRC01 CODE CATEGORY ID 2/2 R
CRC02 YES/NO CONDITION OR ID 1/1 R
RESPONSE CODE
CRC03 CONDITION INDICATOR ID 2/3 R
CRC04 CONDITION INDICATOR ID 2/3 S
CRC CHIROPRACTIC S 2000E 1

CERTIFICATION
INFORMATION
RESPONSE CODE

CRC DURABLE MEDICAL S 2000E 1

EQUIPMENT
INFORMATION

RESPONSE CODE
CRC OXYGEN THERAPY S 2000E 1
CERTIFICATION
INFORMATION
RESPONSE CODE
CRC FUNCTIONAL S 2000E 1

LIMITATIONS
INFORMATION
RESPONSE CODE
CRC ACTIVITIES S 2000E 1

PERMITTED
INFORMATION
RESPONSE CODE
CRC MENTAL STATUS S 2000E 1

INFORMATION
RESPONSE CODE
CL1 INSTITUTIONAL CLAIM S 2000E 1

CODE
CL101 ADMISSION TYPE CODE ID 1/1 S
CL102 ADMISSION SOURCE CODE ID 1/1 S
CL103 PATIENT STATUS CODE ID 1/1 S

CL104 NURSING HOME ID 1/1 S
RESIDENTIAL STATUS CODE
AMBULANCE
TRANSPORT
CR1 INFORMATION S 2000E 1
UNIT OR BASIS FOR
CR101 MEASUREMENT CODE ID 2/2 S
CR102 WEIGHT R 1/10 S
AMBULANCE TRANSPORT
CR103 CODE ID 1/1 R
AMBULANCE TRANSPORT
CR104 REASON CODE ID 1/1 S
UNIT OR BASIS FOR
CR106 QUANTITY R 1/15 S
CR107 ADDRESS INFORMATION AN 1/55 N/U

CR109 DESCRIPTION AN 1/80 S
S 2000E 1
SPINAL
MANIPULATION
SERVICE
CR2 INFORMATION
S
CR201 COUNT NO 1/9
S
CR202 QUANTITY R 1/15
S
CR203 SUBLUXATION LEVEL CODE ID 2/3
S
UNIT OR BASIS FOR N/U
CR205 MEASUREMENT CODE ID 2/2
N/U
N/U
NATURE OF CONDITION N/U
CR208 CODE ID 1/1
YES/NO CONDITION OR R
CR209 RESPONSE CODE ID 1/1
CR210 DESCRIPTION AN 1/80
YES/NO CONDITION OR
HOME OXYGEN
THERAPY
CR501 CERTIFICATION TYPE CODE ID 1/1 N/U

CR502 QUANTITY R 1/15 N/U
OXYGEN EQUIPMENT TYPE
CR503 CODE ID 1/1 R
CR504 CODE ID 1/1 S
CR506 QUANTITY R 1/15 R
OXYGEN TEST CONDITION
CR512 CODE ID 1/1 S
OXYGEN TEST FINDINGS
CR513 CODE ID 1/1 S
CR514 CODE ID 1/1 S
CR515 CODE ID 1/1 S
OXYGEN DELIVERY SYSTEM
CR517 CODE ID 1/1 R
CR518 CODE ID 1/1 S
HOME HEALTH CARE

CR601 PROGNOSIS CODE ID 1/1 R
CR602 DATE DT 8/8 R
CR603 QUALIFIER ID 2/3 S
CR604 DATE TIME PERIOD AN 1/35 S
CR605 DATE DT 8/8 N/U
YES/NO CONDITION OR
CR606 RESPONSE CODE ID 1/1 N/U
YES/NO CONDITION OR
CR607 RESPONSE CODE ID 1/1 R
CR608 CERTIFICATION TYPE CODE ID 1/1 R

CR609 DATE DT 8/8 S
PRODUCT/SERVICE ID
CR611 MEDICAL CODE VALUE AN 1/15 S
CR612 DATE DT 8/8 S
CR613 DATE DT 8/8 S
CR614 DATE DT 8/8 S
CR617 PATIENT LOCATION CODE ID 1/1 S

N/U
CR618 DATE DT 8/8
N/U
CR619 DATE DT 8/8
N/U
CR620 DATE DT 8/8
N/U
CR621 DATE DT 8/8
ADDITIONAL PATIENT
PWK INFORMATION S 2000E 10
ATTACHMENT REPORT
PWK01 TYPE CODE ID 2/2 R
REPORT TRANSMISSION
PWK02 CODE ID 1/2 R
PWK03 REPORT COPIES NEEDED N0 1/2 N/U
PWK04 ENTITY IDENTIFIER CODE ID 2/3 N/U

IDENTIFICATION CODE
PWK05 QUALIFIER ID 1/2 S
ATTACHMENT CODTROL
PWK06 NUMBER AN 2/80 S
ATTACHYMENT
PWK07 DESCRIPTION AN 1/80 S
ACTIONS INDICATED N/U
PWK08
REQUEST CATEGORY CODE ID 1/2 N/U
PWK09
MSG MESSAGE TEXT S 2000E 1
MSG01 FREE FORM MESSAGE TEXT AN 1/264 R

PRINTER CARRIAGE ID 2/2 N/U
MSG02 CONTROL CODE
NUMBER N0 1/9 N/U
MSG03
PATIENT EVENT
NM1 PROVIDER NAME S 2010EA 1

NAME LAST OR
IDENTIFICATION CODE
NM109 IDENTIFICATION CODE AN 2/80 S
CODE

ORGANIZATION NAME
PATIENT EVENT
PROVIDER
SUPPLEMENTAL
REF INFORMATION S 2010EA 7
REFERENCE
REFERENCE
PATIENT EVENT
N3 PROVIDER ADDRESS S 2010EA 1
PATIENT EVENT
PROVIDER CITY,
N4 STATE, ZIP S 2010EA 1
CODE
PATIENT EVENT
PROVIDER CONTACT
PER INFORMATION S 2010EA 1



REFERENCE
PATIENT EVENT
PROVIDER
PRV INFORMATION S 2010EA 1
REFERENCE
REFERENCE
INFORMATION
CODE
PATIENT EVENT
NM1 PROVIDER NAME S 2010EB 5

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
PATIENT EVENT
TRANSPORT
N3 LOCATION ADDRESS S 2010EB 1
PATIENT EVENT
TRANSPORT
LOCATION CITY,
N4 STATE, ZIP S 2010EB 1
CODE
PATIENT EVENT
NM1 OTHER UMO NAME S 2010EB 5

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
OTHER UMO DENIAL

REF REASON S 2010EC 1
REFERENCE
REFERENCE
REF04 REFERENCE IDENTIFIER S
REF04-1 REFERENCE ID 2/3 R
IDENTIFICATION QUALIFIER
REF04-2 REFERENCE AN 1/50 R

IDENTIFICATION
REF04-3 REFERENCE ID 2/3 S
REF04-4 REFERENCE AN 1/50 S

IDENTIFICATION
REF04-5 REFERENCE ID 2/3 S
REF04-6 REFERENCE AN 1/50 S

IDENTIFICATION
OTHER UMO DENIAL
DTP DATE R 2010EC 1
HL SERVICE LEVEL S 2000F 1
PATIENT EVENT
TRN TRACKING NUMBER S 2000F 2
HEALTH CARE
SERVICES REVIEW
UM INFORMATION S 2000F 1
UM01 REQUEST CATEGORY CODE ID 1/2

HEALTH CARE SERVICE

RELATED CAUSES
UM05 INFORMATION N/U
UM06 LEVEL OF SERVICE CODE ID 1/3 N/U

CURRENT HEALTH
UM07 CONDITION CODE ID 1/1 N/U
UM08 PROGNOSIS CODE ID 1/1 N/U
UM09 CODE ID 1/1 N/U
UM10 DELAY REASON CODE ID 1/2 N/U
PREVIOUS REVIEW
AUTHORIZATION
REF NUMBER S 2000F 1
REFERENCE
REFERENCE
PREVIOUS REVIEW
ADMINISTRATIVE
REF REFERENCE NUMBER S 2000F 1
REFERENCE
REFERENCE
DTP SERVICE DATE S 2000F 1

SV1 PROFESSIONAL S 2000F 1

SERVICE
SV101 COMPOSITE MEDICAL R
PROCEDURE IDENTIFIER
SV101-1 PRODUCT/SERVICE ID ID 2/2 R
QUALIFIER
SV101-2 PRODUCT/SERVICE ID AN 1/48 R
SV101-3 PROCEDURE MODIFIER AN 2/2 S
SV101-7 DESCRIPTION AN 1/80 S
SV101-8 PRODUCT/SERVICE ID AN 1/48 S
SV102 MONETARY AMOUNT R 1/18 S
SV103 UNIT OR BASIS FOR ID 2/2 S
MEARUREMENT CODE
SV104 QUALITY R 1/15 S
SV105 FACILITY CODE AN 1/2 N/U
SV106 SERVICE TYPE CODE ID 1/2 N/U
SV107 COMPOSITE DIAGNOSIS S
CODE POIONTER
SV107-1 DIAGNOSIS CODE N0 1/2 R
POIONTER
SV107-2 DIAGNOSIS CODE N0 1/2 S
POIONTER
POIONTER
POIONTER
SV108 MONETARY AMOUNT R 1/18 N/U
SV109 YES/NO CONDITION OR ID 1/1 N/U
RESPONSE CODE
SV110 MULTIPLE PROCEDURE ID 1/2 N/U
CODE
SV111 YES/NO CONDITION OR ID 1/1 S
RESPONSE CODE
RESPONSE CODE
SV113 REVIEW CODE ID 1/2 N/U
SV114 NATIONAL OR LOCAL AN 1/2 N/U
ASSIGNED REVIEW VALUE
SV115 COPAY STATUS CODE ID 1/1 N/U
SV116 HEALTH CARE ID 1/1 N/U
PROFESSIONAL SHORTAGE
AREA CODE
SV117 REFERENCE AN 1/50 N/U

IDENTIFICATION
SV118 POSTAL CODE ID 3/15 N/U
SV120 LEVEL OF CARE CODE ID 1/1 S
SV121 PROVIDER AGREEMENT ID 1/1 N/U
CODE
SV2 INSTITUTIONAL S 2000F 1

SERVICE LINE
SV201 PRODUCT/SERVICE ID AN 1/48 S
SV202 COMPOSITE MEDICAL S
PROCEDURE
QUALIFIER
MEASUREMENT CODE
SV205 QUANTITY R 1/15 S
SV206 UNIT RATE R 1/10 S
RESPONSE CODE
SV209 NURSING HOME ID 1/1 S
SV3 DENTAL SERVICE S 2000F 1

QUALIFIER
SV303 FACILITY CODE VALUE AN 1/2 N/U
SV304 ORAL CAVITY DESIGNATION S
SV304-1 ORAL CAVITY DESIGNATION ID 1/3 R

CODE
SV304-2 ORAL CAVITY DESIGNATION ID 1/3 S
CODE
CODE
CODE
CODE
SV305 PROSTHESIS, CROWN OR ID 1/1 S
INLAY CODE
SV306 QUANTITY R 1/15 R
SV307 DESCRIPTION AN 1/80 S
CODE
RESPONSE CODE
SV311 COMPOSITE DIAGNOSIS N/U
CODE POINTER
TOO TOOTH INFORMATION S 2000F 32
TOO01 CODE LIST QUALIFIER CODE ID 1/3 R
TOO02 INDUSTRY CODE AN 1/30 R

TOO03 TOOTH SURFACE S
TOO03-1 TOOTH SURFACE CODE ID 1/2 R
TOO03-2 TOOTH SURFACE CODE ID 1/2 S
TOO03-5 TOOTH SURFACE CODE ID 1/2
HSD HEALTH CARE S 2000F 1
SERVICES DELIVERY
MEASUREMENT CODE
MODULUS


TIME CODE
ADDITIONAL SERVICE
PWK INFORMATION S 2000F 10
PWK01 REPORT TYPE CODE ID 2/2 R
REPORT TRANSMISSION
PWK02 CODE ID 1/2 R

IDENTIFICATION CODE
IDENTIFICATION CODE
PWK06 QUALIFIER AN 2/80 S
ATTACHYMENT
PWK08
PWK09
MSG MESSAGE TEXT S 2000F 1

MSG02 CONTROL CODE
NUMBER N0 1/9 N/U
MSG03
NM1 SERVICE PROVIDER NAME S 2010F 10

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
PREVIOUS REVIEW
ADMINISTRATIVE
REFERENCE
REFERENCE
SERVICE PROVIDER
N3 ADDRESS S 2010F 1
SERVICE PROVIDER
N4 CITY, STATE, ZIP S 2010EC 1
CODE
SERVICE PROVIDER
CONTACT


REFERENCE
SERVICE PROVIDER
REFERENCE
REFERENCE

INFORMATION
CODE
TRANSACTION SET
SE TRAILER R 1
NUMBER OF INCLUDED
SE01 SEGMENTS NO 1/10
TRANSACTION SET
SE02 CONTROL NUMBER AN 4/9
EQUEST
Values
278
0007
01,13,36
RU
X3
2B,36,PR,X3
1,2
24,34,46,PI,XV
21
1P,2B,36,FA,PR
1,2
1G,1J,EI,G5,N5,N7,SY,ZH
IC
EM,FX,TE,UR
EM,FX,TE,UR
EM,FX,TE,UR
AD,AS,AT,CO,CV,OP,OR,OT,PC,PE,RF
PXC
22
IL
1
II,MI
1L,3L,6P,DP,EJ,F6,HJ,IG,N6,NQ,SY
D8
F,M,U
18
AO,AU,DI,PV,RU
23
QC
1
EJ,SY
D8
F,M,U
01,19,G8
EV
0,1
1,2,3,4,5,6,7,8,11,12,14,15,16,17,18,20,
21,23,24,25,26,27,28,33,35,36,37,38,39,
40,42,44,45,46,54,56,61,62,63,64,65,66,
AR,HS,IN,SC
67,68,69,70,71,72,73,74,75,76,77,78,79,
80,82,83,84,85,86,87,88,93,A4,A6,A9,A
D,AE,AF,AG,AI,AJ,AK,AL,AR,B1,BB,BC
1,2,3,4,I,N,R,S
,BD,BE,BF,BG,GL,BN,BP,BQ,BS,BY,BZ
,C1,CQ,GY,IC,MH,NI,ON,PT,PU,RN,RT
,TC,TN
A,B
AA,AP,EM
AP,EM
AP
03,E,U
1,2,3,4,5,6,7,8,9,E,F,G,P
1,2,3,4,5,6,7
M,Y
1,2,3,4,7,8,10,11,15,16,17
BB
NT
439
D8 (CCYYMMDD)
484
D8 (CCYYMMDD)
ABC
D8 (CCYYMMDD)
431
D8 (CCYYMMDD)
AAH
D8, RD8
435
D8, RD8
96
D8 (CCYYMMDD)
ABF,ABJ,ABK,APR,BF,BJ,BK,DR,PR
D8 (CCYYMMDD)
ABF,ABJ,ABK,APR,BF,BJ,BK,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,PR
D8 (CCYYMMDD)
DY,FL,HS,MN,VS
DA,MO,WK
6,7,21,26,27,34,35
1,2,3,4,5,6,7,8,9,A,B,C,D,E,F,G,H,J,K,L,
M,M,N,O,P,Q,R,S,SA,SA,SB,SC,SD,SG
,SL,SP,SX,SY,SZ,T,U,V,W,X,Y
A,B,C,D,E,F,G,Y
07
N,Y
01,02,03,04,05,06,07,08,09,41,43,5A,60,
9D
01,02,03,04,05,06,07,08,09,41,43,5A,60,
9D
01,02,03,04,05,06,07,08,09,41,43,5A,60,
9D
01,02,03,04,05,06,07,08,09,41,43,5A,60,
9D
01,02,03,04,05,06,07,08,09,41,43,5A,60,
9D
08
N,Y
11,12,14,24,25,27,30
11,12,14,24,25,27,30
11,12,14,24,25,27,30
11,12,14,24,25,27,30
11,12,14,24,25,27,30
09
N,Y
SE TR3 FOR CODES

SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
11
N,Y
06,16,17,25,33,37,39,5A,9J,9K,DY
06,16,17,25,33,37,39,5A,9J,9K,DY
06,16,17,25,33,37,39,5A,9J,9K,DY
06,16,17,25,33,37,39,5A,9J,9K,DY
06,16,17,25,33,37,39,5A,9J,9K,DY
75
N,Y
SE TR3 FOR CODES

SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
76
N,Y
SE TR3 FOR CODES

SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
77
N,Y
SE TR3 FOR CODES

SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
SE TR3 FOR CODES
1,2,3,4,5,6,7,8,9
KG = KILO LB =
POUND
I,R,T,X
A,B,C,D,E,F
DH = MILES DK =
KILOMETERS
SE TR3 FOR CODES
SE TR3 FOR CODES
A,C,D,E,F,G,M
N,Y
N,Y
A,B,C,D,E,O
A,B,C,D,E,O
E,N,O,R,S,W,X
1,2,3
1,2,3
1,2,3
A,B,C,D,E
A,B,C,D,E,O
1,2,3,4,5,6
RD8
1,2,3,4,6,I,R,S
HC,ID
RD8
SEE TR3 FOR CODES
AA,BM,EL,EM,FX,VO
AC
SEE TR3 FOR CODES

1,2
24,34,46,XV
OB,1G,1J,EI,N5,N7,SY,ZH
IC
EM,FX,TE,UR
EX,FX,TE,UR
EM,EX,FX,TE,UR
AD,AS,AT,OP,OR,OT,PC,PE,RF
PXC
45,FS,ND,PW,R3
2
OO,CA,GG
2
ZZ
ZZ
ZZ
ZZ
598
D8 (CCYYMMDD)
SS
HS,SC
1,2,3,4,I,N,R,S
SEE TR3 FOR CODES
A,B
BB
NT
472
D8, RD8
HC,IV,N4,WK
F2,MJ,UN
N,Y
1,2,3,4,5,6,7,8
HC,ID,IV,N4,WK,ZZ
DA,F2
1,2,3,4,5,6,7,8
1,2,3,4,5,6,7,8
AD
I,R
JP
B,D,F,I,L,M,O
B,D,F,I,L,M,O
B,D,F,I,L,M,O
B,D,F,I,L,M,O
B,D,F,I,L,M,O
DY,FL,HS,MN,VS
DA,MO,WK
6,7,21,26,27,34,35
1,2,3,4,5,6,7,8,9,A,B,C,D,E,F,G,H,J,K,L,
M,M,N,O,P,Q,R,S,SA,SA,SB,SC,SD,SG
,SL,SP,SX,SY,SZ,T,U,V,W,X,Y
A,B,C,D,E,F,G,Y
SEE TR3 FOR CODES
AA,BM,EL,EM,FX,VO
AC
1T,72,73,77,33,3K,DQ,FA,
G3,P3,QB,QV,SJ
1,2
242,34,46,XX
0B,1G,1J,EI,N5,N7,SY,ZH
IC
EM,FX,TE,UR
EX,FX,TE,UR
EM,EX,FX,TE,UR
AS,OP,OR,OT,PC,PE
PXC
4010A1 278 Review Response
sponse 5010 278 REVIEW RESPONSE
ST Transaction Set Header 1 R ----------- 1
ST01 Transaction Set Identifier Code ID 3/3 R
ST02 Transaction Set Control AN 4/9 R

Number
ST03 Implementation Convention AN 1/35 R
Reference
BHT Beginning of R 1
Hierarchical
Transaction
BHT01 Hierarchical Structure Code ID 4/4 R
BHT02 Transaction Set Purpose Code ID 2/2 R
BHT03 Reference Identification AN 1/50 R

BHT04 Date DT 8/8 R
BHT05 Time TM 4/8 R
BHT06 Transaction Type Code ID 2/2 S
UTILIZATION
MANAGEMENT
ORGANIZATION (UMO)
HL LEVEL R 2000A 1
HL01 HIERARCHICAL ID NUMBER AN 1/12

HL02 NUMBER AN 1/12 N/U
HL03 HIERARCHICAL LEVEL CODE AN 1/2
HL04 HIERARCHICAL CHILD CODE ID 1/1
AAA REQUEST VALIDATION S 2000A 9
AAA01 YES/NO CONDITION OR ID 1/1 R

RESPONSE CODE
AAA02 AGENCY QUALIFIER CODE ID 2/2 N/U
AAA03 REJECT REASON CODE ID 2/2 R

AAA04 FOLLOW-UP ACTION CODE ID 1/1 R
UTILIZATION
MANAGEMENT
ORGANIZATION (UMO)
NM1 NAME R 2010A 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
PER UTILIZATION S 2010A 9

MANAGEMENT
PER01 ORGANIZATION
CONTACT FUNCTION(UMO)
CODE ID 2/2 R
NAME
PER03 COMMUNICATION NUMBER ID 2/2 S

QUALIFIER

QUALIFIER

QUALIFIER

REFERENCE
AAA UTILIZATION S 2010A 9

MANAGEMENT
AAA01 ORGANIZATION (UMO) ID
YES/NO CONDITION OR 1/1 R
RESPONSE
REQUESTCODE
VALIDATION
HL REQUESTER LEVEL R 2000B 1

NM1 REQUESTER NAME R 2010B 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
REQUESTER
SUPPLEMENTAL
REF IDENTIFICATION S 2010B 8
REFERENCE
REFERENCE
AAA REQUESTER S 2010B 9

REQUEST VALIDATION

RESPONSE CODE

REQUESTER
PROVIDER
PRV INFORMATION S 2010B 1
REFERENCE
REFERENCE

INFORMATION
CODE
HL SUBSCRIBER LEVEL S 2000C 1
NM1 SUBSCRIBER NAME R 2010C 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
SUBSCRIBER
SUPPLEMENTAL
REF IDENTIFICATION S 2010C 9
REFERENCE
REFERENCE
SUBSCRIBER MAILING
N3 ADDRESS S 2010C 1
SUBSCRIBER CITY,
N4 STATE, ZIP S 2010C 1

CODE
AAA SUBSCRIBER S 2010C 9

REQUEST VALIDATION

RESPONSE CODE
I
DMG SUBSCRIBER S 2010C 1
DEMOGRAPHIC
INFORMATION
QUALIFIER
ETHNICITY

CODE
INS SUBSCRIBER S 2010C 1

RELATIONSHIP
RESPONSE CODE
CODE

CODE

INS08 EMPLOYMENT STATUS ID 2/2 R
CODE

RESPONSE CODE
QUALIFIER


INS17 NUMBER N0 1/9 N/U
HL DEPENDENT LEVEL S 2000D 1
NM1 DEPENDENT NAME R 2010D 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
DEPENDENT
SUPPLEMENTAL
REF IDENTIFICATION S 2010D 3
REFERENCE
REFERENCE
DEPENDENT
N3 ADDRESS S 2010D 1
DEPENDENT CITY,
N4 STATE, ZIP S 2010D 1



CODE
AAA DEPENDENT REQUEST S 2010D 9

VALIDATION

RESPONSE CODE

DMG DEPENDENT S 2010D 1

DEMOGRAPHIC
INFORMATION
QUALIFIER
ETHNICITY

CODE
INS DEPENDENT S 2010D 1

RELATIONSHIP
RESPONSE CODE
CODE

CODE

INS08 EMPLOYMENT STATUS ID 2/2 N/U

CODE

RESPONSE CODE
QUALIFIER


INS17 NUMBER N0 1/9 S
HL PATIENT LEVEL S 2000E 1

PATIENT EVENT
TRN TRACKING NUMBER S 2000E 2
PATIENT EVENT
AAA REQUEST VALIDATION S 2000E 9
RESPONSE CODE
HEALTH CARE
SERVICES REVIEW
UM INFORMATION R 2000E 1
UM01 REQUEST CATEGORY CODE ID 1/2 R
UM02 CERTIFICATION TYPE CODE ID 1/1 R
UM03 SERVICE TYPE CODE ID 1/2 S

HEALTH CARE SERVICE

RELATED CAUSES
UM06 LEVEL OF SERVICE CODE ID 1/3 S

CURRENT HEALTH
HEALTH CARE
HCR SERVICES REVIEW S 2000E 1
HCR01 ACTION CODE ID 1/2 R
REFERENCE
HCR02 IDENTIFICATION AN 1/50 S
HCR03 INDUSTRY CODE AN 1/30 S
YES/NO CONDITION OR
HCR04 RESPONSE CODE ID 1/1 S
ADMINISTRATIVE
REFERENCE
REFERENCE
PREVIOUS REVIEW
ADMINISTRATIVE
REFERENCE
REFERENCE
DTP ACCIDENT DATE S 2000E 1

LAST MENSTRUAL
DTP PERIOD DATE S 2000E 1
ESTIMATED DATE OF
DTP BIRTH S 2000E 1
DTP EVENT DATE S 2000E 1

DTP ADMISSION DATE S 2000E 1

DTP DISCHARGE DATE S 2000E 1

CERTIFICATION ISSUE
DTP DATE S 2000E 1
CERTIFICATION
DTP EXPIRATION DATE S 2000E 1
CERTIFICATION
DTP EFFECTIVE DATE S 2000E 1
HI PATIENT DIAGNOSIS S 2000E 1

HEALTH CARE CODE
HI01 INFORMATION R

YES/NO CONDITION OR
HEALTH CARE CODE
HI02 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI03 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI04 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI05 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI06 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI07 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI08 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI09 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI10 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI11 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI12 INFORMATION S

YES/NO CONDITION OR
HSD HEALTH CARE R 2000E 1

SERVICES DELIVERY
MEASUREMENT CODE
MODULUS


TIME CODE
CL1 INSTITUTIONAL CLAIM S 2000E 1

CODE
CL101 ADMISSION TYPE CODE ID 1/1 S
CL102 ADMISSION SOURCE CODE ID 1/1 S
CL103 PATIENT STATUS CODE ID 1/1 S

CL104 NURSING HOME ID 1/1 N/U
AMBULANCE
TRANSPORT
UNIT OR BASIS FOR
CR101 MEASUREMENT CODE ID 2/2 N/U
CR102 WEIGHT R 1/10 N/U
AMBULANCE TRANSPORT
CR103 CODE ID 1/1 R
AMBULANCE TRANSPORT
CR104 REASON CODE ID 1/1 N/U
UNIT OR BASIS FOR

CR109 DESCRIPTION AN 1/80 N/U
S 2000E 1
SPINAL
MANIPULATION
SERVICE
CR2 INFORMATION
S
CR201 COUNT NO 1/9
S
S
S
UNIT OR BASIS FOR N/U
CR205 MEASUREMENT CODE ID 2/2
N/U
N/U
NATURE OF CONDITION N/U
CR208 CODE ID 1/1
YES/NO CONDITION OR N/U
N/U
N/U
YES/NO CONDITION OR N/U
HOME OXYGEN
THERAPY
CR501 CERTIFICATION TYPE CODE ID 1/1 N/U

CR503 CODE ID 1/1 S
CR504 CODE ID 1/1 S
CR506 QUANTITY R 1/15 R
OXYGEN TEST CONDITION
CR512 CODE ID 1/1 N/U
OXYGEN DELIVERY SYSTEM
CR517 CODE ID 1/1 R
CR518 CODE ID 1/1 S
HOME HEALTH CARE
CR601 PROGNOSIS CODE ID 1/1 R
CR602 DATE DT 8/8 R
YES/NO CONDITION OR
CR606 RESPONSE CODE ID 1/1 N/U
YES/NO CONDITION OR
CR607 RESPONSE CODE ID 1/1 R
CR608 CERTIFICATION TYPE CODE ID 1/1 R
PRODUCT/SERVICE ID
CR610 QUALIFIER ID 2/2 N/U
CR611 MEDICAL CODE VALUE AN 1/15 N/U
CR615 QUALIFIER ID 2/3 N/U
CR616 DATE TIME PERIOD AN 1/35 N/U
CR617 PATIENT LOCATION CODE ID 1/1 N/U

N/U
CR618 DATE DT 8/8
N/U
CR619 DATE DT 8/8
N/U
CR620 DATE DT 8/8
N/U
CR621 DATE DT 8/8
ADDITIONAL PATIENT
PWK INFORMATION S 2000E 10
ATTACHMENT REPORT
PWK01 TYPE CODE ID 2/2 R
REPORT TRANSMISSION
PWK02 CODE ID 1/2 R

IDENTIFICATION CODE
ATTACHMENT CODTROL
PWK06 NUMBER AN 2/80 S
ATTACHYMENT
PWK08
PWK09
MSG MESSAGE TEXT S 2000E 1

MSG02 CONTROL CODE
NUMBER N0 1/9 N/U
MSG03
PATIENT EVENT
NM1 PROVIDER NAME S 2010EA 1

NAME LAST OR
IDENTIFICATION CODE
NM108 QUALIFIER ID 1/2 S
CODE
ORGANIZATION NAME
PATIENT EVENT
PROVIDER
SUPPLEMENTAL
REF INFORMATION S 2010EA 7
REFERENCE
REFERENCE
REF03 DESCRIPTION AN 1/80 S
PATIENT EVENT
N3 PROVIDER ADDRESS S 2010EA 1
PATIENT EVENT
PROVIDER CITY,
N4 STATE, ZIP S 2010EA 1

CODE
PROVIDER CONTACT

REFERENCE
AAA PATIENT EVENT S 2010EA 9

PROVIDER REQUEST
VALIDATION
RESPONSE CODE
I
PATIENT EVENT
PROVIDER

REFERENCE
REFERENCE
PRV03 IDENTIFICATION AN 1/50 R
INFORMATION
CODE
PATIENT EVENT
NM1 PROVIDER NAME S 2010EB 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
PATIENT EVENT
TRANSPORT
N3 LOCATION ADDRESS S 2010EB 1
PATIENT EVENT
TRANSPORT
LOCATION CITY,
N4 STATE, ZIP S 2010EB 1

CODE
PER ADDITIONAL PATIENT S 2010EB 1

INFORMATION
CONTACT
INFORMATION




REFERENCE
PATIENT EVENT
NM1 OTHER UMO NAME S 2010EB 5

NAME LAST OR
NM103 ORGANIZATION NAME AN 1/60 R
NM104 NAME FIRST AN 1/35 N/U
NM105 NAME MIDDLE AN 1/25 N/U
NM107 NAME SUFFIX AN 1/10 N/U
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
N3 PATIENT EVENT R 2010EC 1

TRANSPORT
LOCATION ADDRESS
N4 PATIENT EVENT R 2010EC 1

TRANSPORT
LOCATION
CITY/STATE/ZIP CODE
N401 CITY NAME AN 2/30 S

N404 COUNTRY CODE ID 2/3 N/U
N407 COUNTRY SUBDIVISION ID 1/3 N/U
CODE
AAA PATIENT EVENT S 2010EC 9
TRANSPORT
LOCATION REQUEST
VALIDATION
RESPONSE CODE

HL SERVICE LEVEL S 2000F 1
SERVICE TRACE
TRN NUMBER S 2000F 2
SERVICE REQUEST
AAA VALIDATION S 2000F 9
RESPONSE CODE
I AAA03 REJECT REASON CODE ID 2/2 R
HEALTH CARE
SERVICES REVIEW
UM INFORMATION S 2000F 1
UM01 REQUEST CATEGORY CODE ID 1/2 R

HEALTH CARE SERVICE
RELATED CAUSES
UM06 LEVEL OF SERVICE CODE ID 1/3 N/U

CURRENT HEALTH
HEALTH CARE
HCR SERVICES REVIEW S 2000F 1
HCR01 ACTION CODE ID 1/2 R
REFERENCE
HCR02 IDENTIFICATION AN 1/50 S
HCR03 INDUSTRY CODE AN 1/30 S
YES/NO CONDITION OR
HCR04 RESPONSE CODE ID 1/1 S
ADMINISTRATIVE
REFERENCE
REFERENCE
PREVIOUS REVIEW
AUTHORIZATION
REF NUMBER S 2000F 1
REFERENCE
REFERENCE
DTP SERVICE DATE S 2000F 1

CERTIFICATION ISSUE
DTP DATE S 2000F 1
CERTIFICATION
DTP EXPIRATION DATE S 2000F 1
CERTIFICATION
DTP EFFECTIVE DATE S 2000F 1
REQUEST FOR
ADDITIONAL
HI INFORMATION S 2000F 1
HEALTH CARE CODE
HI01 INFORMATION R

HI01-3 QUALIFIER ID 2/3 N/U
HI01-4 DATE TIME PERIOD AN 1/35 N/U
YES/NO CONDITION OR
HEALTH CARE CODE
HI02 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI03 INFORMATION

YES/NO CONDITION OR
HEALTH CARE CODE
HI04 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI05 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI06 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI07 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI08 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI09 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI10 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI11 INFORMATION S

YES/NO CONDITION OR
HEALTH CARE CODE
HI12 INFORMATION S

YES/NO CONDITION OR
SV1 PROFESSIONAL S 2000F 1

SERVICE
QUALIFIER
MEARUREMENT CODE
SV104 QUALITY R 1/15 S
SV105 FACILITY CODE AN 1/2 N/U
SV106 SERVICE TYPE CODE ID 1/2 N/U
CODE POIONTER
RESPONSE CODE
SV110 MULTIPLE PROCEDURE ID 1/2 N/U
CODE
SV111 YES/NO CONDITION OR ID 1/1 S
RESPONSE CODE
RESPONSE CODE
SV113 REVIEW CODE ID 1/2 N/U
SV114 NATIONAL OR LOCAL AN 1/2 N/U
ASSIGNED REVIEW VALUE
SV116 HEALTH CARE ID 1/1 N/U
PROFESSIONAL SHORTAGE
AREA CODE
SV117 REFERENCE AN 1/50 N/U
IDENTIFICATION
SV118 POSTAL CODE ID 3/15 N/U
CODE
SV2 INSTITUTIONAL S 2000F 1

SERVICE LINE
SV201 PRODUCT/SERVICE ID AN 1/48 S
SV202 COMPOSITE MEDICAL S
PROCEDURE
QUALIFIER
MEASUREMENT CODE
SV205 QUANTITY R 1/15 S
SV206 UNIT RATE R 1/10 S
RESPONSE CODE
SV209 NURSING HOME ID 1/1 N/U

SV3 DENTAL SERVICE S 2000F 1
QUALIFIER
SV303 FACILITY CODE VALUE AN 1/2 N/U
SV304 ORAL CAVITY DESIGNATION S
SV304-1 ORAL CAVITY DESIGNATION ID 1/3 R

CODE
CODE
CODE
CODE
CODE
SV305 PROSTHESIS, CROWN OR ID 1/1 S
INLAY CODE
SV306 QUANTITY R 1/15 R
SV307 DESCRIPTION AN 1/80 N/U
CODE
RESPONSE CODE
CODE POINTER
TOO TOOTH INFORMATION S 2000F 32
TOO01 CODE LIST QUALIFIER CODE ID 1/3 R
TOO02 INDUSTRY CODE AN 1/30 R

TOO03-1 TOOTH SURFACE CODE ID 1/2 R
HSD HEALTH CARE S 2000F 1

SERVICES DELIVERY
MEASUREMENT CODE
MODULUS


TIME CODE
ADDITIONAL SERVICE
PWK INFORMATION S 2000F 10
PWK01 REPORT TYPE CODE ID 2/2 R
REPORT TRANSMISSION
PWK02 CODE ID 1/2 R

IDENTIFICATION CODE
IDENTIFICATION CODE
PWK06 QUALIFIER AN 2/80 S
ATTACHYMENT
PWK08
PWK09
MSG MESSAGE TEXT S 2000F 1

MSG02 CONTROL CODE
NUMBER N0 1/9 N/U
MSG03
NM1 SERVICE PROVIDER NAME S 2010FA 10

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
SERVICE PROVIDER
SUPPLEMENTAL
REF IDENTIFICATION S 2010FA 8
REFERENCE
REFERENCE
REF03 DESCRIPTION AN 1/80 S
SERVICE PROVIDER
N3 ADDRESS S 2010FA 1
SERVICE PROVIDER
N4 CITY, STATE, ZIP S 2010FA 1

CODE
SERVICE PROVIDER
CONTACT
PER INFORMATION S 2010FA 1




REFERENCE
SERVICE PROVIDER
AAA REQUEST VALIDATION S 2000F 9
RESPONSE CODE
SERVICE PROVIDER
PRV INFORMATION S 2010FA 1
REFERENCE
PRV02 IDENTIFICATION QUALIFIER ID 2/3 R
REFERENCE
PRV03 IDENTIFICATION AN 1/50 R

INFORMATION
CODE
NM1 SERVICE PROVIDER NAME S 2010FB 1

NAME LAST OR
IDENTIFICATION CODE
CODE

ORGANIZATION NAME
ADDITIONAL SERVICE
INFORMATION
N3 CONTACT ADDRESS S 2010FB 1
ADDITIONAL SERVICE
INFORMATION
CONTACT CITY,
N4 STATE, ZIP S 2010FB 1

CODE
ADDITIONAL SERVICE
INFORMATION
CONTACT
PER INFORMATION S 2010FB 1




REFERENCE
TRANSACTION SET
SE TRAILER R 1
NUMBER OF INCLUDED
SE01 SEGMENTS NO 1/10
TRANSACTION SET
SE02 CONTROL NUMBER AN 4/9
ESPONSE
Values
278
0007
11
18,19,AT,RU
0,1
N,Y
04,41,42,79
C,N,P,Y
2B,36,PR,X3
1,2
24,34,46,PI,XV
IC
EM,FX,TE,UR
EM,FX,TE,UR
EM,EX,FX,TE,UR
42,79,80,T4
N,P,Y
21
0,1
1P,FA
1,2
24,34,46,XX
1G,1J,EI,G5,N5,N7,SY,ZH
15,35,41,43,44,45,46,47,49,51,
79,97
C,N,R
AD,AS,AT,CO,CV,OP,OR,OT,P
C,PE,RF
PXC
22
0,1
IL
1
II,MI
1L,3L,6P,DP,EJ,F6,HJ,IG,N6,N
Q,SY
N
58,64,65,66,67,68,71,72,73,74,
75,76,77,78,79,95
C,N
D8
F,M,U
Y
18
AO,AU,DI,PV,RU
23
0,1
QC
1
II,MI
EJ,SY
15,33,58,64,65,66,67,68,71,77,
95
C,N
D8
F,M,U
01,19,G8
EV
0,1
15,33,52,56,57,60,61,62,AA,AF
,AH,AI,AJ,AK,AM,AN,T5
C,N
1,2,3,4,5,6,7,8,11,12,14,15,16,1
7,18,20,21,23,24,25,26,27,28,3
3,35,36,37,38,39,40,42,44,45,4
6,54,56,61,62,63,64,65,66,67,6
8,69,70,71,72,73,74,75,76,77,7
AR,HS,IN,SC
8,79,80,82,83,84,85,86,87,88,9
3,A4,A6,A9,AD,AE,AF,AG,AI,A
J,AK,AL,AR,B1,BB,BC,BD,BE,
1,2,3,4,I,N,R,S
BF,BG,GL,BN,BP,BQ,BS,BY,B
Z,C1,CQ,GY,IC,MH,NI,ON,PT,
PU,RN,RT,TC,TN
A,B
03,E,U
A1,A2,A3,A4,A6,C,CT,NA
N,Y
NT
BB
439
D8 (CCYYMMDD)
484
D8 (CCYYMMDD)
ABC
D8 (CCYYMMDD)
AAH
D8, RD8
435
D8, RD8
096
D8 (CCYYMMDD)
102
D8 (CCYYMMDD)
036
D8 (CCYYMMDD)
007
RD8, D8
ABF,ABJ,ABK,APR,BF,BJ,BK,
DR,PR,LOI
D8 (CCYYMMDD)
ABF,ABJ,ABK,APR,BF,BJ,DR,
LOI,PR
D8 (CCYYMMDD)
ABF,APR,BF,DR,LOI,PR
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
D8 (CCYYMMDD)
DY,FL,HS,MN,VS
DA,MO,WK
6,7,21,26,27,34,35
1,2,3,4,5,6,7,8,9,A,B,C,D,E,F,G
,H,J,K,L,M,M,N,O,P,Q,R,S,SA,
SA,SB,SC,SD,SG,SL,SP,SX,S
Y,SZ,T,U,V,W,WE,X,Y
A,B,C,D,E,F,G,Y
I,R,T,X
DH = MILES
DK = KILOMETERS
SE TR3 FOR CODES
SE TR3 FOR CODES
A,B,C,D,E,O
A,B,C,D,E,O
A,B,C,D,E
A,B,C,D,E,O
1,2,3,4,5,6,7,8
RD8
1,2,3,4,6,I,R,S
SEE TR3 FOR CODES
BM,EL,EM,FX,VO
AC
SEE TR3 FOR CODES
1,2
24,34,46,XX
OB,1G,1J,EI,N5,N7,SY,ZH
IC
EM,FX,TE,UR
EM,EX,FX,TE,UR
EM,EX,FX,TE,UR
15,33,35,41,43,44,45,46,47,49,
51,52,79,97,IP
C,N
AD,AS,AT,OP,OR,OT,PC,PE,R
F
PXC
L5
1,2
IC
EM,FX,TE,UR
EM,EX,FX,TE
EM,EX,FX,TE
45,FS,ND,PW,R3
2
N
15,33,47,97
C,N
SS
1,2
15,33,52,57,60,61,62,AA,AG,T5
C,N
HS,SC
1,2,3,4,I,N,R,S
SEE TR3 FOR CODES
A,B
A1,A2,A3,A4,A6,C,CT,NA
N,Y
NT
BB
472
D8, RD8
102
D8
036
D8
007
RD8,D8
LOI
LOI
LOI
LOI
LOI
LOI
LOI
LOI
LOI
LOI
LOI
LOI
HC,IV,N4,WK
F2,MJ,UN
N,Y
1,2,3,4,5,6,7,8
HC,ID,IV,N4,WK,ZZ
DA,F2,UN
1,2,3,4,5,6,7,8
AD
I,R
JP
B,D,F,I,L,M,O
B,D,F,I,L,M,O
B,D,F,I,L,M,O
B,D,F,I,L,M,O
B,D,F,I,L,M,O
DY,FL,HS,MN,VS
DA,MO,WK
6,7,21,26,27,29,34,35
1,2,3,4,5,6,7,8,9,A,B,C,D,E,F,G
,H,J,K,L,M,M,N,O,P,Q,R,S,SA,
SA,SB,SC,SD,SG,SL,SP,SX,S
Y,SZ,T,U,V,W,X,Y
A,B,C,D,E,F,G,Y
SEE TR3 FOR CODES
BM,EL,EM,FX,VO
AC
72,73,77,DD,DK,DQ,FA,G3,P3,
QB,QV,SJ
1,2
24,34,46,XX
0B,1G,1J,EI,G5,N5,N7,SY,ZH
IC
EM,FX,TE,UR
EM,EX,FX,TE,UR
EM,EX,TE,UR
15,33,35,41,43,44,45,46,47,49,
51,52,79,97,IP
C,N
AS,OP,OR,OT,PC,PE
PXC
LS
1,2
24,34,46,PI,XV,XX
IC
EM,FX,TE,UR
EM,EX,FX,TE,UR
EM,EX,FX,TE,UR
4010A1 820 Premium Payment 5010
Element Description ID Min. Max. Usage Loop Loop Values Element
Identifier Reg. Repeat Identifier
ISA INTERCHANGE 1 R 1 ISA

CONTROL
HEADER
1 ISA01 Authorization ID 2-2 R 00, 03 ISA01
Information
Qualifier
2 ISA02 Authorization AN 10 - 10 R ISA02
Information
3 ISA03 Security ID 2-2 R 00, 01 ISA03
Information
Qualifier
4 ISA04 Security AN 10 - 10 R ISA04
Information
5 ISA05 Interchange ID ID 2-2 R 01, 14, 20, 27, 28, 29, ISA05
Qualifier 30, 33, ZZ
6 ISA06 Interchange AN 15-15 R ISA06
Sender ID
7 ISA07 Interchange ID ID 2-2 R 01, 14, 20, 27, 28, 29, ISA07
Qualifier 30, 33, ZZ
8 ISA08 Interchange AN 15-15 R ISA08
Receiver ID
9 ISA09 Interchange Date DT 6-6 R YYMMDD ISA09
10 ISA10 Interchange Time TM 4-4 R HHMM ISA10
11 1 ISA11 Interchange ID 1-1 R U ISA11

Control
Standards ID
12 1 ISA12 Interchange ID 5-5 R 401 ISA12

Control Version
Number
13 ISA13 Interchange N0 9-9 R ISA13
Control Number
14 ISA14 Acknowledgemen ID 1-1 R 0, 1 ISA14
t Requested
15 ISA15 Usage Indicator ID 1-1 R P, T ISA15
16 ISA16 Component AN 1-1 R ISA16
Element
Separator
IEA INTERCHANGE R IEA

CONTROL
TRAILER
IEA01 Number of N0 1-5 R IEA01

Included
Functional
Groups
IEA02 Number of N1 1-9 R IEA02

Included
Functional
Groups
GS FUNCTIONAL 1 R >1 GS
GROUP
HEADER
17 GS01 Functional ID 2-2 R HN GS01
Identifier Code
18 GS02 Application AN 2 - 15 R GS02
Sender Code
19 GS03 Application AN 2 - 15 R GS03
Receiver Code
20 GS04 Date DT 8-8 R CCYYMMDD GS04
21 GS05 Time TM 4-8 R HHMMSSDD GS05
22 GS06 Group Control N0 1-9 R GS06
Number
23 GS07 Responsible ID 1-2 R X GS07
Agency Code
24 1 GS08 Version Identifier AN 1 - 12 R 004010X093A1 GS08
Code
GE FUNCTIONAL R GE
GROUP
TRAILER
GE01 Number of N0 1-6 R GE01
Transaction Sets
Included
GE02 Group Control N0 9-Jan R GE02
Number
ST 820 Header ST
R 1
5 ST01 Transaction Set
Identifier Code
ID 3/3 R 820 ST01
6 ST02 Transaction Set
Control Number
AN 4/9 R ST02
ST03
BPR Financial BPR

Information R 1
7 BPR01 Transaction
Handling Code ID 1/2 R C, D, I, P, U, X BPR01
8 BPR02 Monetary Amount
R 1/18 R BPR02
9 BPR03 Credit/Debit Flag
Code ID 1/1 R C, D BPR03
10 BPR04 Payment Method
Code
ACH, BOP, CHK,

ID 3/3 R FWT, SWT BPR04
11 BPR05 Payment Format
Code ID 1/10 S CCP, CTX BPR05
12 BPR06 (DFI) ID Number
Qualifier ID 2/2 S 01, 04 BPR06
13 BPR07 (DFI)
Identification
Number
AN 3/12 S BPR07
14 BPR08 Account Number
Qualifier
ID 1/3 S ALC, DA BPR08
AN 1/35 S BPR09
16 BPR10 Originating
Company
Identifier
AN 10/10 S BPR10
17 BPR11 Originating
Company
Supplemental
Code
AN 9/9 S BPR11
Qualifier ID 2/2 S 01, 04 BPR12
19 BPR13 (DFI)
Identification
Number
AN 3/12 S BPR13
Qualifier
ID 1/3 S DA, SG BPR14
AN 1/35 S BPR15
22 BPR16 Date
(CCYYMMDD) DT 8/8 R BPR16
23 BPR17 Business
Function Code ID 1/3 N/U BPR17
Qualifier ID 2/2 N/U BPR18
25 BPR19 (DFI)
Identification
Number
AN 3/12 N/U BPR19
Qualifier
ID 1/3 N/U BPR20
AN 1/35 N/U BPR21
TRN Reassociation TRN

Key R 1
28 1 TRN01 Trace Type Code
ID 1/2 R 1, 3 TRN01
29 1 TRN02 Reference
Identification AN 1/30 R TRN02
30 TRN03 Originating
Company
Identifier
AN 10/10 S TRN03
31 TRN04 Reference
Identification AN 1/30 S TRN04
CUR Non-US Dollars

Currency
S 1 CUR
32 CUR01 Entity Identifier
Code ID 2/3 R 2B, PR CUR01
33 CUR02 Currency Code
ID 3/3 R MXP, CAD, USD CUR02

34 CUR03 Exchange Rate
R 4/10 S CUR03
35 CUR04 Entity Identifier
Code ID 2/3 N/U CUR04
36 CUR05 Currency Code
ID 3/3 N/U CUR05
37 CUR06 Currency
Market/Exchange
Code
ID 3/3 N/U CUR06
38 CUR07 Date/Time
Qualifier ID 3/3 N/U CUR07
39 CUR08 Date
DT 8/8 N/U CUR08
40 CUR09 Time
TM 4/8 N/U CUR09
41 CUR10 Date/Time
42 CUR11 Date
DT 8/8 N/U CUR11
43 CUR12 Time
TM 4/8 N/U CUR12
44 CUR13 Date/Time
45 CUR14 Date
DT 8/8 N/U CUR14
46 CUR15 Time
TM 4/8 N/U CUR15
47 CUR16 Date/Time
48 CUR17 Date
DT 8/8 N/U CUR17
49 CUR18 Time
TM 4/8 N/U CUR18
50 CUR19 Date/Time
51 CUR20 Date
DT 8/8 N/U CUR20
52 CUR21 Time
TM 4/8 N/U CUR21
REF Premium
Receivers
Identification
Key
S >1 REF
53 REF01 Reference
Identification
Qualifier
ID 2/3 R 14, 18, 2F, 38, 72 REF01
54 REF02 Reference
Identification AN 1/30 R REF02
55 REF03 Description
AN 1/80 N/U REF03
56 REF04 Reference
Identifier N/U REF04
DTM Process Date

S 1 DTM
57 DTM01 Date/Time
Qualifier ID 3/3 R 009 DTM01
58 DTM02 Date
DT 8/8 R DTM02
59 DTM03 Time
TM 4/8 N/U DTM03
60 DTM04 Time Code
ID 2/2 N/U DTM04
61 DTM05 Date Time Period
Format Qualifier
ID 2/3 N/U DTM05
AN 1/35 N/U DTM06
DTM Delivery Date

S 1 DTM
63 DTM01 Date/Time
64 DTM02 Date
DT 8/8 R DTM02
65 DTM03 Time
TM 4/8 N/U DTM03
66 DTM04 Time Code
ID 2/2 N/U DTM04
Format Qualifier
ID 2/3 N/U DTM05
AN 1/35 N/U DTM06
DTM Coverage
Period S 1 DTM
69 DTM01 Date/Time
70 DTM02 Date
DT 8/8 N/U DTM02
71 DTM03 Time
TM 4/8 N/U DTM03
72 DTM04 Time Code
ID 2/2 N/U DTM04
Format Qualifier
ID 2/3 R RD8 DTM05
AN 1/35 R DTM06
DTM
DTM01
DTM02
DTM03
DTM04
DTM05
DTM06
1000A
PREMIUM
RECEIVER’S
NAME
1000A 1
N1 Premium
Receiver’s
Name
R 1000A 1 N1
75 N101 Entity Identifier
Code ID 2/3 R PE N101
76 N102 Name
AN 1/60 S N102
77 N103 Identification
Code Qualifier ID 1/2 S 1, 9, EQ, FI, XV N103
Code AN 2/80 S N104
79 N105 Entity
Relationship
Code
ID 2/2 N/U N105
80 N106 Entity Identifier N106
Code ID 2/3
N2 Premium
Receiver
Additional
Name
S 1000A 1 N2
81 N201 Name
AN 1/60 R N201
82 N202 Name
AN 1/60 N/U N202
N3 Premium
Receiver’s
Address
S 1 N3
83 N301 Address
Information AN 1/55 R N301
84 N302 Address
Information AN 1/55 S N302
3 N4 Premium
Receiver’s City,
State, Zip
S 1000A 1 N4
4 N401 City Name
AN 2/30 R N401
5 N402 State or Province
Code ID 2/2 R N402
6 N403 Postal Code
ID 3/15 R N403
7 N404 Country Code
ID 2/3 S N404
8 N405 Location Qualifier
ID 1/2 N/U N405
9 N406 Location Identifier
AN 1/30 N/U N406
N407
100 1000B Premium

Payer’s
Administrative
Contact
RDM
RDM01
RDM02
RDM03
RDM04
RDM05
1000B
PREMIUM
PAYER’S NAME
R 1000B 1
101 N1 Premium Payer’s
Name R 1000B 1 N1
102 N101 Entity Identifier
Code ID 2/3 R PR N101
103 N102 Name
AN 1/60 S N102N103
104 N103 Identification N103
Code Qualifier ID 1/2 S 1, 9, 24, 75, EQ, FI, PI
Code AN 2/80 S N104
106 N105 Entity
Relationship
Code
ID 2/2 N/U N105
107 N106 Entity
Relationship
Code
ID 2/3 N/U N106
N2 Premium Payer
Additional
Name
S 1000B 1 N2
108 N201 Name
AN 1/60 R N201
109 N202 Name
AN 1/60 N/U N202
N3 Premium
Payer’s Address
S 1000B 1 N3
110 N301 Address
Information AN 1/55 R N301
111 N302 Address
Information AN 1/55 S N302
N4 Premium
Payer’s City,
State, Zip
S 1000B 1 N4
112 N401 City Name N401
AN 2/30 R
113 N402 State or Province
Code ID 2/2 R N402
114 N403 Postal Code
ID 3/15 R N403
115 N404 Country Code
ID 2/3 S N404
116 N405 Location Qualifier
ID 1/2 N/U N405
117 Location Identifier
N406 AN 1/30 N/U N406
N407
PER Premium
Payer’s
Administrative
Contact
S 1000B >1 PER
PER01 Contact Function
Code ID 2/2 R IC PER01
PER02 Name PER02
AN 1/60 R
PER03 Communication PER03
Number Qualifier
ID 2/2 S EM, FX, TE
PER04 Communication Communic
Number ation
Number
AN 1/80 S
PER05 Communication
Number Qualifier
ID 2/2 S EM, EX, FX, TE PER05
PER06 Communication
Number AN 1/80 S PER06
PER07 Communication
Number Qualifier
ID 2/2 S EM, EX, FX, TE PER07
PER08 Communication
Number AN 1/80 S PER08
PER09 Contact Inquiry
Reference AN 1/20 N/U PER09
N1
N101
N102
N103
N104
N105
N106
N2
N201
N202
N3
N301
N302
N4
N401
N402
N403
N404
N405
N406
N407
PER
PER01
PER02
PER03
PER04
PER05
PER06
PER07
PER08
PER09
2000A
ORGANIZATION
SUMMARY
S 2000A 1
ENT Organization
Summary
Remittance
ENT
ENT01 Assigned ENT01
Number NO 1/6 R
ENT02 Entity Identifier ENT02
Code ID 2/3 R 2L
ENT03 Identification
Code Qualifier ID 1/2 S 1, 9, FI ENT03
ENT04 Identification
Code AN 2/80 S ENT04
Code ID 2/3 N/U
ENT06 Identification ENT06
Code Qualifier ID 1/2 N/U
Code AN 2/80 N/U
ENT08 Reference ENT08
Identification
Qualifier
ID 2/3 N/U
Identification AN 1/30 N/U
ADX
ADX01
ADX02
ADX03
ADX04
2300A
ORGANIZATION
SUMMARY
R 2300A 1
RMR Organization
Summary
Remittance
Detail
R 2300A 1 RMR
RMR01 Reference
Identification
Qualifier
ID 2/3 R 11, 1L, CT, IK RMR01
RMR02 Reference
Identification AN 1/30 R RMR02
RMR03 Payment Action
Code ID 2/2 S PA, PI, PO, PP RMR03
RMR04 Monetary Amount
R 1/18 R RMR04
R 1/18 S RMR05
RMR06 Monetary Amount RMR06
R 1/18 N/U
RMR07 Adjustment RMR07
Reason Code ID 2/2 N/U
R 1/18 N/U
REF
REF01
REF02
REF03
REF04
DTM
DTM01
DTM02
DTM03
DTM04
DTM06
2310A
SUMMARY LINE
ITEM
S 2310A 1
IT1 Summary Line
Item S IT1
IT101 Assigned
Identification AN 1/20 R IT101
IT102 Quantity Invoiced IT102
R 1/10 N/U
IT103 Unit or Basis for IT103
Measurement
Code
ID 2/2 N/U
IT104 Unit Price IT104
R 1/17 N/U
IT105 Basis of Unit IT105
Price Code ID 2/2 N/U
IT106 Product/Service
ID Qualifier ID 2/2 N/U IT106
IT107 Product/Service IT107
ID AN 1/48 N/U
ID Qualifier ID 2/2 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
SAC
SAC01
SAC02
SAC03
SAC04
SAC05
SAC06
SAC07
SAC08
SAC09
SAC10
SAC11
SAC12
SAC13
SAC14
SAC15
SAC16
2315A MEMBER
COUNT
S 2315A >1
SLN Member Count
S SLN
SLN01 Assigned
Identification AN 1/20 R SLN01
SLN02 Assigned
Identification AN 1/20 N/U SLN02
SLN03 Relationship
Code ID 1/1 R O SLN03
SLN04 Quantity
R 1/15 R SLN04
Composite Unit
SLN05 of Measure R SLN05
Unit or Basis for
Measurement
Code
SLN05-1 ID 2/2 R 10, IE, SLN05 - 1

Exponent
SLN05-2 R 1/15 N/U SLN05 - 2
Multiplier
SLN05-3 R 1/10 N/U SLN05 - 3
Unit or Basis for
Measurement
Code
SLN05-4 ID 2/2 N/U SLN05 - 4

Exponent
SLN05-5 R 1/15 N/U SLN05 - 5
Multiplier
SLN05-6 R 1/10 N/U SLN05 - 6
Unit or Basis for
Measurement
Code
SLN05-7 ID 2/2 N/U SLN05 - 7

Exponent
SLN05-8 R 1/15 N/U SLN05 - 8
Multiplier
SLN05-9 R 1/10 N/U SLN05 - 9
Unit or Basis for
Measurement
Code
SLN05-10 ID 2/2/ N/U SLN05 - 10

Exponent
SLN05-11 R 1/15 N/U SLN05 - 11
Multiplier
SLN05-12 R 1/10 N/U SLN05 - 12
Unit or Basis for
Measurement
Code
SLN05-13 ID 2/2 N/U SLN05 - 13

Exponent
SLN05-14 R 1/15 N/U SLN05 - 14
Multiplier
SLN05-15 R 1/10 N/U SLN05 - 15
SLN06 Unit Price SLN06
R 1//17 N/U
SLN07 Basis of Unit SLN07
Price Code ID 2/2 N/U
SLN08 Relationship SLN08
Code ID 1/1 N/U
SLN09 Product/Service SLN09
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
ID AN 1/48 N/U
SLN19 Product/Service
ID Qualifier ID 2/2 N/U SLN19
ID AN 1/48 N/U SLN20
2320A
ORGANIZATION
SUMMARY
REMITTANCE
LEVEL
ADJUSTMENT
S 2320A >1
ADX Organization
Summary
Remittance Level
Adjustment S 1
S ADX
ADX01 Monetary Amount ADX01
R 1/18 R
ADX02 Adjustment 20, 52, 53, AA, H1, ADX02
Reason Code ID 2/2 R H6, IA, J3
ADX03 Reference ADX03
Identification
Qualifier
ID 2/3 N/U
2000B
INDIVIDUAL
REMITTANCE
S 2000B >1
ENT Individual ENT
Remittance S
ENT01 Assigned ENT01
Number NO 1/6 R
Code ID 2/3 R 2J
Code Qualifier ID 1/2 R 34, EI, ZZ
Code AN 2/80 R
Code ID 2/3 N/U
Code Qualifier ID 1/2 N/U
Code AN 2/80 N/U
Identification
Qualifier
ID 2/3 N/U
2100B
INDIVIDUAL
NAME
S 2100B >1
NM1 Individual Name NM1
S
NM101 Entity Identifier NM101
Code ID 2/3 R EY,QE
NM102 Entity Type NM102
Qualifier ID 1/1 R
NM103 Name Last or
Organization
Name
AN 1/35 S NM103
NM104 Name First
AN 1/25 S NM104
NM105 Name Middle
AN 1/25 S NM105
NM106 Name Prefix NM106
AN 1/10 SS
NM107 Name Suffix NM107
AN 1/10
NM108 Identification NM108
Code Qualifier ID 1/2 S 34, EI, N
NM109 Identification NM109
Code AN 2/80 S
NM110 Entity NM110
Relationship
Code
ID 2/2 N/U
Entity Identifier
NM111 Code ID 2/3 N/U NM111
NM112
ADX
ADX01
ADX02
ADX03
ADX04
2300B Individual
Premium
Remittance
Detail
R 2300B 1
RMR Individual S RMR
Premium
Remittance Detail
RMR01 Reference
Identification
Qualifier 11, 9J, AZ, B7, CT,
ID 2/3 R ID, IG, IK, KW RMR01
RMR02 Reference
Identification AN 1/30 R RMR02
RMR03 Payment Action
Code ID 2/2 S PI, PP RMR03
R 1/18 R RMR04
R 1/18 S
R 1/18 N/U
RMR07 Adjustment
Reason Code ID 2/2 N/U RMR07
Monetary Amount
RMR08 R 1/18 N/U RMR08
REF
REF01
REF02
REF03
REF04
DTM Individual
Coverage
Period
S 2300B 1 DTM
DTM01 Date/Time DTM01
Qualifier ID 3/3 R 582
DTM02 Date DTM02
DT 8/8 N/U
DTM03 Time DTM03
TM 4/8 N/U
DTM04 Time Code DTM04
ID 2/2 N/U
DTM05 Date Time Period DTM05
Format Qualifier
ID 2/3 R RD8
DTM06 Date Time Period DTM06
AN 1/35 R
2320B
INDIVIDUAL
PREMIUM
S 2320B 1
ADX Individual ADX
Premium
Adjustment
S
ADX01 Monetary Amount ADX01
R 1/18 R
ADX02 Adjustment 20, 52, 53, AA, AX, ADX02
Reason Code
ID 2/2 R H1, H6,IA,J3
Identification
Qualifier
ID 2/3 N/U
SE 820 Trailer
R 1 SE
SE01 Number of
Included
Segments
NO 1/10 R SE01
SE02 Transaction Set SE02
Control Number
AN 4/9 R
820 Premium Payment
Description ID Min. Usage Loop Loop Values
Max. Reg. Repeat
INTERCHANGE CONTROL 1 R 1
HEADER
Authorization Information ID 2-2 R 00, 03

Qualifier
Authorization Information AN 10 - 10 R
Security Information Qualifier ID 2-2 R 00, 01
Security Information AN 10 - 10 R
Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29,

30, 33, ZZ
Interchange Sender ID AN 15-15 R
Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29,

30, 33, ZZ
Interchange Receiver ID AN 15-15 R
Interchange Date DT 6-6 R YYMMDD
Interchange Time TM 4-4 R HHMM
Repetition Seperator AN 1-1 R
Interchange Control Version ID 5-5 R 501

Number
Interchange Control Number N0 9-9 R
Acknowledgement Requested ID 1-1 R 0, 1
Usage Indicator ID 1-1 R P, T

Component Element Separator AN 1-1 R
INTERCHANGE CONTROL R
TRAILER
Number of Included Functional N0 1-5 R

Groups
Number of Included Functional N1 1-9 R

Groups
FUNCTIONAL GROUP 1 R >1
HEADER
Functional Identifier Code ID 2-2 R HR
Application Sender Code AN 2 - 15 R
Application Receiver Code AN 2 - 15 R
Date DT 8-8 R CCYYMMDD

Time TM 4-8 R HHMMSSDD
Group Control Number N0 1-9 R
Responsible Agency Code ID 1-2 R X
Version Identifier Code AN 1 - 12 R 005010X212
FUNCTIONAL GROUP R
TRAILER
Number of Transaction Sets N0 1-6 R

Included
Group Control Number N0 9-Jan R
820 Header
R 1
Transaction Set Identifier Code
ID 3/3 R 820
Transaction Set Control
Number
AN 4/9 R
Implementation Convention
Reference AN 1/35 R
Financial Information
R 1
Transaction Handling Code
ID 1/2 R C, D, I, P, U, X
Total Premium Payment
Amount R 1/18 R
Credit/Debit Flag Code
ID 1/1 R C
Payment Method Code
ACH, BOP, CHK, FWT,

ID 3/3 R NON, SWT
Payment Format Code
ID 1/10 S CCP, CTX
(DFI) ID Number Qualifier
ID 2/2 S 01, 02, 04
(DFI) Identification Number
AN 3/12 S
Account Number Qualifier
ID 1/3 S ALC, DA
Account Number
AN 1/35 S
Originating Company Identifier
AN 10/10 R
Originating Company
Supplemental Code
AN 9/9 S
ID 2/2 S 01, 02, 04
AN 3/12 S
ID 1/3 S DA, SG
Account Number
AN 1/35 S
Check Issue or EFT Effective
Date DT 8/8 R
Business Function Code
ID 1/3 N/U
ID 2/2 N/U
AN 3/12 N/U
ID 1/3 N/U
Account Number
AN 1/35 N/U
Reassociation Key
R 1
Trace Type Code
ID 1/2 R 1, 3
Reference Identification
AN 1/50 R
Originating Company Identifier
AN 10/10 S
Originating Company
Supplemental Code AN 1/50 S
Foreign Currency Information
S
Entity Identifier Code
ID 2/3 R 2B, PR
Currency Code
ID 3/3 R MXP, CAD

Exchange Rate
R 4/10 N/U
ID 2/3 N/U
Currency Code
ID 3/3 N/U
Currency Market/Exchange
Code
ID 3/3 N/U
Date/Time Qualifier
ID 3/3 N/U
Date
DT 8/8 N/U
Time
TM 4/8 N/U
Date/Time Qualifier
ID 3/3 N/U
Date
DT 8/8 N/U
Time
TM 4/8 N/U
Date/Time Qualifier
ID 3/3 N/U
Date
DT 8/8 N/U
Time
TM 4/8 N/U
Date/Time Qualifier
ID 3/3 N/U
Date
DT 8/8 N/U
Time
TM 4/8 N/U
Date/Time Qualifier
ID 3/3 N/U
Date
DT 8/8 N/U
Time
TM 4/8 N/U
Premium Receivers
Identification Key
S >1
Qualifier
ID 2/3 R 14, 17, 18, 2F, 38, 72, LB
Premium Receiver Reference
Identifier AN 1/50 R
Description
AN 1/80 N/U
Reference Identifier
N/U
Process Date
S 1
Date/Time Qualifier
ID 3/3 R 009
Payer Process Date
DT 8/8 R
Time
TM 4/8 N/U
Time Code
ID 2/2 N/U
Date Time Period Format
Qualifier
ID 2/3 N/U
Date Time Period
AN 1/35 N/U
Delivery Date
S 1
Date/Time Qualifier
ID 3/3 R 035
Date
DT 8/8 R
Time
TM 4/8 N/U
Time Code
ID 2/2 N/U
Qualifier
ID 2/3 N/U
Date Time Period
AN 1/35 N/U
Coverage Period
S 1
Date/Time Qualifier
ID 3/3 R 582
Date
DT 8/8 N/U
Time
TM 4/8 N/U
Time Code
ID 2/2 N/U
Qualifier
ID 2/3 R RD8
Coverage Period
AN 1/35 R
Creation Date
S 1
Date/Time Qualifier
ID 3/3 R 097
Date
DT 8/8 R
Time
TM 4/8 N/U
Time Code
ID 2/2 N/U
Qualifier ID 2/3 N/U
Date Time Period
AN 1/35 N/U
1000A PREMIUM
RECEIVER’S NAME
1000A 1
Premium Receiver’s Name
R 1000A 1
ID 2/3 R PE
Premium Receiver’s Last or
Organization Name AN 1/60 S
Identification Code Qualifier
ID 1/2 S 1, 9, EQ, FI, XV
Premium Receiver’s
Identification Code AN 2/80 S
Entity Relationship Code
ID 2/2 N/U
ID 2/3 N/U
Premium Receiver
Additional Name
S 1000A 1
Name
AN 1/60 R
Name
AN 1/60 N/U
Address
S 1000A 1
Address Information
AN 1/55 R
Address Information
AN 1/55 S
Premium Receiver’s City,

State, and Zip Code
S 1000A 1
City Name
AN 2/30 R
State or Province Code
ID 2/2 S
Postal Code
ID 3/15 S
Country Code
ID 2/3 S
Location Qualifier
ID 1/2 N/U
Location Identifier
AN 1/30 N/U
Country Subdivision Code
ID 1/3 S
Remittance Delivery Method
S 1000A 1
Report Transmission code
ID 1/2 R BM, EM, FT, FX, IA, OL
Name
AN 1/60 S
Communication Number
AN 1/256
N/U
N/U
1000B PREMIUM PAYER’S

NAME
R 1000B 1
Premium Payer’s Name
R 1000B 1
ID 2/3 R PR
Premium Payer Name
AN 1/60 S
ID 1/2 S 1, 9, 24, 75, EQ, FI, PI
Premium Payer Identifier
AN 2/80 S
ID 2/2 N/U
ID 2/3 N/U
Premium Payer Additional

Name
S 1000B 1
Name
AN 1/60 R
Name
AN 1/60 N/U
Premium Payer’s Address
S 1000B 1
Premium Payer Address Line
AN 1/55 R
Premium Payer Address Line
AN 1/55 S
Premium Payer’s City, State,

Zip Code
S 1000B 1
City Name
AN 2/30 R
ID 2/2 S
Postal Code
ID 3/15 S
Country Code
ID 2/3 S
Location Qualifier
ID 1/2 N/U
Location Identifier
AN 1/30 N/U
Country Subdivision Conde
ID 1/3 S
Premium Payer’s
Administrative Contact
S 1000B >1
Contact Function Code
ID 2/2 R IC
Name
AN 1/60 R EM, FX,
Qualifier
ID 2/2 S EM, FX, TE
Communication Number AN 1/256 R

Qualifier
ID 2/2 S EM, EX, FX, TE
AN 1/256 S
Qualifier
ID 2/2 S EM, EX, FX, TE
AN 1/256 S
Contact Inquiry Reference
AN 1/20 N/U
Intermediary Bank
Information S 1000C 14
04, 0B, 8W, AK, BE, BK,
C1, C2, IAT,
ID 2/3 R MJ, RB, Z6, ZB, ZL
Name
AN 1/60 S 31, 57, 94, A3, A4, A6, CF, G, PA
ID 1/2 S
Identification Code
AN 2/80 S
ID 2/2 N/U
ID 2/3 N/U
Intermediary Bank Additional

Name S 1000C 1
Name
AN 1/60 R
Name
AN 1/60 N/U
Intermediary Bank’s Address

S 1000C 1
Address Information
AN 1/55 R
Address Information
AN 1/56 S
Intermediary Bank’s City,

State, Zip Code S 1000C 1
City Name
AN 2/30 R
ID 2/2 S
Postal Code
ID 3/15 S
Country Code
ID 2/3 S
Location Qualifier
ID 1/2 N/U
Location Identifier
AN 1/30 N/U
Country Subdivision Code
AN 1/3 S
Intermediary Bank’s
Administrative Contact S 1000C 1
Contact Function Code
ID 2/2 R IC
Name
AN 1/60 R EM, FX,
Qualifier ID 2/2 R EM, FX, TE
AN 1/256 R
Qualifier ID 2/2 S EM, EX, FX, TE
AN 1/256 S
Qualifier ID 2/2 S EM, EX, FX, TE
AN 1/256 S
Contact Inquiry Reference
AN 1/20 N/U
2000A ORGANIZATION
SUMMARY
S 2000A 1
Organization Summary
Remittance
S
Assigned Number
NO 1/6 R
ID 2/3 R 2L,AG,NH,RGA,UN
ID 1/2 R 1, 9, 24, FI
Identification Code
AN 2/80 R
ID 2/3 N/U
ID 1/2 N/U
Identification Code
AN 2/80 N/U
Qualifier
ID 2/3 N/U
AN 1/50 N/U
Organization Summary 2200a

Remittance Level Adjustment
for Previous Payment
S >1
Premium Payment Adjustment
Amount R 1/18 R
Reason ID 2/2 R 52, 53, 80, 81, 86, BJ, H1, H6, RU, WO, WW
AN 1/50 N/U
2300A ORGANIZATION
SUMMARY
R 2300A 1
Remittance Detail
R 2300A 1
Qualifier
ID 2/3 R 11, 1L, CT, IK
AN 1/50 R
Payment Action Code
ID 2/2 S PA, PI, PO, PP
Detail Premium Payment
Amount R 1/18 R
Billed Premium Amount
R 1/18 S
Monetary Amount
R 1/18 N/U
Adjustment Reason Code
ID 2/2 N/U
Monetary Amount
R 1/18 N/U
Premium Receivers
Identification Key S 2300A >1
Qualifier ID 2/3 R 14, 17, 18, 2F, 38, E9, LB, LU, ZZ
AN 1/50 R
Description
AN 1/80 N/U
N/U
Organizational Coverage
Period S 2300A
Date/Time Qualifier
ID 3/3 R 582, AAG
Date
DT 8/8 S
Time
TM 4/8 N/U
Time Code
ID 2/3 N/U
Date Time Period
AN 1/35 S
2310A SUMMARY LINE ITEM
S 2310A 1
Summary Line Item
S
Assigned Identification
AN 1/20 R
Quantity Invoiced
R 1/15 N/U
Unit or Basis for Measurement
Code
ID 2/2 N/U
Unit Price
R 1/17 N/U
Basis of Unit Price Code
ID 2/2 N/U
Product/Service ID Qualifier
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
2312A LOOP - SERVICE,

PROMOTION, ALLOWANCE,
OR CHARGE INFORMATION
S 2312A 4
Service, Promotion, Allowance,
or Charge Information
S
Allowance or Charge Indicator
ID 1/1 R C
Service, Promotion, Allowance,
or Charge Code ID 4/4 R A172, B680, D940, G740
Agency Qualifier Code
ID 2/2 N/U
Agency Service, Promotion,
Allowance, or Charge Code ID 1/10 N/U
Amount
ID 1/15 R
Allowance/Charge Percent
Percent, Decimal Format
R 1/6 N/U
Rate
R 1/9 N/U
Code ID 2/2 N/U
Quantity
R 1/15 N/U
Quantity
R 1/15 N/U
Allowance or Charge Method of
Handling Code ID 2/2 N/U
AN 1/50 N/U
Option Number
AN 1/20 N/U
Description
AN 1/80 N/U
Language Code
ID 2/3
2315A MEMBER COUNT
S 2315A >1
Member Count
S
Line Item Control Number
AN 1/20 R
Assigned Identification
AN 1/20 N/U
Relationship Code
ID 1/1 R O
Head Count
R 1/15 R
Composite Unit of Measure
R
Code
ID 2/2 R 10, IE,

Exponent
R 1/15 N/U
Multiplier
R 1/10 N/U
Code
ID 2/2 N/U
Exponent
R 1/15 N/U
Multiplier
R 1/10 N/U
Code
ID 2/2 N/U
Exponent
R 1/15 N/U
Multiplier
R 1/10 N/U
Code
ID 2/2/ N/U
Exponent
R 1/15 N/U
Multiplier
R 1/10 N/U
Code
ID 2/2 N/U
Exponent
R 1/15 N/U
Multiplier
R 1/10 N/U
Unit Price
R 1//17 N/U
Basis of Unit Price Code
ID 2/2 N/U
Relationship Code
ID 1/1 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
ID 2/2 N/U
Product/Service ID
AN 1/48 N/U
2320A ORGANIZATION
SUMMARY REMITTANCE
LEVEL ADJUSTMENT FOR
CURRENT PAYMENT
S 2320A >1
Remittance Level Adjustment
for Current Payment
S
Adjustment Amount
R 1/18 R
ID 2/2 R 20, 52, 53, AA, H1, H6, IA, J3
Qualifier
ID 2/3 N/U
AN 1/50 N/U
2000B INDIVIDUAL
REMITTANCE
S 2000B >1
Individual Remittance
S
Assigned Number
NO 1/6 R
ID 2/3 R 2J
ID 1/2 R 34, EI, ZZ
Identification Code
AN 2/80 R
ID 2/3 N/U
ID 1/2 N/U
Identification Code
AN 2/80 N/U
Qualifier
ID 2/3 N/U
AN 1/50 N/U
2100B INDIVIDUAL NAME
S 2100B >1
Individual Name
S
ID 2/3 R DO, EY, IL, QE
Entity Type Qualifier
ID 1/1 R
Name Last or Organization
Name
AN 1/60 S
Name First
AN 1/35 S
Name Middle
AN 1/25 S
Name Prefix
AN 1/10 SS
Name Suffix
AN 1/10
ID 1/2 S 34, EI, N
Identification Code
AN 2/80 S
ID 2/2 N/U
ID 2/3 N/U
Name AN 1/60 N/U
2200B INDIVIDUAL PREMIUM
ADJUSTMENT FOR
PREVIOUS PAYMENT
S 2200B 1
Individual Premium Adjustment
for Previous Payment
S
Amount R 1/18 R
ID 2/2 R 52, 53, 80, 81, 86, BJ, H1, H6, RU, WO
AN 1/50 N/U
R 2300B 1
Individual Premium Remittance S
Detail
Qualifier
11, 9J, AZ, B7, CT, ID,
ID 2/3 R IG, IK, KW
Insurance Remittance
Reference Number AN 1/50 R
Payment Action Code
ID 2/2 N/U PI, PP
Detail Premium Payment
Amount R 1/18 R
Billed Premium Amount
R 1/18 S
Monetary Amount
R 1/18 N/U
ID 2/2 N/U
Monetary Amount
R 1/18 N/U
Reference Information S 2300B >1

Qualifier ID 2/3 R 14, 18, 2F, 38, E9, LU, ZZ
AN 1/50 R
Description
AN 1/80 N/U
N/U
Individual Coverage Period
S 2300B 1
Date/Time Qualifier
ID 3/3 R 582, AAG
Date
DT 8/8 S
Time
TM 4/8 N/U
Time Code
ID 2/2 N/U
Qualifier
ID 2/3 S RD8
Date Time Period
AN 1/35 S

ADJUSTMENT FOR
CURRENT PAYMENT
S 2320B 1
Individual Premium Adjustment
S
Adjustment Amount
R 1/18 R
ID 2/2 R 20, 52, 53, AA, AX, H1,

Qualifier
ID 2/3 N/U
AN 1/50 N/U
Transaction Set Trailer

R 1
Number of Included Segments
NO 1/10 R
Number
AN 4/9 R
4010A1 834 Member Enrollment
Element Description ID Min. Usage Loop
Identifier Max. Reg.
ST Transaction Set Header R

Transaction Set Identifier
ST01 ID 3-3 R N/A
Code
ST02 AN 4-9 R
Number
BGN Beginning Segment R

Transaction Set Purpose
BGN01 ID 2-2 R N/A
Code
BGN02 AN 1-30 R
Code
Transaction Set Creation
BGN03 DT 8-8 R
Date
Transaction Set Creation
BGN04 TM 4-8 R
Time
BGN05 Time Zone Code ID 2-2 S

BGN06 AN 1-30 S
Code
BGN07 Transaction Type Code ID 2-2 N
BGN08 Action Code ID 1-2 R
BGN09 Security Level Code ID 2-2 N
Transaction Set Policy

REF S
Number
REF01 ID 2-3 R
Qualifier
REF02 Master Policy Number AN 1-30 R
REF03 Description AN 1/80 N
REF04 Reference Identifier N
DTP File Effective Date S
DTP01 Date Time Qualifier ID 3-3 R

DTP02 ID 2-3 R
Qualifier
DTP03 Date Time Period AN 1-35 R
N1 Sponsor Name 1000A
N101 Entity Identifier Code ID 2-3 R
N102 Plan Sponsor Name AN 1-60 S
N103 Identification Code Qualifier ID 1-2 R
N104 Sponsor Identifier AN 2-80 R

N105 Entity Relationship Code ID 2-2 N
N106 Entity Identifier Code ID 2-3 N
N1 Payer 1000B
N102 InsurerName AN 1-60 S
N104 Insurer Identification Code AN 2-80 R
N105 Entity Relationship Code ID 2/2 N

N106 Entity Identifier Code ID 2/3 N
N1 TPA/BROKER NAME 1000C

N102 Name AN 1-60 S
N104 Identification Code AN 2-80 R

N105 Entity Relationship Code ID 2/2 N/U
N106 Entity Identifier Code ID 2/3 N/U
TPABroker Account
ACT01 S 1100C
Information
ACT01 Account Number AN 1/35 R
ACT02 Name AN 1/60 N/U
ACT03 Identification Code Qualifier ID 1/2 N/U
ACT04 Identification Code AN 2/80 N/U
ACT05 Account Number Qualifier ID 1/3 N/U
ACT06 Account Number AN 1/35 S

ACT07 Description AN 1/80 N/U
Payment Method Type
ACT08 ID 1/2 N/U
Code
ACT09 Benefit Status Code ID 1/1 N/U
MEMBER LEVEL DETAIL 2000
INS01 Insured Indicator ID 1-1 R
Individual Relationship
INS02 ID 2-2 R
Code
INS03 Maintenance Type Code ID 3-3 R
INS04 Maintenance Reason Code ID 2-3 S
INS05 Benefit Status Code ID 1-1 R

INS06 Medicare Plan Code ID 1-1 S
Consolidated Omnibus
Budget Reconciliation Act
INS07 ID 1-2 S
(COBRA) Qualifying Event
Code
INS08 Employment Status Code ID 2-2 S
INS09 Student Status Code ID 1-1 S
INS10 Handicap Indicator ID 1-1 S

INS11 ID 2-3 S
Qualifier
Insured Individual Death
INS12 AN 1-35 S
Date
INS13 ConfidentialityCode ID 1-1 N
INS14 CityName AN 2-30 N
INS15 State or Province Code ID 2-2 N
INS16 CountryCode ID 2-3 N
INS17 Birth Sequence Number N0 1-9 S
REF Subscriber Identifier R 2000

REF01 ID 2-3 R
Qualifier
REF02 Subscriber Identifier AN 1-30 R
REF03 Description AN 1-80 N
REF Member Policy Number S 2000

REF01 ID 2-3 R
Qualifier
Insured Group or Policy
REF02 AN 1-30 R
Number
Member Supplemental
REF S 2000
Identifier
REF01 ID 2-3 R
Qualifier
Subscriber Supplemental
REF02 AN 1-30 R
Identifier
Member Prior Coverage

Months
REF01 R
Qualifier
Prior Coverage Month
REF02 R
Count
REF03 Description N
DTP Member Level Dates S 2000

DTP02 ID 2-3 R
Qualifier
Status Information Effective
DTP03 AN 1-35 R
Date
NM1 Member Name R 2100A

NM101 Entity Identifier Code ID 2-3 R
NM102 Entity Type Qualifier ID 1-1 R
NM103 Subscriber Last Name AN 1-35 R
NM104 Subscriber First Name AN 1-25 R

NM105 Subscriber Middle Name AN 1-25 S
NM106 Subscriber Name Prefix AN 1-10 S
NM107 Subscriber Name Suffix AN 1-10 S
NM108 Identification Code Qualifier ID 1-2 S
NM109 Subscriber Identifier AN 2-80 S

NM110 Entity Relationship Code ID 2-2 N
NM111 Entity Identifier Code ID 2-3 N
Member Communications
PER S 2100A
Numbers
PER01 Contact Function Code ID 2-2 R

PER02 Name AN 1-60 N
PER03 ID 2-2 R
Qualifier
PER05 ID 2-2 S
Qualifier
PER07 ID 2-2 S
Qualifier
PER09 Contact Inquiry Reference AN 1-20 N
Member Residence Street

N3 S 2100A
Address
N301 Subscriber Address Line AN 1-55 R
N302 Subscriber Address Line AN 1-55 S
Member Residence City,

N4 S 2100A
State, ZIP Code
N401 Subscriber City Name AN 2-30 R
N402 Subscriber State Code ID 2-2 R
Subscriber Postal Zone or
N403 ID 3-15 R
ZIP Code
N404 CountryCode ID 2-3 S
N405 Location Qualifier ID 1-2 S
N406 Location Identification Code AN 1-30 S
ID
DMG Member Demographics S 2100A

DMG01 ID 2-3 R
Qualifier
DMG02 Member Birth Date AN 1-35 R
DMG03 GenderCode ID 1-1 R
DMG04 Marital Status Code ID 1-1 S
DMG05 Race or Ethnicity Code ID 1-1 S
ID
ID
DMG06 Citizen Status Code ID 1-2 S
DMG07 CountryCode ID 2-3 N
DMG08 Basis of Verification Code ID 1-2 N
DMG09 Quantity R 1-15 N

ID
AN
Member Income
ICM S 2100A
ICM01 FrequencyCode ID 1-1 R
ICM02 Wage Amount R 1-18 R

ICM03 Work Hours Count R 1-15 S
ICM04 Location Identification Code AN 1-30 S
ICM05 Salary Grade Code AN 1-5 S

ICM06 CurrencyCode ID 3-3 N
AMT Member Policy Amounts S 2100A
AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Contract Amount R 1-18 R

AMT03 Credit/Debit Flag Code ID 1-1 N
MEMBER HEALTH
HLH S 2100A
INFORMATION
HLH01 Health Related Code ID 1-1 S
HLH02 MemberHeight R 1-8 S
HLH03 Member Weight R 1-10 S
HLH04 Weight R 1-10 N
HLH05 Description AN 1-80 N
Current Health Condition
HLH06 ID 1-1 N
Code
HLH07 Description AN 1-80 N
LUI Member Language S 2100A
LUI01 Identification Code Qualifier ID 1-2 S
LUI02 LanguageCode AN 2-80 S

LUI03 Language Description ID 1-80 S
LUI04 Language Use Indicator ID 1-2 S
Language Proficiency
LUI05 ID 1-1 N
Indicator
NM1 Incorrect Member Name S 2100B

NM103 AN 1-35 R
Name
NM104 Name First AN 1-25 S
NM105 Name Middle AN 1-25 S
NM106 Name Prefix AN 1-10 C
NM107 Name suffix AN 1-10 C
NM109 Identification Code AN 2-80 S

Incorrect Member
DMG S 2100B
Demographics
DMG01 ID 2-3 S
Qualifier
DMG02 Date Time Period AN 1-35 S
DMG03 Gender Code ID 1-1 S
Race or Ethnicity
DMG05-1 ID 1-1 S
Information
DMG05-2 Code List Qualifier Code ID 1-3 S
DMG05-3 Industry Code AN 1-30 S
DMG06 Citizenship Status Code ID 1-2 S

DMG09 Quantity R 1-15 N/U
NM1 Member Mailing Address S 2100C

NM103 AN 1-35 N/U
Name
NM104 Name First AN 1-25 N/U
NM105 Name Middle AN 1-25 N/U
NM106 Name Prefix AN 1-10 N/U
NM107 Name suffix AN 1-10 N/U
NM108 Identification Code Qualifier ID 1-2 N/U
NM109 Identification Code AN 2-80 N/U

Member Mail Street

N3 S 2100C
Address
N301 Address Information AN 1-55 R
N302 Address Information AN 1-55 S
Member Mail City, State,

N4 S 2100C
Zip
N401 City Name AN 2-30 R
N402 State or Province Code AN 2-2 S
N403 Postal Code ID 3-15 S
N406 Location Identifier AN 1-30 N/U
MEMBER EMPLOYER 2100D

NM103 AN 1-35 R
Name
NM106 Name Prefix AN 1-10 S
NM107 Name suffix AN 1-10 S

Member Employer
PER S 2100D
Comunications Numbers

PER02 Name AN 1-60 S
PER03 ID 2-2 R
Qualifier
PER05 ID 2-2 S
Qualifier
PER07 ID 2-2 S
Qualifier
PER09 Contact Inquiry Reference AN 1-20 N/U
Member Employer Street

N3 S 2100D
Adddrsss
Member Employer City,

N4 R 2100D
State, Zip
NM1 Member School S 2100E

NM103 AN 1-35 N/U
Name

Member School
PER Communications S 2100E
Numbers
PER03 ID 2-2 R
Qualifier
PER05 ID 2-2 S
Qualifier
PER07 ID 2-2 S
Qualifier
Member School Street

N3 S 2100E
Address
Member School City,

N4 R 2100E
State, Zip
NM1 Custodial Parent S 2100F

NM103 AN 1-35 N/U
Name

Custodial Parent
PER S 2100F
Comunications Numberx

PER03 ID 2-2 R
Qualifier
PER05 ID 2-2 S
Qualifier
PER07 ID 2-2 S
Qualifier
Custodial Parent Street

N3 S 2100F
Address
Custodial Parent City,

N4 R 2100F
State, Zip
N407 Country Subdivision Code ID 1-3 S
NM01 Responsible Person S 2100G

NM103 AN 1-35 N/U
Name

Responsible Person
PER S 2100G

PER03 ID 2-2 R
Qualifier
PER05 ID 2-2 S
Qualifier
PER07 ID 2-2 S
Qualifier
Responsible Person
N3 S 2100G
Street Address
Responsible Person City,

N4 R 2100G
State, Zip
DSB Disability Information S 2200
DSB01 Disability Type Code ID 1-1 R
DSB02 Quantity ID 1-15 N/U
DSB03 Occupation Code ID 4-6 N/U
DSB04 Work Intensity Code ID 1-1 N/U
DSB05 Product Option Code ID 1-2 N/U
DSB06 Monetary Amount R 1-18 N/U
DSB07 Product/Service ID Qualifier ID 2-2 N/U
DSB08 Medical Code Value AN 1-15 N/U
DTP Disability Eligibility Dates S 2200
DTP01 Date/Time Qualifier ID 3-3 R

DTP02 ID 2-3 R
Qualifier
HD Health Coverage S 2300

HD01 Maintenance Type Code ID 3-3 R
HD02 Maiintenance Reason Code ID 2-3 N/U
HD03 Insurance Line Code ID 2-3 R
HD04 Plan Coverage Description AN 1-50 S
HD05 Coverage Level Code ID 3-3 S
HD06 Count N0 1-9 N/U

HD08 Underwriting Decision Code ID 1-1 N/U
Yes/No condition or
HD09 ID 1-1 S
Response Code
HD10 Drug House Code ID 2-3 N/U
Yes/No condition or
HD11 ID 1-1 N/U
Response Code
DTP Health Coverage Dates R 2300
DTP01 Date/Time Qualifier ID 3-3 R

DTP02 ID 2-3 R
Qualifier
AMT Health Coverage Policy S 2300
AMT02 Monetary Amount R 1-18 R

AMT03 Credit/Debit Flag Code R 1-1 N/U
Health Coverage Policy

REF S 2300
Number
REF01 ID 2-3 R
Qualifier
REF02 Reference Identification AN 1-30 R

REF03 Description AN 1-80 N/U

IDC Identification Card S 2300
IDC01 Plan Coverage Description AN 1-50 R
Identification Card Type

IDC02 ID 1-1 R
Code
IDC03 Identification Card Count R 1-15 S
IDC04 ActionCode ID 1-2 S
PROVIDER INFORMATION 2310
LX01 Assigned Number 1-6 R
NM1 Provider Name R 2310

Provider Last or
NM103 AN 1-35 S
Organization Name
NM104 Provider First Name AN 1-25 S
NM105 Provider Middle Name AN 1/25 S
NM106 Provider Name Prefix AN 1/10 S
NM107 Provider Name Suffix AN 1/10 S
NM108 Identification Code Qualifier ID 1/2 S
NM109 Provider Identifier AN 2/80 S

NM110 Entity Relationship Code ID 2/2 R
NM111 Entity Identifier Code ID 2/3 N
Provider City, State, ZIP

N4 R 2310
Code
N401 Member City Name AN 2/30 R
N402 Member State Code ID 2/2 R
Member Postal Zone or Zip
N403 ID 3-15 R
Code
N404 CountryCode ID 2-3 S
N405 Location Qualifier ID 1-2 S
N406 Location Identification Code AN 1-30 S
Provider Communications
PER S 2310
Numbers

PER02 ContactName AN 1-60 N
PER03 ID 2-2 R
Qualifier
PER05 ID 2-2 S
Qualifier
PER07 ID 2/2 S
Qualifier
PER09 Contact Inquiry Reference AN 1-20 N
PLA Provider Change Reason S 2310
PLA01 ActionCode ID 1-2 R
PLA02 Entity Identifier Code ID 2-3 R

PLA03 Plan Effective Date DT 8-8 R
PLA04 Time TM 4-8 N
PLA05 Maintenance Reason Code ID 2-3 R
COORDINATION OF
COB 2320
BENEFITS
Payer Responsibility
COB01 ID 1-1 R
Sequence Number Code

COD02 AN 1-30 S
Number
Coordination of Benefits
COB03 ID 1-1 R
Code
Additional Coordination
REF S 2320
of Benefits Identifiers
REF01 ID 2-3 R
Qualifier
REF02 AN 1-30 R
Number
Other Insurance Company

N1 2320
Name
N101 Entity Identifier Code R
N102 InsurerName S
N103 Identification Code Qualifier S

N104 S
Number
N105 Entity Relationship Code N
N106 Entity Identifier Code N
DTP S 2320
Eligibility Dates

DTP02 ID 2-3 R
Qualifier
DTP03 AN 1-35 R
Date
SE Transaction Set Trailer R 9999
SE01 Transaction Segment Count N0 1-10 R

SE02 AN 4-9 R
Number
Member Enrollment 5010 834 Member Enrollment
Values Element Description ID Min. Usage Loop
Identifier Max. Reg.
ST Transaction Set Header R

ST01 ID 3-3 R
Code
ST02 AN 4-9 R
Number
Implementation Convention
ST03 AN 1-35 R
Reference
BGN Beginning Segment R

Transaction Set Purpose
00,15,22 BGN01 ID 2-2 R
Code
BGN02 Reference Identification AN 1-50 R
BGN03 Date DT 8-8 R
BGN04 Time TM 4-8 R
01,02,03,04,05,06,07,08,
09,10,11,12,13,14,15,16,
17,18,19,20,21,22,23,24,AD
,AS,AT,CD,CS,CT,ED, BGN05 Time Code ID 2-2 S
ES,ET,GM,HD,HS,HT,LT,
MD,MS,MT,ND,NS,NT,
PD,PS,PT,TD,TS,TT,UT
BGN06 Reference Identification AN 1-50 S
BGN07 Transaction Type Code ID 2/2 N/U

2,4 BGN08 Action Code ID 1-2 R
BGN09 Security Level Code ID 2/2 N/U
Transaction Set Policy

REF S
Number
38 REF01 ID 2-3 R
Qualifier
REF03 Description AN 1/80 N/U
DTP File Effective Date S
007,303,382,388 DTP01 Date/Time Qualifier ID 3-3 R

D8 DTP02 ID 2-3 R
Qualifier
QTY S
Totals
QTY01 Quantity Qualifier ID 2-2 R
QTY02 Quantity R 1-15 R
QTY03 Composite Unit of Measure N/U
QTY04 Free-form Information AN 1/30 N/U
N1 Sponsor Name R 1000A

P5 N101 Entity Identifier Code ID 2-3 R
N102 Name AN 1-60 S
FI,ZZ N103 Identification Code Qualifier ID 1-2 R

N1 Payer R 1000B
IN N101 Entity Identifier Code ID 2-3 R
N102 Name AN 1-60 S
FI,XV N103 Identification Code Qualifier ID 1-2 R

N1 TPA/Broker Name R 1000C

BO,TV N101 Entity Identifier Code ID 2-3 R
N102 Name AN 1-60 S
94,FI,XV N103 Identification Code Qualifier ID 1-2 R

TPABroker Account
ACT01 S 1100C
Information
ACT01 Account Number AN 1/35 R
ACT02 Name AN 1/60 N/U
ACT03 Identification Code Qualifier ID 1/2 N/U
ACT04 Identification Code AN 2/80 N/U
ACT05 Account Number Qualifier ID 1/3 N/U
ACT06 Account Number AN 1/35 S

ACT07 Description AN 1/80 N/U
Payment Method Type
ACT08 ID 1/2 N/U
Code
ACT09 Benefit Status Code ID 1/1 N/U
INS Member Level Detail R 2000

Yes/No Condition or
Y,N INS01 ID 1-1 R
Response Code
01,03,04,05,06,07,08,09,
10,11,12,13,14,15,16,17, Individual Relationship
18,19,23,24,25,26,31, INS02 ID 2-2 R
Code
32,33,38,48,49,53
001,021,024,025,030 INS03 Maintenance Type Code ID 3-3 R
01,02,03,04,05,06,07,08,09,
10,11,14,15,16,17,18,20,21,
INS04 Maintenance Reason Code ID 2-3 S
22,25,26,27,28,29,31,32,33,
37,38,39,40,41,43,XN,XT
A,C,S,T INS05 Benefit Status Code ID 1-1 R
A,B,C,D,E INS06 Medicare Status Code ID 1-1 S

INS06-1 Medicare Plan Code ID 1/1 S
INS06-2 Eligibility Reason Code ID 1/1 S
INS06-3 Eligibility Reason Code ID 1/1 N/U
INS06-4 Eligibility Reason Code ID 1/1 N/U
Consolidated Omnibus
1,2,3,4,5,6,7,8 INS07 Budget Reconciliation Act ID 1/2 S
(COBRA) Qualifying
AO,AU,FT,L1,PT,RT,TE INS08 Employment Status Code ID 2/2 S
F,N,P INS09 Student Status Code ID 1/1 S

Yes/No Condition or
N,Y INS10 ID 1/1 S
Response Code
D8 INS11 ID 2/3 S
Qualifier
INS12 Date Time Period AN 1/35 S
INS13 Confidentiality Code ID 1/1 S

INS14 City Name AN 2/30 N/U
INS15 State or Province Code ID 2/2 N/U
INS16 Country Code ID 2/3 N/U
INS17 Number N0 1/9 S
REF Subscriber Identifier R 2000

0F REF01 ID 2/3 R
Qualifier
REF02 Reference Identification AN 1/50 R
REF Member Policy Number S 2000

1L REF01 ID 2/3 R
Qualifier

Member Supplemental
REF S 2000
Identifier
17,23,3H,DX,F6,Q4,ZZ REF01 ID 2/3 R
Qualifier

QQ
DTP Member Level Dates S 2000
286,296,297,300,301,303,3
36,337,338,339,340,341,35
DTP01 Date/Time Qualifier ID 3/3 R
0,351,356,357,383,393,394,
473,474

D8 DTP02 ID 2/3 R
Qualifier
DTP03 Date Time Period AN 1/35 R
NM1 Member Name R 2100A

74,IL NM101 Entity Identifier Code ID 2-3 R
NM103 AN 1-60 R
Name
34,ZZ NM108 Identification Code Qualifier ID 1-2 S

NM112 AN 1-60 N/U
Name
Member Communications
PER S 2100A
Numbers
IP PER01 Contact Function Code ID 2-2 R

PER02 Name AN 1-60 N/U
EM,EX,FX,HP,TE,WP PER03 ID 2-2 R
Qualifier
EM,EX,FX,HP,TE,WP PER05 ID 2-2 S
Qualifier
EM,EX,FX,HP,TE,WP PER07 ID 2-2 S
Qualifier
Member Residence Street

N3 S 2100A
Address
Member Residence City,

N4 S 2100A
State, ZIP Code

60, CY N405 Location Qualifier ID 1-2 S
N406 Location Identifier AN 1-30 S
DMG Member Demographics S 2100A

D8 DMG01 ID 2-3 R
Qualifier
DMG02 Date Time Period AN 1-35 R
F,M,U DMG03 Gender Code ID 1-1 R
B,D,I,M,R,S,U,W,X DMG04 Marital Status Code ID 1-1 S
Composite Race or
7,A,B,C,H,I,N,O DMG05-1 ID 1-1 S
Ethnicity Code
DMG05-2 Code List Qualifier ID 1-30 S

DMG05-3 Industry Code ID 1-2 S
1,2,3,4,5,6,7 DMG06 Citizenship Status Code ID 1-2 S

DMG10 Code List Qualifier Code ID 1-3 S
DMG11 Industry Code AN 1-30 S
EC Employment Class S 2100A
ECO1 Employment Class code ID 2-3 R
ECO2 Employment Class code ID 2-3 S
ECO3 Employment Class code ID 2-3 S

ECO4 Percentage as Decimal R 1-10 N/U
ECO5 Information Status Code ID 1-1 N/U
ECO6 Occupation Code ID 4-6 N/U
Member Income
ICM S 2100A
1,2,3,4,6,7,8,9,B,C,H,Q,S,U ICM01 Frequency Code ID 1-1 R
ICM02 Monetary Amount R 1-18 R

ICM03 Quantity R 1-15 S
ICM04 Location Identifier AN 1-30 S
ICM05 Salary Grade AN 1-5 S

ICM06 Currency Code ID 3-3 N/U
AMT Member Policy Amounts S 2100A
B9,C1,D2,P3 AMT01 Amount Qualifier Code ID 1-3 R

MEMBER HEALTH
HLH S 2100A
INFORMATION
N,S,T,U,X HLH01 Health Related Code ID 1-1 R
HLH02 Height R 1-8 S
HLH03 Wieght R 1-10 S
HLH04 Weight R 1-10 N/U
HLH05 Description AN 1-80 N/U
Current Health Condition
HLH06 ID 1-1 N/U
Code
HLH07 Description AN 1-80 N/U
LUI Member Language S 2100A
LD,LE LUI01 Identification Code Qualifier ID 1-2 S
LUI02 Identification Code AN 2-80 S

LUI03 Language Description ID 1-80 S
5,7,8 LUI04 Use of Language Indicator ID 1-2 S
Lauguage Proficiency
LUI05 ID 1-1 N/U
Indicator
NM1 Incorrect Member Name S 2100B

NM103 AN 1-60 R
Name
NM106 Name Prefix AN 1-10 C
NM107 Name suffix AN 1-10 C
34,ZZ NM108 Identification Code Qualifier ID 1-2 S

NM112 AN 1-60 N/U
Name
Incorrect Member
DMG S 2100B
Demographics
D8 DMG01 ID 2-3 S
Qualifier
DMG02 Date Time Period AN 1-35 S
F,M,U DMG03 Gender Code ID 1-1 S
Race or Ethnicity
DMG05-1 ID 1-1 S
Information
DMG05-2 Code List Qualifier Code ID 1-3 S
DMG05-3 Industry Code AN 1-30 S
DMG06 Citizenship Status Code ID 1-2 S

DMG10 Code List Code Qualifier ID 1-3 N/U
DMG11 Industry Code AN 1-30 N/U
NM1 Member Mailing Address S 2100C

NM103 AN 1-60 N/U
Name

NM112 AN 1-60 N/U
Name
Member Mail Street

N3 S 2100C
Address
Member Mail City, State,

N4 S 2100C
Zip
N402 State or Province Code AN 2-2 S
N407 Couuntry Subdivision Code ID 1-3 S
NM1 Member Employer 2100D
ES NM101 Entity Identifier Code ID 2-3 R

1,2 NM102 Entity Type Qualifier ID 1-1 R
NM103 AN 1-60 R
Name
ZZ NM108 Identification Code Qualifier ID 1-2 S

NM112+L3 Name Last or Organization
AN 1-60 N/U
13 Name
Member Employer
PER S 2100D
EP PER01 Contact Function Code ID 2-2 R

EM,EX,FX,TE PER03 ID 2-2 R
Qualifier
EM,EX,FX,TE PER05 ID 2-2 S
Qualifier
Qualifier
Member Employer Street

N3 S 2100D
Adddrsss
Member Employer City,

N4 R 2100D
State, Zip
NM1 Member School S 2100E

M8 NM101 Entity Identifier Code ID 2-3 R
NM103 AN 1-60 N/U
Name

NM112 AN 1-60 N/U
Name
Member School
PER Communications S 2100E
Numbers
SK PER01 Contact Function Code ID 2-2 R
EM,EX,FX,TE PER03 ID 2-2 R
Qualifier
Qualifier
Qualifier
Member School Street

N3 S 2100E
Address
Member School City,

N4 R 2100E
State, Zip
NM1 Custodial Parent S 2100F

S3 NM101 Entity Identifier Code ID 2-3 R
NM103 AN 1-60 N/U
Name
34,ZZ NM108 Identification Code Qualifier ID 1-2 N/U

NM112 AN 1-60 N/U
Name
Custodial Parent
PER S 2100F
Comunications Numberx
PQ PER01 Contact Function Code ID 2-2 R

EM,EX,FX,TE,WP PER03 ID 2-2 R
Qualifier
EM,EX,FX,TE,WP PER05 ID 2-2 S
Qualifier
Qualifier
Custodial Parent Street

N3 S 2100F
Address
Member School City,

N4 R 2100F
State, Zip
NM01 Responsible Person S 2100G
E1,EI,EXS,GD,J6,LR,QD NM101 Entity Identifier Code ID 2-3 R

NM103 AN 1-60 N/U
Name
34,ZZ NM108 Identification Code Qualifier ID 1-2 N/U

NM112 AN 1-60 N/U
Name
Responsible Person
PER S 2100G
RP PER01 Contact Function Code ID 2-2 R

EM,EX,FX,TE,WP PER03 ID 2-2 R
Qualifier
Qualifier
Qualifier
Responsible Person
N3 S 2100G
Street Address
Responsible Person City,

N4 R 2100G
State, Zip
NM01 Drop Off Location S 2100H

NM103 AN 1-60 S
Name

NM112 AN 1-60 N/U
Name
Drop Off Location Street

N3 S 2100H
Address
Drop Off Location City,

N4 R 2100H
State, Zip
DSB Disability Information S 2200

1,2,3,4 DSB01 Disability Type Code ID 1-1 R
DSB02 Quantity ID 1-15 N/U
DSB03 Occupation Code ID 4-6 N/U
DSB04 Work Intensity Code ID 1-1 N/U
DSB05 Product Option Code ID 1-2 N/U
DSB06 Monetary Amount R 1-18 N/U
DX DSB07 Product/Service ID Qualifier ID 2-2 N/U
DSB08 Medical Code Value AN 1-15 N/U
DTP Disability Eligibility Dates S 2200
360,361 DTP01 Date/Time Qualifier ID 3-3 R

D8 DTP02 ID 2-3 R
Qualifier
HD Health Coverage S 2300

001,002,021,024,025,
HD01 Maintenance Type Code ID 3-3 R
026,030,032
HD02 Maiintenance Reason Code ID 2-3 N/U
AG,AH,AJ,AK,DCP,DEN,
EPO,FAC,HE,HLT,HMO,
HD03 Insurance Line Code ID 2-3 R
LTC,LTD,MM,MOD,PDG,P
OS,PPO,PRA,STD,UR, VIS
HD04 Plan Coverage Description AN 1-50 S
CHD,DEP,E1D,E3D,E5D,E
6D,E7D,E8D,E9D,ECH,
HD05 Coverage Level Code ID 3-3 S
EMP,ESP,FAM,IND,SPC,
SOP,TWO

HD08 Underwriting Decision Code ID 1-1 N/U
Yes/No condition or
HD09 ID 1-1 S
Response Code
HD10 Drug House Code ID 2-3 N/U
Yes/No condition or
HD11 ID 1-1 N/U
Response Code
DTP Health Coverage Dates R 2300
303, 348, 349, 543 DTP01 Date/Time Qualifier ID 3-3 R

D8 DTP02 ID 2-3 R
Qualifier
AMT Health Coverage Policy S 2300
B9,C1,D2,P3 AMT01 Amount Qualifier Code ID 1-3 R

AMT03 Credit/Debit Flag Code R 1-1 N/U
Health Coverage Policy

REF S 2300
Number
17,1L,ZZ REF01 ID 2-3 R
Qualifier


REF Prior Coverage Months S 2300
REF01 ID 2-3 R
Qualifier
REF03 Description AN 1--80 N/U
IDC Identification Card S 2300
IDC01 Plan Coverage Description AN 1-50 R
Identification Card Type

D,H,P IDC02 ID 1-1 R
Code
IDC03 Quantity R 1-15 S
1,2,RX IDC04 Action Code ID 1-2 S
LX Provider Information S 2310
LX01 Assigned Number
NM1 Provider Name R 2310
3D,OD,P3,QA,QN,Y2 NM101 Entity Identifier Code ID 2/3 R
1,2 NM102 Entity Type Qualifier ID 1/1 R

NM103 AN 1/60 S
Name
NM104 Name First AN 1/35 S
NM105 Name Middle AN 1/25 S
NM106 Name Prefix AN 1/10 S
NM107 Name Suffix AN 1/10 S
34,FI,XX NM108 Idenification Code Qualifier ID 1/2 S
NM109 Identification Code AN 2/80 S

25,26,72 NM110 Entity Relationship Code ID 2/2 R
NM111 Entity Identifier Code ID 2/3 N/U
NM112 AN 1/60 N/U
name
N3 Provider Address S 2310

N301 Address Information AN 1/55 R
N302 Address Information AN 1/55 S
Provider City, State, ZIP

N4 R 2310
Code
N401 City Name AN 2/30 R
N402 State or Province Code ID 2/2 S
N403 Postal Code ID 3/15 S

N404 Country Code ID 2/3 S
60,CY,RJ N405 Location Qualifier ID 1/2 N/U
N406 Location identifier AN 1/30 N/U
N407 Country Subdivision Code ID 1/3 S
Provider Communications
PER S 2310
Numbers
IC PER01 Contact Function Code ID 2/2 R

PER02 Name AN 1/60 N/U
EM,EX,FX,HP,TE,WP PER03 ID 2/2 R
Qualifier
PER04 Communication Number AN 1/256 R
EM,EX,FX,HP,TE,WP PER05 ID 2/2 S
Qualifier
PER06 Communication Number AN 1/256 S
EM,EX,FX,HP,TE,WP PER07 ID 2/2 S
Qualifier
PER08 Communication Number AN 1/256 S
PER09 Contact Inquiry Reference AN 1/20 N/U
PLA Provider Change Reason S 2310
2 PLA01 Action Code ID 1/2 R
1P PLA02 Entity Identifier Code ID 2/3 R

PLA03 Date DT 8/8 R
PLA04 Time TM 4/8 N/U
14,22,46,AA,AB,AC,AD,AE,
PLA05 Maintenance Reason Code ID 2/3 R
AF,AG,AH,AI,AJ
COB Coordination of Benefits S 2320
Payer Responsibility
P,S,T,U COB01 ID 1-1 R
COB02 Reference Identification AN 1-50 S
1,5,6 COB03 ID 1-1 R
Code
COB04 Service Type Code ID 1/2 S
Additional Coordination
REF S 2320
of Benefits Identifiers
60,6P,A6,SY,ZZ REF01
Qualifier
ID 2/3 R

IN
FI,NI,XV
DTP S 2320
Eligibility Dates
344,345 DTP01 Date/Time Qualifier ID 3/3 R

D8 DTP02 ID 2/3 R
Qualifier
NM1 S 2330
Related Entity
NM101 Entity Identifier Code ID 2/3 R
NM102 Entity Type Qualifier ID 1/1 S
NM103 AN 1/60 S
Name
NM104 Name First AN 1/35 N/U
NM105 Name Middle AN 1/25 N/U
NM106 Name Prefix AN 1/10 N/U
NM107 Name Suffix AN 1/10 N/U
NM108 Identification Code Qualifier ID 1/2 S
NM109 Identification Code AN 2/80 S

NM110 Entity Relationship Code ID 2/2 N/U
NM111 Entit Identifier Code ID 2/3 N/U
NM112 AN 1/60 N/U
Name
N3 S 2330
Related Entity Address
N301 Address Information AN 1/55 R

N302 Address Information AN 1/55 S
N4 Other Insurance Company R 2330
City, State, ZIP Code
N401 City Name AN 2/30 R

N402 State or Province Code ID 2/2 S
N403 Postal Code ID 3/15 S
N404 Country Code ID 2/3 S
N405 Location Qualifier ID 2/3 N/U
N406 Location Identifier AN 2/30 N/U
N407 Country Subdivision Code ID 2/3 S
Administrative
PER S 2330
Communications Contact
PER01 Contact Function Code ID 2/2 R

PER 02 Name AN 1/60 N/U
PER03 ID 2/2 R
Qualifier
PER04 Communication Number AN 1/256 R
PER05 ID 2/2 N/U
Qualifier
PER06 Communication Number AN 1/256 N/U
PER07 ID 2/2 N/U
Qualifier
PER08 Communication Number AN 1/256 N/U
PER09 Contact Inquiry Reference AN 1/20 N/U
Additional Reporting
LS 2700
Categories
LS01 Loop Identifier Code AN 1-4 R
Member Reporting
LX S 2710
Categories
LX01 Assigned Number N0 1-6 R
N1 Reporting Category S 2750
N101 Entity Identifier Code ID 2/3 R

N102 Name AN 1/60 R
N103 Identification Code Qualifier ID 1/2 N/U
N104 Identification Code AN 2/80 N/U

Reporting Category
REF S 2750
Reference
REF01 ID 2/3 R
Qualifier

DTP Reporting Category Date S 2750
DTP01 Date/Time Qualifier ID 3/3 R

DTP02 ID 2/3 R
Qualifier
Additional reporting
LE Categories Loop S 2700
Termination
LE01 Loop Identifier Code AN 1-4 R
SE Transaction Set Trailer R

Number of Included
SE01 N0 1/10 R
Segments
SE02 AN 4/9 R
Number
ember Enrollment
Values
00,15,22
01,02,03,04,05,06,07,08,
09,10,11,12,13,14,15,16,
17,18,19,20,21,22,23,24,AD
,AS,AT,CD,CS,CT,ED,
ES,ET,GM,HD,HS,HT,LT,
MD,MS,MT,ND,NS,NT,
PD,PS,PT,TD,TS,TT,UT
2,4,RX
38
007,090,091,303,382,3
88
D8
DT,ET,TO
P5
24,94,FI
IN
94,FI,XV
BO,TV
94,FI,XV
Y,N
01,03,04,05,06,07,08,09,
10,11,12,13,14,15,16,17,
18,19,23,24,25,26,31,38,
53,60,D2,G8,G9
001,021,024,025,030
01,02,03,04,05,06,07,08,09,
10,11,14,15,16,17,18,20,21,
22,25,26,27,28,29,31,32,33,
37,38,39,40,41,43,59,A
A,AB,AC,
AD,AE,AF,AG,
AH,AI,AJ,AL,EC,
XN,XT
A,C,S,T
A,B,C,D,E
0,1,2
1,2,3,4,5,6,7,8,9,10
,ZZ
AC,AO,AU,FT,L1,PT,RT,
TE
F,N,P
N,Y
D8
R,U
0F
1L
17,23,3H,4A,6O,
ABB,D3,DX,F6,P5,Q
4,QQ,ZZ
050,286,296,297,300,
301,303,336,337,338,339,3
40,341,350,351,356,357,38
3,385,386,393,394,473
,474
D8
74,IL
1
34,ZZ
IP
AP,BN,CP,EM,EX,
FX,HP,TE,WP
AP,BN,CP,EM,EX,
FX,HP,TE,WP
AP,BN,CP,EM,EX,
FX,HP,TE,WP
60, CY
D8
F,M,U
B,D,I,M,R,S,U,W,X
7,8,A,B,C,D,E,F,G,H,I
,J,N,O,P,Z
RET
1,2,3,4,5,6,7
REC
01,02,03,04,05,06,07
08,09,10,11,12,17,18,
19,20,21,22,23
01,02,03,04,05,06,07
08,09,10,11,12,17,18,
19,20,21,22,23
01,02,03,04,05,06,07
08,09,10,11,12,17,18,
19,20,21,22,23
1,2,3,4,6,7,8,9,B,C,H,Q,S,U
B9,C1,D2,EBA,FK,
P3,R
N,S,T,U,X
LD,LE
5,6,7,8
70
1
34,ZZ
D8
F,M,U
31
1
36
1,2
24,34
EP
AP,BN,CP,EM,EX,
FX,TE
AP,BN,CP,EM,EX,
FX,TE
AP,BN,CP,EM,EX,
FX,TE
MB
2
SK
EM,EX,FX,TE
EM,EX,FX,TE
EM,EX,FX,TE
S3
1
34,ZZ
PQ
AP,BN,CP,EM,EX,
FX,TE,WP
AP,BN,CP,EM,EX,
FX,TE,WP
AP,BN,CP,EM,EX,
FX,TE,WP
6Y, 9K, E1, EI, EXS,

GB, GD, J6, LR, QD,
S1, TZ, X4
1
34,ZZ
RP
AP,BN,CP,EM,EX,
FX,TE,WP
AP,BN,CP,EM,EX,
FX,TE,WP
AP,BN,CP,EM,EX,
FX,TE,WP
45
1
1,2,3,4
DX, ZZ
360,361
D8
001,002,021,024,025,
026,030,032
AG,AH,AJ,AK,DCP,DEN,
EPO,FAC,HE,HLT,HMO,
LTC,LTD,MM,MOD,PDG,P
OS,PPO,PRA,STD,UR, VIS
CHD,DEP,E1D,E3D,E5D,E
6D,E7D,E8D,E9D,ECH,
EMP,ESP,FAM,IND,SPC,
SOP,TWO
300, 303, 343, 348,

543, 695
D8 ,RD8
B9,C1,D2,EBA,FK,
P3,R
17,1L,9V,CE,E8
,M7,PID,RB,X9,X
M,XX1,XX2,ZX, ZZ
QQ
D,H,P
1,2,RX
1X,3D,80,FA,OD,P3,Q
A,QN,Y2
1,2
34,FI,SV,XX
25,26,72
IC
AP,BN,CP,EM,EX
,FX,HP,TE,WP
AP,BN,CP,EM,EX
,FX,HP,TE,WP
AP,BN,CP,EM,EX
,FX,HP,TE,WP
1P
14,22,46,AA,AB,AC,AD,AE,
AF,AG,AH,AI,AJ
P,S,T,U
1,5,6
60,6P,SY,ZZ
344,345
D8
36,GW,IN
2
FI, NI,XV
CN
TE
2700
75
00,17,18,19,26,3L,6M,9V,9
X,GE,LU,PID,XX1,XX2,YY,
ZZ
007
D8,RD8
2700
4010A1 835 Remittance Advice 5010
Element Description ID Min. Usage Loop Loop Values Element
Identifier Max. Reg. Repea Identifier
t
ISA INTERCHANGE 1 R 1 ISA

CONTROL HEADER
ISA01 Authorization Information ID 2--2 R 00,03 ISA01
Qualifier
ISA02 Authorization Information AN 10--10 R ISA02
ISA03 Security Information Qualifier ID 2--2 R 00,01 ISA03
ISA04 Security Information AN 10--10 R ISA04

ISA05 Interchange ID Qualifier ID 2--2 R 01,14,20,27, 28, ISA05
29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15--15 R ISA06

ISA07 Interchange ID Qualifier ID 2--2 R 01,14,20,27, 28, ISA07
29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15--15 R ISA08

ISA09 Interchange Date DT 6--6 R YYMMDD ISA09
ISA10 Interchange Time TM 4--4 R HHMM ISA10
ISA11 Interchange Control Standards ID 1--1 R U ISA11
ID
ISA12 Interchange Control Version ID 5--5 R 401 ISA12
Number
ISA13 Interchange Control Number N0 9--9 R =IEA02 ISA13
ISA14 Acknowledgement Requested ID 1--1 R 0 ISA14
ISA15 Usage Indicator ID 1--1 R P,T ISA15

ISA16 Component Element Separator 1--1 R ISA16
GS Functional Group 1 R --------- 1 GS

Header -
GS01 Functional Identifier Code ID 2--2 R HP GS01
GS02 Application Sender's Code AN 2--15 R GS02
GS03 Application Receiver's Code AN 2--15 R GS03
GS04 Date DT 8--8 R CCYYMMDD GS04
GS05 Time TM 4--8 R HHMM GS05
GS06 Group Control Number N0 1--9 R #REF! GS06
GS07 Responsible Agency Code ID 1--2 R X GS07
GS08 Version/Release/Industry Id AN 1--12 R 004010X091 GS08
code 004010X091A1
ST Transaction Set Header 1 R --------- 1 ST

--
ST01 Transaction Set Identifier Code ID 3--3 R 835 ST01
ST02 AN 4--9 R =SE02 ST02
BPR Financial Information 1 R --------- 1 BPR

-
BPR01 Transaction Handling Code ID 1--2 R C,D,H,I,P BPR01
BPR02 Total Actual Provider Payment R 1--18 R BPR02

Amt S9(8)V99
BPR03 Credit or Debit Flag Code ID 1--1 R C BPR03
BPR04 Payment Method Code ID 3--3 R ACH,CHK,NON BPR04
BPR05 Payment Format Code ID 1--10 S CCP,CTX BPR05
BPR06 DFI ID # Qualifier ID 2--2 S 1 BPR06
BPR07 Sender DFI Identifier AN 3--12 S BPR07
BPR08 Acct # Qualifier ID 1--3 S DA BPR08
BPR09 Sender Bank Acct # AN 1--35 S BPR09
BPR10 Payer Identifier AN 10--10 S =TRN03 BPR10
BPR11 Originating Co Supplemental AN 9--9 S N/A Medicare BPR11
Code
BPR12 DFI ID # Qualifier ID 2--2 S 1 BPR12
BPR13 Receiver or Provider Bank ID # AN 3--12 S BPR13
BPR14 Acct # Qualifier ID 1--3 S DA,SG BPR14

BPR15 Receiver or Provider Acct # AN 1--35 S BPR15
BPR16 Check Issue or EFT Effective DT 8--8 R BPR16
Date
BPR17 Business Function Code ID 1--3 N/U BPR17
BPR18 (DFI) ID Number Qualifier ID 2--2 N/U BPR18
BPR19 (DFI) Identification Number AN 3--12 N/U BPR19
BPR20 Account Number Qualifier ID 1--3 N/U BPR20
BPR21 Account Number AN 1--35 N/U BPR21
TRN Reassociation Trace 1 R --------- 1 TRN

Number -
TRN01 Trace Type Code ID 1--2 R 1 TRN01
TRN02 Check or EFT Trace # AN 1--30 R TRN02
TRN03 Payer Identifier AN 10--10 R =BPR10 TRN03
TRN04 Originating Co Supplemental AN 1--30 S N/A Medicare TRN04
Code
CUR Foreign Currency 1 S --------- 1 N/A CUR

Information -
REF Reference 1 S --------- 1 REF

Identification -
REF01 Receiver ID Qualifier ID 2--3 R EV REF01
REF02 Receiver Identifier AN 1--30 R REF02
REF03 Description AN 1--80 N/U REF03
REF04 Reference Identifier N/U REF04
REF Version Identification 1 S --------- 1 REF

-
REF01 Receiver ID Qualifier ID 2--3 R F2 REF01
REF02 Version ID Code AN 1--30 R REF02
DTM Production Date 1 S --------- 1 DTM

-
DTM01 Date Time Qualifier ID 3--3 R 405 DTM01
DTM02 Production Date DT 8--8 R CCYYMMDD DTM02
DTM03 Time TM 4--8 N/U DTM03
DTM04 Time Code ID 2--2 N/U DTM04
DTM05 Date Time Period Format ID 2--3 N/U DTM05
Qualifier
DTM06 Date Time Period AN 1--35 N/U DTM06
N1 Payer Identification 1 R 1000A 1 N1
N101 Entity Identifier Code ID 2--3 R PR N101

N102 Payer Name AN 1--60 S N102
N103 ID Code Qualifier ID 1--2 S XV N103
N104 Payer Identifier AN 2--80 S N104
N105 Entity Relationship Code ID 2--2 N/U N105
N106 Entity Identifier Code ID 2--3 N/U N106
N3 Payer Address 1 R 1000A N3
N301 Payer Address Line AN 1--55 R N301

N302 Payer Address Line AN 1--55 S N302
N4 Payer City, State, Zip 1 R 1000A N4
N401 Payer City Name AN 2--30 R N401

N402 Payer State Code ID 2--2 R N402
N403 Payer Postal Zone or ZIP Code ID 3--15 R N403
N404 Country Code ID 2--3 N/U N404

N405 Location Qualifier ID 1--2 N/U N405
N406 Location Identifier AN 1--30 N/U N406
N407
REF Additional Payer 4 S 1000A REF

Identification
REF01 Reference Identification ID 2--3 R 2U REF01
Qualifier
REF02 Additional Payer ID AN 1--30 R REF02

PER Payer Contact 1 S 1000A PER

Information
PER01 Contact Function Code ID 2--2 R CX PER01
PER02 Payer Contact Name AN 1--60 S PER02
PER03 Communication # Qualifier ID 2--2 S EM,FX,TE PER03
PER04 Payer Contact Communication AN 1--80 S PER04
#
PER05 Communication Number ID 2--2 S EM,EX,FX,TE PER05
Qualifier 2
#
PER07 Communication Number ID 2--2 S EX PER07
Qualifier 3
#
PER09 Contact Inquiry Reference AN 1 -- 20 N/U PER09
PER
PER01
PER02
PER03
PER04
PER05
PER06
PER07
PER08
PER09
PER
PER01
PER02
PER03
PER04
PER05
PER06
PER07
PER08
PER09
N1 Payee Identification 1 R 1000B 1 N1
N101 Entity Identifier Code ID 2--3 R PE N101

N102 Payee Name AN 1--60 S N102
N103 Identification Code Qualifier ID 1--2 R XX N103
N104 Payee ID Code AN 2--80 R N104
N105 Entity Relationship Code ID 2--2 N/U N105
N106 Entity Identifier Code ID 2--3 N/U N106
N3 Payee Address 1 S 1000B N3
N301 Payee Address Line AN 1--55 R N301

N302 Payee Address Line AN 1--55 S N302
N4 Payee City,State,Zip 1 S 1000B N4
N401 Payee City Name AN 2--30 R N401

N402 Payee State Code ID 2--2 R N402
N403 Payee Postal Zone or ZIP Code ID 3 -- 15 R N403
N404 Country Code ID 2--3 S N404

N405 Location Qualifier ID 1--2 N/U N405
N406 Location Identifier AN 1--30 N/U N406
N407
REF Payee Additional >1 S 1000B REF
Identification
REF01 Reference Identification ID 2--3 R TJ REF01
Qualifier
REF02 Additional Payee ID # AN 1--30 R REF02
REF03 Description AN 1 -- 80 N/U REF03
RDM
RDM01
RDM02
RDM03
RDM04
RDM05
LX Header Number 1 S 2000 >1 LX

LX01 Assigned # N0 1--6 R 1,0 LX01
TS3 Provider Summary 1 S 2000 TS3

Information
TS301 Reference Identification AN 1--30 R NPI TS301
TS302 Facility Code Value AN 1--2 R POS Code TS302
TS303 Date DT 8--8 R CCYYMMDD TS303
TS304 Quantity R 1--15 R TS304
TS305 Monetary Amount R 1--18 R TS305
TS306 Monetary Amount R 1--18 S TS306




TS323 Quantity R 1--15 S TS323

TS2 Provider Supplemental 1 S 2000 N/A TS2
Summary Info


TS 208 Monetary Amount R 1--18 S TS 208
TS 209 Monetary Amount R 1--18 S TS 209
TS 210 Quantity R 1--15 S TS 210
TS 211 Quantity R 1--15 S TS 211


CLP Claim Level Data 1 R 2100 >1 CLP

CLP01 Patient Control # AN 1--38 R CLP01
CLP02 Claim Status Code ID 1--2 R 1, 2, 3, 4, 5, 10, CLP02
13, 15, 16, 17,
19, 20, 21, 22, 23
CLP03 Total Claim Charge Amount R 1--18 R CLP03

S9(7)V99
CLP04 Claim Payment Amount R 1--18 R CLP04
S9(7)V99
CLP05 Patient Responsibility Amount R 1--18 S CLP05
S9(7)V99
CLP06 Claim Filling Indicator Code ID 1--2 R MB CLP06
CLP07 Payer Claim Control # AN 1--30 S CLP07
CLP08 Facility Type Code AN 1--2 S CLP08
CLP09 Claim Frequency Code ID 1--1 S N/A Medicare CLP09
CLP10 Patient Status Code ID 1--2 N/U CLP10

CLP11 DRG Code ID 1--4 S N/A Carriers CLP11
CLP12 DRG Weight R 1--15 S N/A Carriers CLP12
CLP13 Discharge Fraction R 1--10 S N/A Carriers CLP13
CLP14
CAS Claim Adjustment 99 S 2100 CAS

CAS01 Claim Adjustment Group Code ID 1--2 R CO,CR,OA,PR CAS01
CAS02 Adjustment Reason Code ID 1--5 R CAS02

CAS03 Adjustment Amount S9(7)V99 R 1--18 R CAS03
CAS04 Adjustment Quantity 9(7) R 1--15 S N/A Medicare CAS04

CAS05
CAS06
CAS07
CAS08
CAS09
CAS10
CAS11
CAS12
CAS13
CAS14
CAS15
CAS16
CAS17
CAS18
CAS19
NM1 Patient Name 1 R 2100 NM1

NM101 Entity Identifier Code ID 2--3 R QC NM101
NM102 Entity Type Qualifier ID 1--1 R 1 NM102
NM103 Patient Last Name AN 1--35 R NM103
NM104 Patient First Name AN 1--25 R NM104
NM105 Patient Middle Name AN 1--25 S NM105
NM106 Name Prefix AN 1 -- 10 N/U NM106
NM107 Patient Name Suffix AN 1--10 S NM107
NM108 ID Code Qualifier ID 1--2 S HN,II, MI NM108
NM109 Patient Identifier AN 2--80 S NM109
NM110 Entity Relationship Code ID 2--2 N/U NM110
NM111 Entity Identifier Code ID 2--3 N/U NM111
NM112
NM1 Insured's Name 1 S 2100 N/A NM1
NM1 Corrected 1 S 2100 NM1

Patient/Insured Name
NM101 Entity Identifier Code ID 2--3 R 74 NM101

NM103 Corrected Patient/Ins Last AN 1--35 S NM103
Name
NM104 Corrected Patient/Ins First AN 1--25 S NM104
Name
NM105 Corrected Patient/Ins Middle AN 1--25 S NM105
Name
NM106 Name Prefix AN 1--10 N/U NM106
NM107 Corrected Patient Name Suffix AN 1--10 S NM107
NM108 Identification Code Qualifier ID 1--2 S C NM108

NM109 Corrected Ins Identification AN 2--80 S NM109
Indicator
NM112
NM1 Service Provider Name 1 S 2100 NM1
NM101 Entity Identifier Code ID 2--3 R 82 NM101

NM102 Entity Type Qualifier ID 1--1 R 1, 2 NM102
NM103 Rendering Provider Last/Org AN 1--35 S N/A Medicare NM103
Name
NM104 Rendering Provider First Name AN 1--25 S N/A Medicare NM104
NM105 Rendering Provider Middle AN 1--25 S N/A Medicare NM105

Name
NM107 Rendering Provider Name AN 1--10 S N/A Medicare NM107
Suffix
NM108 ID Code Qualifier ID 1--2 R XX NM108
NM109 Rendering Provider Identifier AN 2--80 R NM109
NM112
NM1 Crossover Carrier 1 S 2100 NM1

Name
NM101 Entity Identifier Code ID 2--3 R TT NM101
NM103 COB Carrier Name AN 1--35 R NM103
NM104 First name AN 1--25 N/U NM104
NM105 Middle name AN 1--25 N/U NM105
NM106 Not Used AN 1--10 N/U NM106
NM107 name suffix AN 1--10 N/U NM107
NM108 ID Code Qualifier ID 1--2 R PI,XV NM108
NM109 COB Carrier Identifier AN 2--80 R NM109
NM112
NM1 Corrected Priority 2 S 2100 NM1

Payer Name
NM101 Entity Identifier Code ID 2--3 R PR NM101
NM103 Corrected Priority Payer Name AN 1--35 R NM103
NM104 First name AN 1--25 N/U NM104

NM105 middle name AN 1--25 N/U NM105
NM107 name suffix AN 1--10 N/U NM107
NM108 ID Code Qualifier ID 1--2 R PI,XV NM108
NM109 Corrected Priority Payer ID AN 2--80 R NM109
NM112
NM1
MIA Inpatient Adjudication 1 S 2100 N/A MIA

Information
MIA01 Quantity R 1--15 R MIA01
MIA02 Quantity R 1--15 S MIA02
MIA04 Monetary Amount R 1--18 S MIA04
MIA05 Reference Identification AN 1--30 S MIA05

MOA Outpatient 1 S 2100 MOA

Adjudication
Information
MOA01 Reimbursement Rate 9(3)V99 R 1--10 S N/A Carriers MOA01
MOA02 Claim HCPCS Payable Amount R 1--18 S N/A Carriers MOA02

S9(7)V99
MOA03 Remark Code AN 1--30 S MOA03
MOA08 Claim ESRD Payment Amount R 1--18 S N/A Carriers MOA08
S9(7)V99
MOA09 Nonpayable Professional Comp R 1--18 S N/A Carriers MOA09
Amt S9(7)V99
REF Other Claim-Related 5 S 2100 N/A REF

Identification
REF01 Reference Identification ID 2--3 R 1L, 1W, 9A, 9C, REF01
Qualifier A6, BB, CE, EA,
F8, G1, G3, IG,
SY
REF02 Other Claim Related Identifier AN 1--30 R REF02

REF Rendering Provider 10 S 2100 N/A REF

Identification
REF01 Reference Identification ID 2--3 R 1A, 1B, 1C, 1D, REF01
Qualifier 1G, 1H, D3, G2
REF02 Rendering Provider Secondary AN 1--30 R REF02
Identifier
DTM Claim Payment Date 4 S 2100 DTM
DTM01 Date Time Qualifier ID 3--3 R 50 DTM01

DTM02 Claim Date DT 8--8 R CCYYMMDD DTM02
Qualifier
DTM
DTM01
DTM02
DTM03
DTM04
DTM05
DTM06
DTM
DTM01
DTM02
DTM03
DTM04
DTM05
DTM06
PER Claim Contact 3 S 2100 PER

Information
PER01 Contact Function Code ID 2--2 R CX PER01
PER02 Claim Contact Name AN 1--60 S PER02
PER03 Communication # Qualifier ID 2--2 S EM,FX,TE PER03
PER04 Claim Contact Communication AN 1--80 S PER04
#
PER05 Communication # Qualifier ID 2--2 S EM,EX,FX,TE PER05
PER06 Claim Contact Communication AN 1--80 S PER06
#
PER07 Communication # Qualifier ID 2--2 S EX PER07
PER08 Communication # Extension AN 1--80 S PER08
PER09 Contact Inquiry Reference AN 1--20 N/U PER09
AMT Claim Supplemental 14 S 2100 AMT

Information
AMT01 Amount Qualifier Code ID 1--3 R F5,I AMT01
AMT02 Claim Supplemental R 1--18 R AMT02

Information Amt S9(7)V99
AMT03 Credit/Debit Flag Code ID 1--1 N/U AMT03
QTY Claim Supplemental 15 S 2100 N/A QTY

Infor Quantity
QTY01 Quantity Qualifier ID 2--2 R CA, CD, LA, LE, QTY01
NA, NE, NR, OU,
PS, VS, ZK, ZL,
ZM, ZN, ZO
QTY02 Quantity Qualifier R 1--15 R QTY02

QTY03 Composite Unit Of Measure N/U QTY03
QTY04 Free-Form Message AN 1--30 N/U QTY04
SVC Information 1 S 2110 999 SVC

SVC01 Composite Medical Procedure R SVC01
Identifier
SVC01-1 Product or Service ID Qualifier ID 2--2 R HC,N4 SVC01-1
SVC01-2 Procedure Code AN 1--48 R SVC01-2
SVC01-3 Procedure Modifier AN 2--2 S SVC01-3

SVC01-7 Procedure Code Description AN 1--80 S N/A Medicare SVC01-7
SVC01-8
SVC02 Line Item Charge Amount R 1--18 R SVC02
S9(7)V99
SVC03 Line Item Provider Payment R 1--18 R SVC03
S9(7)V99
SVC04 NUBC Revenue Code AN 1--48 S N/A Carriers SVC04
SVC05 SVC01-1=N4 Units of Service R 1--15 S SVC05
Paid Count S9(7)V999 SVC01-
1 = HC Units of Service Paid
Count S9(3)V9
SVC06 Composite Medical Procedure S SVC06

Identifier
SVC06-1 Product or Service ID Qualifier ID 2--2 R HC,N4 SVC06-1
SVC06-2 Procedure Code AN 1--48 R SVC06-2

SVC06-7 Procedure Code Description AN 1--80 S N/A Medicare SVC06-7
SVC06-8
SVC07 SVC06-1=N4 Units of Service R 1--15 S SVC07
Original Count S9(7)V999
SVC06-1 = HC Units of Service
Original Count S9(7)V9
DTM Service Date Time 3 S 2110 DTM

Reference
DTM01 Date Time Qualifier ID 3--3 R 150,151,472 DTM01
DTM02 Claim Date DT 8--8 R CCYYMMDD DTM02
Qualifier
CAS Service Adjustment 99 S 2110 CAS

CAS01 Claim Adjustment Group Code ID 1--2 R CO,CR,OA,PR CAS01
CAS02 Adjustment Reason Code ID 1--5 R CAS02

CAS03 Adjustment Amount S9(7)V99 R 1--18 R CAS03

CAS05 Adjustment Reason Code ID 1--5 S CAS05
CAS06 Adjustment Amount S9(7)V99 R 1--18 S CAS06




REF Service Identification 7 S 2110 REF

REF01 Reference ID Qualifier ID 2--3 R LU,6R REF01
REF02 Provider ID AN 1--30 R REF02
REF
REF01
REF02
REF03
REF04
REF Rendering Provider 10 S 2110 REF

Information
REF01 Reference ID Qualifier ID 2--3 R HPI REF01
REF02 Rendering Provider ID AN 1--30 R REF02
REF
REF01
REF02
REF03
REF04
AMT Service Supplemental 12 S 2110 AMT

Amount
AMT01 Amount Qualifier Code ID 1--3 R B6,KH AMT01

AMT02 Service Supplemental Amount R 1--18 R AMT02
S9(7)V99
AMT03 Credit/Debit Flag Code ID 1--1 N/U AMT03
QTY Service Supplemental 6 S 2110 N/A QTY

Quantity
QTY01 Quantity Qualifier ID 2--2 R NE, ZK, ZL, ZM, QTY01

ZN, ZO
QTY02 Quantity R 1--15 R QTY02
QTY03 Composite Unit Of Measure N/U QTY03

QTY04 Free-Form Message AN 1--30 N/U QTY04
LQ Health Care Remarks 99 S 2110 LQ

Codes
LQ01 Code List Qualifier Code ID 1--3 R HE LQ01
LQ02 Remark Code AN 1--30 R LQ02
PLB Provider Level >1 S ------ 1 PLB

Adjustment
PLB-01 Provider Identifier AN 1--30 R NPI PLB-01
PLB02 Fiscal Period Date DT 8--8 R CCYYMMDD PLB02
PLB03 Adjustment Identifier R PLB03
PLB03-1 Adjustment Reason Code ID 2--2 R CS, AP, FB, LE, PLB03-1
L6, 50, SL, WO,
B2, IR, 72, J1
PLB03-2 Provider Adjustment Identifier AN 1--30 S PLB03-2
PLB04 Provider Adjustment Amount R 1--18 R PLB04

S9(7)V99
PLB05 Adjustment Identifier S PLB05
L6, 50, SL, WO,
B2, IR, 72, J1
PLB06 Provider Adjustment Amount R 1--18 S PLB06

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
SE Transition Set Trailer 1 R --- 1 SE
SE01 Transition Segment Count N0 1--10 R SE01
SE02 Transition Set Control # AN 4--9 R =ST02 SE02
GE Functional Group 1 R -- 1 GE

Trailer
GE01 # Transaction Sets Included N0 1 -- 6 R GE01
GE02 Group Control # N0 1 -- 9 R GE02
IEA Interchange Control 1 R --- 1 IEA

Trailer
IEA01 # Included Functional Groups N0 1 -- 5 R IEA01
IEA02 Interchange Control # N0 9 -- 9 R IEA02

835 Remittance Advice
Description ID Min. Usa Loop Loo Values
Max. ge p
Re Rep
g. eat
INTERCHANGE 1 R 1
CONTROL HEADER
Authorization Information ID 2--2 R 00,03
Qualifier
Authorization Information AN 10--10 R
Security Information Qualifier ID 2--2 R 00,01
Security Information AN 10--10 R

Interchange ID Qualifier ID 2--2 R 01,14,20,27, 28,
29, 30, 33, ZZ
Interchange Sender ID AN 15--15 R

Interchange ID Qualifier ID 2--2 R 01,14,20,27, 28,
29, 30, 33, ZZ
Interchange Receiver ID AN 15--15 R

Interchange Date DT 6--6 R YYMMDD
Interchange Time TM 4--4 R HHMM
Interchange Control Standards ID 1--1 R U
ID
Interchange Control Version ID 5--5 R 401
Number
Interchange Control Number N0 9--9 R =IEA02
Acknowledgement Requested ID 1--1 R 0
Usage Indicator ID 1--1 R P,T

Component Element Separator 1--1 R
Functional Group 1 R ---------- 1

Header
Functional Identifier Code ID 2--2 R HP
Application Sender's Code AN 2--15 R
Application Receiver's Code AN 2--15 R
Date DT 8--8 R CCYYMMDD
Time TM 4--8 R HHMM
Group Control Number N0 1--9 R #REF!
Responsible Agency Code ID 1--2 R X
Version Identifier Code AN 1--12 R 005010X221
Transaction Set Header 1 R ----------- 1
Transaction Set Identifier Code ID 3--3 R 835
Transaction Set Control AN 4--9 R =SE02

Number
Financial Information 1 R ---------- 1

Transaction Handling Code ID 1--2 R C, D, H, I ,P, U, X
Total Actual Provider Payment R 1--18 R

Amt S9(8)V99
Credit or Debit Flag Code ID 1--1 R C
Payment Method Code ID 3--3 R ACH,CHK,NON
Payment Format Code ID 1--10 S CCP,CTX
DFI ID # Qualifier ID 2--2 S 1
Sender DFI Identifier AN 3--12 S
Acct # Qualifier ID 1--3 S DA
Sender Bank Acct # AN 1--35 S
Payer Identifier AN 10--10 S
Originating Co Supplemental AN 9--9 S
Code
DFI ID # Qualifier ID 2--2 S 1
Receiver or Provider Bank ID # AN 3--12 S
Acct # Qualifier ID 1--3 S DA,SG

Receiver or Provider Acct # AN 1--35 S
Check Issue or EFT Effective DT 8--8 R
Date
Business Function Code ID 1--3 N/U
(DFI) ID Number Qualifier ID 2--2 N/U
(DFI) Identification Number AN 3--12 N/U
Account Number Qualifier ID 1--3 N/U
Account Number AN 1--35 N/U
Reassociation Trace 1 R ---------- 1

Number
Trace Type Code ID 1--2 R 1
Check or EFT Trace # AN 1--50 R
Payer Identifier AN 10--10 R
Originating Company AN 1--30 S N/U
Supplemental Code
Foreign Currency 1 S ---------- 1 N/A

Information
Reference 1 S ---------- 1
Identification
Receiver ID Qualifier ID 2--3 R EV
Receiver Identifier AN 1--50 R
Description AN 1--80 N/U
Reference Identifier N/U
Version Identification 1 S ---------- 1
Receiver ID Qualifier ID 2--3 R F2

Version ID Code AN 1--50 R
Production Date 1 S ---------- 1
Date Time Qualifier ID 3--3 R 405

Production Date DT 8--8 R CCYYMMDD
Time TM 4--8 N/U
Time Code ID 2--2 N/U
Date Time Period Format ID 2--3 N/U
Qualifier
Date Time Period AN 1--35 N/U
Payer Identification 1 R 1000A 1
Entity Identifier Code ID 2--3 R PR

Payer Name AN 1--60 R
ID Code Qualifier ID 1--2 S XV
Payer Identifier AN 2--80 S
Entity Relationship Code ID 2--2 N/U
Entity Identifier Code ID 2--3 N/U
Payer Address 1 R 1000A
Payer Address Line AN 1--55 R

Payer Address Line AN 1--55 S
Payer City, State, Zip 1 R 1000A
Payer City Name AN 2--30 R

Payer State Code ID 2--2 R
Payer Postal Zone or ZIP Code ID 3--15 R
Country Code ID 2--3 N/U

Location Qualifier ID 1--2 N/U
Location Identifier AN 1--30 N/U
Country Subdivision Code ID 1--3 S N/U
Additional Payer 4 S 1000A

Identification
Reference Identification ID 2--3 R 2U
Qualifier
Additional Payer ID AN 1--50 R

Payer Business 1 S 1000A

Contact Information
Contact Function Code ID 2--2 R CX
Payer Contact Name AN 1 -- 60 S
Communication # Qualifier ID 2--2 S EM,FX,TE
Payer Contact Communication AN 1-256 S
#
Communication Number ID 2--2 S EM,EX,FX,TE
Qualifier 2
#
Communication Number ID 2--2 S EX
Qualifier 3
#
Contact Inquiry Reference AN 1 -- 20 N/U
Payer Technical >1 R 1000A
Contact Information
Contact Function Code ID 2--2 R BL
Payer Contact Name AN 1 -- 60 S
Communication # Qualifier ID 2--2 S EM, TE, UR
#
Communication Number ID 2--2 S UR
Qualifier 2
#
Communication Number ID 2--2 S EM, EX, FX, UR
Qualifier 3
#
Payer Web Site 1 S 1000A

Contact Function Code ID 2--2 R 1C
Name AN 1 -- 60 N/U
Communication # Qualifier ID 2--2 R UR
Payer Contact Communication AN 1-256 R
#
Communication Number ID 2--2 N/U
Qualifier
Communication Number AN 1-256 N/U
Communication Number ID 2--2 N/U
Qualifier
Communication Number AN 1-256 N/U
Payee Identification 1 R 1000B 1
Entity Identifier Code ID 2--3 R PE

Payee Name AN 1--60 R
Identification Code Qualifier ID 1--2 R XX, FI, XV
Payee ID Code AN 2--80 R
Payee Address 1 S 1000B
Payee Address Line AN 1--55 R

Payee Address Line AN 1--55 S
Payee City,State,Zip 1 R 1000B
Payee City Name AN 2--30 R

Payee State Code ID 2--2 S
Payee Postal Zone or ZIP Code ID 3 -- 15 S
Country Code ID 2--3 S

Location Qualifier ID 1--2 N/U
Location Identifier AN 1--30 N/U
Country Subdivision Code ID 1--3 S
Payee Additional >1 S 1000B
Identification
Reference Identification ID 2--3 R TJ
Qualifier
Additional Payee ID # AN 1--50 R
Description AN 1 -- 80 N/U
Remittance Delivery 1 S 1000B

Method
Report Transmission Code ID 1--2 BM, EM, FT, OL
Name AN 1--60
Communication Number AN 1--256
Header Number 1 S 2000 >1

Assigned # N0 1--6 R TTYYMM
Provider Summary 1 S 2000

Information
Provider Identifier AN 1--60 R NPI
Facility Code Value AN 1--2 R TT
Total Claim Count 9(6) R 1--15 R
Total Claim Change Amount R 1--18 R
S9(9)V99
Monetary Amount R 1--18 N/U
Total MSP Payer Amount R 1--18 S
S9(9)V99
Total Non-Lab Charge Amount R 1--18 S
S9(9)V99
Total HCPCS Reported Charge R 1--18 S
Amount S9(9)V99
Total HCPCS Payable Amount R 1--18 S
S9(9)V99
Total Professional Component R 1--18 S
Amount S9(9)V99
Total MSP Patient Liability Met R 1--18 S

Amount S9(9)V99
Total Patient Reimbursement R 1--18 S
Amount S9(9)V99
Total PIP Claim Coint 9(6) R 1--15 S
Total PIP Adjustment Amount R 1--18 S
S9(9)V99
Provider Supplemental 1 S 2000
Summary Info
Total DRG Amount S9(9)V99 R 1--18 S
Total Federal Specific Amount R 1--18 S
Total Hospital Specifc Amount R 1--18 S
Total Disproportionate Amount R 1--18 S
Total Capital Amount R 1--18 S

Total Indirect Medical R 1--18 S
Education Amount
Total Outlier Day Count 9(6) R 1--15 S
Total Day Outlier Amount R 1--18 S
Total Cost Outlier Amount R 1--18 S
Average DRG Length of Stay R 1--15 S
9(6)
Total Discharge Count 9(6) R 1--15 S
Total Cost Report Day Count R 1--15 S
9(6)
Total Covered Day Count 9(6) R 1--15 S
Total Noncovered Day Count R 1--15 S

9(6)
Total MSP Pass-Through R 1--18 S
Amount
Average DRG Weight R 1--15 S
Total PPS Capital FSP DRG R 1--18 S
Amount
Total PSP Capital HSP DRG R 1--18 S
Amount
Total PPS DSH DRG Amount R 1--18 S
Claim Level Data 1 R 2100 >1

Patient Control # AN 1--38 R
Claim Status Code ID 1--2 R 1, 2, 3, 4, 19, 20,
21, 22, 23
Total Claim Charge Amount R 1--18 R

S9(9)V99
Claim Payment Amount R 1--18 R
S9(9)V99
Patient Responsibility Amount R 1--18 S
S9(9)V99
Claim Filling Indicator Code ID 1--2 R MA
Payer Claim Control # AN 1--50 S
Facility Type Code (1st and 2nd AN 1--2 S
position of TOB)
Claim Frequency Code (3rd ID 1--1 S
position of TOB)
Patient Status Code ID 1--2 N/U
DRG Code ID 1--4 S
DRG Weight S9(3)V9999 R 1--15 S
Discharge Fraction S9(4)V999 R 1--10 S
Yes/No Condition or Response ID 1--1 N/U
Code
Claim Adjustment 99 S 2100

Claim Adjustment Group Code ID 1--2 R CO, OA, PR, PI
Adjustment Reason Code ID 1--5 R

Adjustment Amount S9(7)V99 R 1--18 R
Adjustment Quantity 9(5) R 1--15 S

Adjustment Reason Code ID 1--5 S
Adjustment Amount S9(7)V99 R 1--18 S




Patient Name 1 R 2100

Entity Identifier Code ID 2--3 R QC
Entity Type Qualifier ID 1--1 R 1
Patient Last Name AN 1--60 S
Patient First Name AN 1--35 S
Patient Middle Name AN 1--25 S
Name Prefix AN 1--10 N/U
Patient Name Suffix AN 1--10 S N/U
ID Code Qualifier ID 1--2 S HN
Patient Identifier AN 2--80 S HIC #
Name Last or Organization AN 1--60 N/U
Name
Insured's Name 1 S 2100 N/A
Corrected 1 S 2100
Patient/Insured Name
Entity Identifier Code ID 2--3 R 74

Corrected Patient/Ins Last AN 1--60 S
Name
Corrected Patient/Ins First AN 1--35 S
Name
Corrected Patient/Ins Middle AN 1--25 S
Name
Corrected Patient Name Suffix AN 1--10 S
Identification Code Qualifier ID 1--2 S C

Corrected Ins Identification AN 2--80 S
Indicator
Name
Service Provider Name 1 S 2100
Entity Identifier Code ID 2--3 R 82

Rendering Provider Last/Org AN 1--60 S
Name
Rendering Provider First Name AN 1--35 S NA
Rendering Provider Middle AN 1--25 S NA

Name
Name Prefix AN 1--10 N/U NA
Rendering Provider Name AN 1--10 S NA
Suffix
ID Code Qualifier ID 1--2 R XX
Rendering Provider Identifier AN 2--80 R NPI
Name
Crossover Carrier 1 S 2100

Name
Entity Identifier Code ID 2--3 R TT
COB Carrier Name AN 1--60 R
First name AN 1--35 N/U
Middle name AN 1--25 N/U
Name suffix AN 1--10 N/U
ID Code Qualifier ID 1--2 R PI,XV
COB Carrier Identifier AN 2--80 R
Name
Corrected Priority 1 S 2100

Payer Name
Entity Identifier Code ID 2--3 R PR
Corrected Priority Payer Name AN 1--60 R
First name AN 1--35 N/U

middle name AN 1--25 N/U
Name suffix AN 1--10 N/U
ID Code Qualifier ID 1--2 R PI,XV
Corrected Priority Payer ID AN 2--80 R
Name
Other Subscriber Name N/A
Inpatient Adjudication 1 S 2100

Information
Covered Daya or Visits Count R 1--15 R

S(9)3
PPS Operating Outlier Amount R 1--18 S
S9(7)V99
Lifetime Psychiatric Days Count R 1--15 S
S9(3)
CLAIM DRG AMOUNT R 1--18 S
S9(7)V99
CLAIM PAYMENT REMARK AN 1--50 S
CD
CLAIM DSH AMOUNT R 1--18 S
S9(7)V99
CLAIM MSP PASS THRU AMT R 1--18 S
S9(7)V99
CLAIM PPS CAPITAL R 1--18 S
AMOUNT S9(7)V99
PPS CAPITAL FSP DRG AMT R 1--18 S
S9(7)V99
PPS CAPITAL HSP DRG AMT R 1--18 S
S9(7)V99
PPS CAPITAL DSH DRG AMT R 1--18 S
S9(7)V99
OLD CAPITAL AMOUNT R 1--18 S
S9(7)V99
PPS CAPITAL IME AMOUNT R 1--18 S
S9(7)V99
PPS OPER HSP SPEC DRG R 1--18 S
AMT S9(7)V99
COST REPORT DAY COUNT R 1--15 S
S(9)3
PPS OPER FSP SPEC DRG R 1--18 S
AMT S9(7)V99
CLAIM PPS OUTLIER R 1--18 S
AMOUNT S9(7)V99
CLAIM INDIRECT TEACHING R 1--18 S
S9(7)V99
NON PAY PROF COMP AMT R 1--18 S
S9(7)V99
CD
CD
CD
CD
PPS CAPITAL EXCEPTION R 1--18 S
AMT S9(7)V99
Outpatient 1 S 2100
Adjudication
Information
Reimbursement Rate R 1--10 S
S9(4)V9999
Claim HCPCS Payable Amount R 1--18 S
S9(7)V99
Remark Code AN 1--50 S
Claim ESRD Payment Amount R 1--18 S
S9(7)V99
Nonpayable Professional Comp R 1--18 S
Amt S9(7)V99
Other Claim-Related 5 S 2100

Identification
Reference Identification ID 2--3 R EA, 6P, 28
Qualifier
Other Claim Related Identifier AN 1--50 R
Rendering Provider 10 S 2100

Identification
Reference Identification ID 2--3 R 1J
Qualifier
Rendering Provider Secondary AN 1--50 R
Identifier
Statement From or To 2 S 2100

Date
Claim Date DT 8--8 R CCYYMMDD
Time TM 4--8 N/U
Qualifier
Coverage Expiration 1 S 2100 N/A

Date
Date/Time Qualifier ID 3--3 R
Date DT 8--8 R
Time TM 4--8 N/U
Qualifier
Claim Received Date 1 S 2100

Date/Time Qualifier ID 3--3 R 50
Time TM 4--8 N/U
Qualifier
Claim Contact 2 S 2100

Information
Contact Function Code ID 2--2 R CX
Claim Contact Name AN 1--60 S
Communication # Qualifier ID 2--2 R EM,FX,TE
Claim Contact Communication AN 1--256 R
#
Communication # Qualifier ID 2--2 S EM,EX,FX,TE
Claim Contact Communication AN 1--256 S
#
Communication # Qualifier ID 2--2 S EX
Communication # Extension AN 1--256 S
Contact Inquiry Reference AN 1--20 N/U
Claim Supplemental 13 S 2100

Information
Amount Qualifier Code ID 1--3 R AU, DY, F5, I,
NL, ZK, ZL
Claim Supplemental R 1--18 R
Information Amt S9(7)V99
Credit/Debit Flag Code ID 1--1 N/U
Claim Supplemental 14 S 2100

Infor Quantity
Quantity Qualifier ID 2--2 R CA, CD, LA, OU
ZK, ZL
Quantity Qualifier R 1--15 R

Composite Unit Of Measure N/U
Free-formInformation AN 1--30 N/U
Information 1 S 2110 999

Composite Medical Procedure R
Identifier
Product or Service ID Qualifier ID 2--2 R HC, HP, N4, N/U
Adjudicated Procedure Code AN 1--48 R
Procedure Modifier AN 2--2 S

Product/Service ID AN 1--48 N/U
Line Item Charge Amount R 1--18 R
S9(7)V99
Line Item Provider Payment R 1--18 R
S9(7)V99
N/UBC Revenue Code AN 1--48 S
Units of Service Paid Count R 1--15 S
S9(6)
Composite Medical Procedure S

Identifier
Product or Service ID Qualifier ID 2--2 R HC, HP, N4, N/U
Procedure Code AN 1--48 R

Procedure Code Description AN 1--80 S
Product/Service ID AN 1--48 N/U
Original Units of Service Count R 1--15 S
S9(6)
Service Date 2 S 2110

Service Date DT 8--8 R CCYYMMDD
Time TM 4--8 N/U
Qualifier
Service Adjustment 99 S 2110

Claim Adjustment Group Code ID 1--2 R CO,OA,PR
Adjustment Reason Code ID 1--5 R

Adjustment Amount S9(7)V99 R 1--18 R
Adjustment Quantity S9(5) R 1--15 S





Service Identification 8 S 2110

Reference ID Qualifier ID 2--3 R LU
Provider ID AN 1--50 R
Line Item Control 1 S 2110

Number
Reference ID Qualifier ID 2--3 R
Line Item Control Number AN 1--50 R
Rendering Provider 10 S 2110

Information
Reference ID Qualifier ID 2--3 R HPI
Rendering Provider ID AN 1--50 R
Health Care Policy 5 S 2110

Identification
Reference ID Qualifier ID 2--3 R 0K
Healthcare Policy ID AN 1--50 R
Service Supplemental 9 S 2110

Amount
Amount Qualifier Code ID 1--3 R B6, KH

Service Supplemental Amount R 1--18 R
S9(7)V99
Credit/Debit Flag Code ID 1--1 N/U
Service Supplemental 6 S 2110

Quantity
Quantity Qualifier ID 2--2 R
Service Supplemental Quantity R 1--15 R

Count
Composite Unit Of Measure N/U
Free-formInformation AN 1--30 N/U
Health Care Remarks 99 S 2110

Codes
Code List Qualifier Code ID 1--3 R HE
Remark Code AN 1--30 R
Provider Level >1 S ------ 1

Adjustment
Provider Identifier AN 1--50 R NPI
Fiscal Period Date DT 8--8 R CCYYMMDD
Adjustment Identifier R
Adjustment Reason Code ID 2--2 R CS, AP, FB, LE,
L6, 50, SL, WO,
B2, IR, 72, J1
Provider Adjustment Identifier AN 1--50 S
Provider Adjustment Amount R 1--18 R

S9(7)V99
Adjustment Identifier S
L6, 50, SL, WO,
B2, IR, 72, J1
Provider Adjustment Amount R 1--18 S

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
L6, 50, SL, WO,
B2, IR, 72, J1

S9(7)V99
Transition Set Trailer 1 R --- 1
Transition Segment Count N0 1--10 R
Transition Set Control # AN 4--9 R =ST02
Functional Group 1 R -- 1

Trailer
# Transaction Sets Included N0 1 -- 6 R
Group Control # N0 1 -- 9 R
Interchange Control 1 R --- 1

Trailer
# Included Functional Groups N0 1 -- 5 R
Interchange Control # N0 9 -- 9 R
ID Transaction 4010 4010 Description ID Min. Usage Loop Loop Values
Element Max. Reg. Repeat
Identifier
1
2 837H
3 837
4 837
5 837
6 837
7 837
8 837
9 837
10 837
11 837
12 837
13 837
14 837
15 837
16 837
17 837
18 837
19
20
21
22
23
24
25
26
27
28 ST TRANSACTION SET R 1
HEADER
29 ST01 Transaction Set Identifier ID 3-3 R 837
Code
Number
31
32 BHT BEGINNING OF R 1
HIERARCHICAL
TRANSACTION
33 BHT01 Hierarchical Structure ID 4-4 R 0019
Code
34 BHT02 Transaction Set Purpose ID 2-2 R 00,18
Code
35 BHT03 Reference Identification AN 1-30 R
36 BHT04 Date DT 8-8 R

38 BHT06 Transaction Type Code ID 2-2 R CH,RP
REF TRANSACTION TYPE 3 R 1

IDENTIFICATION
REF01 Reference Identification ID 2-3 R 87
Qualifier

40 NM1 SUBMITTER NAME R 1000A 1

42 NM102 Entity Type Qualifier ID 1-1 R 1,2
43 NM103 NAME LAST OR ID 1-60 R
ORGANIZATION NAME
44 NM104 Name First AN 1 - 35 S

45 NM105 Name Middle AN 1-25 S
46 NM106 Name Prefix AN 1-10 N/U
47 NM107 Name Suffix AN 1-10 N/U
48 NM108 Identification Code ID 1-2 R 46
Qualifier
49 NM109 Identification Code AN 2-80 R

52
N2 ADDITIONAL S 1000A 1
SUBMITTER NAME
INFORMATION
N201 Name AN 1-60 R

N202 Name AN 1-60 N/U
53 PER SUBMITTER CONTACT R 1000A 2

INFORMATION
54 PER01 Contact Function Code ID 2-2 R IC
55 PER02 Name AN 1-60 R

56 PER03 Communication Number ID 2-2 R ED,EM,F
Qualifier X,TE
57 PER04 Communication Number AN 1-80 R
58 PER05 Communication Number ID 2-2 S ED,EM,E

Qualifier X,FX,TE
59 PER06 Communication Number AN 1-80 S

Qualifier
62 PER09 Contact Inquiry AN 1-20 N/U

Reference
64 NM1 RECEIVER NAME R 1000B 1

67 NM103 NAME LAST OR AN 1 - 35 R
ORGANIZATION NAME
68 NM104 Name First AN 1-25 N/U

69 NM105 Name Middle AN 1-25 N/U
72 NM108 Identification Code ID 1-2 R 46
Qualifier

76
N2 RECEIVER ADDITIONAL S 1000B 1

NAME INFORMATION
N201 Name AN 1-60 R

77 HL BILLING/PAY-TO R 2000A >1

PROVIDER
HIERARCHICAL LEVEL
79 HL01 Hierarchical ID Number AN 1-12 R
80 HL02 Hierarchical Parent ID AN 1-12 N/U

Number
83 PRV BILLING/PAY-TO S 2000A 1

PROVIDER SPECIALTY
INFORMATION
84 PRV01 Provider Code ID 1-3 R BI,PT

85 PRV02 Reference Identification ID 2-3 R ZZ
Qualifier
86 PRV03 Reference Identification AN 1-30 R


INFORMATION
Code
90 CUR FOREIGN CURRENCY S 2000A 1

INFORMATION
91 CUR01 Entity Identifier Code ID 2-3 R 85
92 CUR02 Currency Code ID 3-3 R
93 CUR03 Exchange Rate R 4-10 N/U
94 CUR04 Entity Identifier Code ID 2-3 N/U
95 CUR05 Currency Code ID 3-3 N/U
96 CUR06 Currency ID 3-3 N/U
Market/Exchange Code
97 CUR07 Date/Time Qualifier ID 3-3 N/U

98 CUR08 Date DT 8-8 N/U
99 CUR09 Time TM 4-8 N/U
113 NM1 BILLING PROVIDER R 2010AA 1

NAME
116 NM103 NAME LAST OR ID 1 - 35 R
ORGANIZATION NAME
117 NM104 Name First AN 1-25 S

120 NM107 Name Suffix AN 1-10 S
121 NM108 Identification Code ID 1-2 R 24,34,XX
Qualifier

125
N2 ADDITIONAL BILLING S 2010AA 1

PROVIDER NAME
INFORMATION
N201 Name AN 1-60 R

126 N3 BILLING PROVIDER R 2010AA 1

ADDRESS
127 N301 Address Information AN 1-55 R
128 N302 Address Information AN 1-55 S
129 N4 BILLING PROVIDER R 2010AA 1

CITY, STATE, ZIP
CODE
132 N403 Postal Code ID 3-15 R

135 N406 Location Identifier AN 1-30 N/U
136
137 REF BILLING PROVIDER S 2010AA 5

SECONDARY
IDENTIFICATION
NUMBER
138 REF01 Reference Identification ID 2-3 R 0B,1A,1B
Qualifier ,1C,1D,1
E,1H,EI,G
2,G5,LU,
SY,TJ
139 REF02 Reference Identification AN 1-30 R
140 REF03 Description AN 1-80 N/U

142 REF CLAIM SUBMITTER S 2010AA 8
CREDIT/DEBIT CARD
INFORMATION
143 REF01 Reference Identification ID 2-3 R 06,8U,EM
Qualifier ,IJ,LU,RB
,ST,TT

147
148
149
150
151
152
153
154
155
156
157 NM1 PAY-TO PROVIDERS S 2010AB 1

NAME
ORGANIZATION NAME

Qualifier

170
N2 ADDITIONAL PAY-TO S 2010AB 1

PROVIDER NAME
INFORMATION
N201 Name AN 1-60 R

171 N3 PAY-TO PROVIDERS R 2010AB 1

ADDRESS
174 N4 PAY-TO PROVIDER R 2010AB 1

CITY, STATE, ZIP
CODE

181
REF PAY-TO PROVIDER S 2010AB 5

SECONDARY
IDENTIFICATION
NUMBER
REF01 Reference Identification ID 2-3 R 0B,1A,1B
Qualifier ,1C,1D,1
E,1H,EI,G
2,G5,LU,
SY,TJ

196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
218 HL SUBSCRIBER 2000B 1

HIERARCHICAL LEVEL
220 HL02 Hierarchical Parent ID AN 1-12 R

Number
222 HL04 Hierarchical Child Code ID 1-1 R 0,1
223 SBR SUBSCRIBER R 2000B 1

INFORMATION
224 SBR01 Payer Responsibility ID 1-1 R P,S,T
225 SBR02 Individual Relationship ID 2-2 S 18

Code
226 SBR03 Reference Identification AN 1-30 S
227 SBR04 Name AN 1-60 S

228 SBR05 Insurance Type Code ID 1-3 N/U
229 SBR06 Coordination of Benefits ID 1-1 R 1,6

Code
230 SBR07 Yes/No Condition or ID 1-1 N/U
Response Code
231 SBR08 Employment Status Code ID 2-2 N/U
232 SBR09 Claim Filing Indicator ID 1-2 S 09,11,12,
Code 13,14,15,
16,17,BL,
CH,CI,DS
,FI,HM,L
M,MB,MC
,MH,OF,S
A,VA,WC,
ZZ
234 NM1 SUBSCRIBER NAME R 2010BA 1

ORGANIZATION NAME

242 NM108 Identification Code ID 1-2 S MI,ZZ
Qualifier
243 NM109 Identification Code AN 2-80 S

246
N2 ADDITIONAL S 2010BA 1
SUBSCRIBER NAME
INFORMATION
N201 Name AN 1-60 R

N3 SUBSCRIBER ADDRESS S 2010BA 1

N4 SUBSCRIBER S 2010BA 1
CITY,STATE,ZIP CODE

257
258 DMG SUBSCRIBER S 2010BA 1

DEMOGRAPHIC
INFORMATION
259 DMG01 Date Time Period Format ID 2-3 R D8

Qualifier
260 DMG02 Date Time Period AN 1 - 35 R
261 DMG03 Gender Code ID 1-1 R F,M,U
263 DMG05 COMPOSITE RACE OR N/U
ETHNICITY

Code
267 DMG09 Quantity R 1-15 N/U
268
269
270 REF SUBSCRIBER S 2010BA 4

SECONDARY
IDENTIFICATION
271 REF01 Reference Identification ID 2-3 R 1W,23,IG,

Qualifier SY

275 REF PROPERTY AND S 2010BA 1

CASUALTY CLAIM
NUMBER
276 REF01 Reference Identification ID 2-3 R Y4

Qualifier

291 NM1 PAYER NAME R 2010BB 1

292 NM101 Entity Identifier Code ID 2-3 R PR
ORGANIZATION NAME

299 NM108 Identification Code ID 1-2 R PI,XV
Qualifier

303
N2 ADDITIONAL PAYER S 2010BB 1

NAME INFORMATION
N201 Name AN 1-60 R
304 N3 PAYER ADDRESS S 2010BB 1

307 N4 PAYER CITY, STATE, ZIP S 2010BB 1

CODE

314
315 REF PAYER SECONDARY S 2010BB 3
IDENTIFICATION
316 REF01 Reference Identification ID 2-3 R 2U,FY,NF,
Qualifier TJ

320
321
322
323
324
291 NM1 CREDIT/DEBIT CARD S 2010BC 1

HOLDER NAME
292 NM101 Entity Identifier Code ID 2-3 R AO
ORGANIZATION NAME

299 NM108 Identification Code ID 1-2 R MI
Qualifier
N2 ADDITIONAL PAYER S 2010BC 1

NAME INFORMATION
N201 Name AN 1-60 R
N202 Name AN 1-60 S
315 REF PAYER SECONDARY S 2010BC 3
IDENTIFICATION
316 REF01 Reference Identification ID 2-3 R BB
Qualifier

327 HL PATIENT S 2000C 1

HIERARCHICAL LEVEL
329 HL02 Hierarchical Parent ID AN 1-12 R

Number
332 PAT PATIENT INFORMATION R 2000C 1
333 PAT01 Individual Relationship ID 2-2 R 01,19,20,

Code 22,29,41,
53,76
334 PAT02 Patient Location Code ID 1-1 N/U

335 PAT03 Employment Status Code ID 2-2 N/U
336 PAT04 Student Status Code ID 1-1 S F,N,P

337 PAT05 Date Time Period Format ID 2-3 N/U
Qualifier
338 PAT06 Date Time Period AN 1 - 35 N/U
339 PAT07 Unit or Basis for ID 2-2 N/U
Measurement Code
340 PAT08 Weight R 1-10 N/U
341 PAT09 Yes/No Condition or ID 1-1 N/U
Response Code
343 NM1 PATIENT NAME R 2010CA 1

344 NM101 Entity Identifier Code ID 2-3 R QC
ORGANIZATION NAME
347 NM104 Name First AN 1-25 R

351 NM108 Identification Code ID 1-2 S MI,ZZ
Qualifier

355
N2 ADDITIONAL NAME S 2010CA 1

INFORMATION
N201 Name AN 1-60 R
356 N3 PATIENT ADDRESS R 2010CA

359 N4 PATIENT CITY, STATE, R 2010CA 1

ZIP CODE

366
367 DMG PATIENT DEMOGRAPHIC R 2010CA 1

INFORMATION

Qualifier
372 DMG05 COMPOSITE RACE OR N/U
ETHNICITY

Code
377
378
379 REF PATIENT SECONDARY S 2010CA 5

IDENTIFICATION

Qualifier SY

379 REF PROPERTY AND S 2010CA 1

CASUALTY CLAIM
NUMBER
380 REF01 Reference Identification ID 2-3 R Y4

Qualifier

395 CLM CLAIM INFORMATION R 2300 100

396 CLM01 Claim Submitter’s AN 1-38 R
Identifier
397 CLM02 Monetary Amount R 1-18 R
398 CLM03 Claim Filing Indicator ID 1-2 N/U
Code
399 CLM04 Non-Institutional Claim ID 1-2 N/U
Type Code
400 CLM05 HEALTH CARE SERVICE R
LOCATION
INFORMATION
401 CLM05 - 1 Facility Code Value AN 1-2 R
402 CLM05 - 2 Facility Code Qualifier ID 1-2 N/U
403 CLM05 - 3 Claim Frequency Type ID 1-1 R 1,6,7,8

Code
404 CLM06 Yes/No Condition or ID 1-1 R N,Y
Response Code
405 CLM07 Provider Accept ID 1-1 S A,C,P
Assignment Code
406 CLM08 Yes/No Condition or ID 1-1 R N,Y
Response Code
407 CLM09 Release of Information ID 1-1 R N,Y
Code
408 CLM10 Patient Signature Source ID 1-1 N/U
Code
409 CLM11 RELATED CAUSES S
INFORMATION
410 CLM11 - 1 Related-Causes Code ID 2-3 R AA,EM,O
A
411 CLM11 - 2 Related-Causes Code ID 2-3 S AA,EM,O
A
412 CLM11 - 3 Related-Causes Code ID 2-3 S AA,EM,O
A
413 CLM11 - 4 State or Province Code ID 2-2 S
414 CLM11 - 5 Country Code ID 2-3 S
415 CLM12 Special Program Code ID 2-3 S 01,02,03,

05
416 CLM13 Yes/No Condition or ID 1-1 N/U
Response Code
417 CLM14 Level of Service Code ID 1-3 N/U
Response Code
419 CLM16 Provider Agreement ID 1-1 N/U
Code
420 CLM17 Claim Status Code ID 1-2 N/U
Response Code
422 CLM19 Claim Submission ID 2-2 S PB
Reason Code
423 CLM20 Delay Reason Code ID 1-2 S 1,2,3,4,5,
6,7,8,9,10
,11
424 DTP DATE - ADMISSION S 2300 1

425 DTP01 Date/Time Qualifier ID 3-3 R 435
426 DTP02 Date Time Period Format ID 2-3 R D8
Qualifier
427 DTP03 Date Time Period AN 1 - 35 R
428 DTP DATE - DISCHARGE S 2300 1

Qualifier
432 DTP DATE - REFERRAL S 2300 1

Qualifier
436 DTP DATE - ACCIDENT S 2300 1

Qualifier
432 DTP DATE - APPLIANCE S 2300 5

PLACEMENT
Qualifier
436 DTP DATE - SERVICE S 2300 1

438 DTP02 Date Time Period Format ID 2-3 R D8,RD8
Qualifier
440 DN1 ORTHODONTIC TOTAL S 2300 1
MONTHS OF
TREATMENT
441 DN101 Quantity R 1-15 S

442 DN102 Quantity R 1-15 S
443 DN103 Yes/No Condition or ID 1-1 S
Response Code
444 DN104 Description AN 1-80 N/U
445 DN2 TOOTH STATUS S 2300 35

446 DN201 Reference Identification AN 1-30 R
447 DN202 Tooth Status Code ID 1-2 R E,I,M

448 DN203 Quantity R 1-15 N/U
449 DN204 Date Time Period Format ID 2-3 N/U
Qualifier
450 DN205 Date Time Period AN 1 - 35 N/U
451
452 PWK CLAIMS SUPPLEMENTAL S 2300 10

INFORMATION
453 PWK01 Report Type Code ID 2-2 R B4,DA,DG

,EB,OB,OZ
,P6,RB,RR
454 PWK02 Report Transmission ID 1-2 R AA,BM,EL

Code ,EM,FX
455 PWK03 Report Copies Needed N0 1-2 N/U
456 PWK04 Entity Identifier Code ID 2-3 N/U

457 PWK05 Identification Code ID 1-2 S AC
Qualifier
458 PWK06 Identification Code AN 2-80 S
459 PWK07 Description AN 1-80 N/U
460 PWK08 ACTIONS INDICATED N/U
461 PWK09 Request Category Code ID 1-2 N/U
462
463
464
465
466
467
468
469 AMT PATIENT AMOUNT PAID S 2300 1
470 AMT01 Amount Qualifier Code ID 1-3 R F5
471 AMT02 Monetary Amount R 1-18 R

469 AMT CREDIT/DEBIT CARD - S 2300 1

MAXIMUM AMOUNT
470 AMT01 Amount Qualifier Code ID 1-3 R MA

473 REF PREDETERMINATION S 2300 5

IDENTIFICATION
474 REF01 Reference Identification ID 2-3 R G3
Qualifier

478 REF SERVICE S 2300 1

AUTHORIZATION
EXCEPTION CODE
479 REF01 Reference Identification ID 2-3 R 4N

Qualifier
480 REF02 Reference Identification AN 1-30 R 1,2,3,4,5,

6,7
483 REF ORIGINAL REFERENCE S 2300 1

NUMBER (ICN/DCN)
484 REF01 Reference Identification ID 2-3 R F8
Qualifier

488 REF REFERRAL S 2300 1

IDENTIFICATION
489 REF01 Reference Identification ID 2-3 R 9F
Qualifier

493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508 REF CLAIM IDENTIFICATION S 2300 1

NUMBER FOR
CLEARINGHOUSES AND
OTHER TRANSMISSION
INTERMEDIARIES
509 REF01 Reference Identification ID 2-3 R D9

Qualifier

513
514
515
516
517 NTE CLAIM NOTE S 2300 20

518 NTE01 Note Reference Code ID 3-3 R ADD
519 NTE02 Description AN 1-80 R
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586 NM1 REFERRING S 2310A 2
PROVIDER NAME
587 NM101 Entity Identifier Code ID 2-3 R DN,P3
ORGANIZATION NAME

594 NM108 Identification Code ID 1-2 S 24,34,XX
Qualifier

598
599 PRV REFERRING PROVIDER S 2310A 1

SPECIALTY
INFORMATION
600 PRV01 Provider Code ID 1-3 R RF

Qualifier

INFORMATION
Code
N2 ADDITIONAL REFERRING S 2310A 1

PROVIDER NAME
INFORMATION
N201 Name AN 1-60 R

REF REFERRING PROVIDER S 2310A 5

SECONDARY
IDENTIFICATION
607 REF01 Reference Identification ID 2-3 R 0B,1A,1B,

Qualifier 1C,1D,1E,
1H,EI,G2,
G5,LU,SY,
TJ

611
612 NM1 RENDERING PROVIDER S 2310B 1
NAME
ORGANIZATION NAME

620 NM108 Identification Code ID 1-2 S 24,34,XX
Qualifier

624
625 PRV RENDERING PROVIDER R 2310B 1
SPECIALTY
INFORMATION
626 PRV01 Provider Code ID 1-3 R PE

Qualifier

INFORMATION
Code
N2 ADDITIONAL S 2310B 1
RENDERING PROVIDER
NAME INFORMATION
N201 Name AN 1-60 R

632 REF RENDERING PROVIDER S 2310B 5

SECONDARY
IDENTIFICATION

Qualifier 1C,1D,1E,
1H,EI,G2,
G5,LU,SY,
TJ

638 NM1 SERVICE FACILITY S 2310C 1

LOCATION NAME
639 NM101 Entity Identifier Code ID 2-3 R FA
ORGANIZATION NAME

Qualifier

650
N2 ADDITIONAL SERVICE S 2310C 1

FACILITY LOCATION
NAME INFORMATION
N201 Name AN 1-60 R

651
652
653
655
656
657
658
659
660
661
662 REF SERVICE FACILITY S 2310C 5

LOCATION SECONDARY
IDENTIFICATION

Qualifier 1C,1D,1G,
1H,G2,LU,
TJ,X4,X5

667
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
694
695
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
713 SBR OTHER SUBSCRIBER S 2320 10

INFORMATION
714 SBR01 Payer Responsibility ID 1-1 R P,S,T
715 SBR02 Individual Relationship ID 2-2 R 01,18,19,

Code 20,21,22,
29,76
716 SBR03 Reference Identification AN 1-30 S
717 SBR04 Name AN 1-60 S

719 SBR06 Coordination of Benefits ID 1-1 N/U

Code
720 SBR07 Yes/No Condition or ID 1-1 N/U
Response Code
722 SBR09 Claim Filing Indicator ID 1-2 S 09,11,12,

Code 13,14,15,
16,17,BL,
CH,CI,DS,
FI,HM,LM
,MB,MC,
MH,OF,SA
,VA,WC,Z
Z
723 CAS CLAIM ADJUSTMENT S 2320 5
724 CAS01 Claim Adjustment Group ID 1-2 R CO,CR,OA

Code ,PI.PR
725 CAS02 Claim Adjustment ID 1-5 R
Reason Code
726 CAS03 Monetary Amount R 1-18 R
727 CAS04 Quantity R 1-15 S
728 CAS05 Claim Adjustment ID 1-5 S
Reason Code
729 CAS06 Monetary Amount R 1-18 S
Reason Code
Reason Code
Reason Code
Reason Code
743 AMT COORDINATION OF S 2320 1

BENEFITS (COB) PAYER
PAID AMOUNT
744 AMT01 Amount Qualifier Code ID 1-3 R D

743
744
745
746
743
744
745
746

BENEFITS (COB)
APPROVED AMOUNT
744 AMT01 Amount Qualifier Code ID 1-3 R AAE


BENEFITS (COB)
ALLOWED AMOUNT
744 AMT01 Amount Qualifier Code ID 1-3 R B6


BENEFITS (COB) PATIENT
RESPONSIBILITY
AMOUNT


BENEFITS (COB)
COVERED AMOUNT
744 AMT01 Amount Qualifier Code ID 1-3 R AU


BENEFITS (COB)
DISCOUNT AMOUNT
744 AMT01 Amount Qualifier Code ID 1-3 R D8

BENEFITS (COB) PATIENT
PAID AMOUNT

367 DMG PATIENT DEMOGRAPHIC S 2320 1

INFORMATION

Qualifier
372 DMG05 RACE OR ETHNICITY N/U
CODE

Code
755 OI OTHER INSURANCE R 2320 1

COVERAGE
INFORMATION
756 OI01 Claim Filing Indicator ID 1-2 N/U

Code
757 OI02 Claim Submission ID 2-2 N/U
Reason Code
758 OI03 Yes/No Condition or ID 1-1 R N,Y
Response Code
759 OI04 Patient Signature Source ID 1-1 N/U
Code
760 OI05 Provider Agreement ID 1-1 N/U
Code
761 OI06 Release of Information ID 1-1 R N,Y
Code
762
763
764
765
766
767
768
769
770
771
773 NM1 OTHER SUBSCRIBER R 2330A 1

NAME
ORGANIZATION NAME

781 NM108 Identification Code ID 1-2 R 24,MI,ZZ
Qualifier

785
N2 ADDITIONAL OTHER S 2330A 1

SUBSCRIBER NAME
INFORMATION
N201 Name AN 1-60 R

786 N3 OTHER SUBSCRIBER S 2330A 1
ADDRESS

CITY,STATE,ZIP CODE

796
797 REF OTHER SUBSCRIBER S 2330A 3

SECONDARY
IDENTIFICATION

Qualifier SY

803 NM1 OTHER PAYER NAME R 2330B 1

ORGANIZATION NAME

Qualifier

815
N2 ADDITIONAL OTHER S 2330B 1

PAYER NAME
INFORMATION
N201 Name AN 1-60 R


ADDRESS

CITY,STATE,ZIP CODE

796
384 PER OTHER PAYER S 2330B 2

CONTACT
INFORMATION
385 PER01 Contact Function Code ID 2-2 R IC
386 PER02 Name AN 1-60 S

387 PER03 Communication Number ID 2-2 R ED,EM,FX,
Qualifier TE
388 PER04 Communication Number AN 1-80 R
389 PER05 Communication Number ID 2-2 S ED,EM,EX

Qualifier ,FX,TE
391 PER07 Communication Number ID 2-2 S ED,EM,EX

Qualifier ,FX,TE
393 PER09 Contact Inquiry AN 1-20 N/U
Reference
827 DTP CLAIM PAID DATE S 2330B 1

Qualifier
831 REF OTHER PAYER S 2330B 3

SECONDARY IDENTIFIER
832 REF01 Reference Identification ID 2-3 R 2U,D8,F8,

Qualifier FY,NF,TJ

836
837
838
839
840
841 REF OTHER PAYER REFERRAL S 2330B 1

NUMBER
Qualifier

846 REF OTHER PAYER CLAIM S 2330B 1
ADJUSTMENT
INDICATOR
847 REF01 Reference Identification ID 2-3 R T4

Qualifier

851
852
853
854
855
856
857
858
859
860
861
NM1 OTHER PAYER PATIENT S 2330C 1
INFORMATION
862 NM101 Entity Identifier Code ID 2-3 R QC

ORGANIZATION NAME

869 NM108 Identification Code ID 1-2 R MI
Qualifier

873
874
REF OTHER PAYER PATIENT S 2330C 3
IDENTIFICATION

Qualifier SY

879
NM1 OTHER PAYER S 2330D 1
REFERRING PROVIDER

882 NM103 NAME LAST OR AN 1 - 35 N/U DN,P3
ORGANIZATION NAME
883 NM104 Name First AN 1-25 N/U 1,2

Qualifier
888 NM109 Identification Code AN 2-80 N/U

891
892
REF OTHER PAYER S 2330D 3
REFERRING PROVIDER
IDENTIFICATION

Qualifier 1C,1D,1E,
1H,EI,G2,
G5,LU,SY,
TJ

897
NM1 OTHER PAYER S 2330E 1
RENDERING PROVIDER

900 NM103 NAME LAST OR AN 1 - 35 N/U
ORGANIZATION NAME

Qualifier
906 NM109 Identification Code AN 2-80 N/U

909
910
REF OTHER PAYER S 2330E 3
RENDERING PROVIDER
IDENTIFICATION

Qualifier 1C,1D,1E,
1H,EI,G2,
G5,LU,SY,
TJ

915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
946
947
948
949
950
951
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
969
LX LINE COUNTER R 2400 50
970 LX01 Assigned Number N0 1-6 R

971
SV3 DENTAL SERVICE R 2400 1
972 SV301 COMPOSITE MEDICAL R
973 SV301 - 1 Product/Service ID ID 2-2 R AD

Qualifier
974 SV301 - 2 Product/Service ID AN 1-48 R
975 SV301 - 3 Procedure Modifier AN 2-2 S
979 SV301 - 7 Description O AN 1-80 N/U
980
982 SV302 Monetary Amount R 1-18 R
983 SV303 Facility Code Value AN 1-2 S 11,12,21,
22,31,35
984 SV304 ORAL CAVITY S
DESIGNATION
985 SV304 - 1 Oral Cavity Designation ID 1-3 R 00,01,02,
Code 09,10,20,
30,40,L,R
986 SV304 - 2 Oral Cavity Designation ID 1-3 S 00,01,02,
Code 09,10,20,
30,40,L,R

Code 09,10,20,
30,40,L,R

Code 09,10,20,
30,40,L,R

Code 09,10,20,
30,40,L,R
990 SV305 Prosthesis, Crown or ID 1-1 S I,R

Inlay Code
991 SV306 Quantity R 1-15 R
992 SV307 Description AN 1-80 N/U
993 SV308 Copay Status Code ID 1-1 N/U
994 SV309 Provider Agreement ID 1-1 N/U
Code
995 SV310 Yes/No Condition or ID 1-1 N/U
Response Code
996 SV311 COMPOSITE DIAGNOSIS N/U
CODE POINTER
997
998
999
1000
1001
TOO TOOTH INFORMATION S 2400 32
1002 TOO01 Code List Qualifier Code ID 1-3 R JP
1003 TOO02 Industry Code AN 1-30 S

1004 TOO03 TOOTH SURFACE S
1005 TOO03 - 1 Tooth Surface Code ID 1-2 R B,D,F,I,L,
M,O
1006 TOO03 - 2 Tooth Surface Code ID 1-2 S B,D,F,I,L,
M,O
M,O
M,O
M,O
1010
DTP DATE - SERVICE S 2400 1
Qualifier
DTP DATE - PRIOR S 2400 1

PLACEMENT
Qualifier
DTP DATE - APPLIANCE S 2400 1

PLACEMENT
Qualifier
DTP DATE - REPLACEMENT S 2400 1

Qualifier
1017
1018
1019
1020
1021
1022
QTY ANESTHESIA QUANTITY S 2400 5
QTY01 Quantity Qualifier ID 2-2 R BF,EM,H

M,HO,HP,
P3,P4,P5,
SG
QTY02 Quantity R 1-15 R

QTY03 Composite Unit of N/U
Measure
QTY04 Free-Form Message AN 1-30 N/U
1030
1031
1032
1033
1034
1035
1036
REF SERVICE S 2400 1
PREDETERMINATION
IDENTIFICATION
1037 REF01 Reference Identification ID 2-3 R G3

Qualifier

1041
1042
1043
1044
1045
1046
1047
1048
1049
1050
1051
1052
1053
1054
1055
1056
REF LINE ITEM CONTROL S 2400 1

NUMBER
1057 REF01 Reference Identification ID 2-3 R 6R
Qualifier

1061
1057
1058
1059
1060
1061
1057
1058
1059
1060
1061
REF REFERRAL NUMBER S 2400 1
Qualifier

1074
1075
1076
1077
1078
1079
1080
AMT APPROVED AMOUNT S 2400 1
1081 AMT01 Amount Qualifier Code ID 1-3 R AAE

1084
1081
1082
1083
1084
1091
1092
1093
1094
1095
1096
1097
1098
1099
1100
1101
1102
1103
1104
NM1 RENDERING PROVIDER S 2420A 1
NAME
ORGANIZATION NAME

Qualifier

1116
1117
PRV RENDERING PROVIDER R 2420A 1
SPECIALTY
INFORMATION
1118 PRV01 Provider Code ID 1-3 R PE

Qualifier

INFORMATION
Code
1124
N2 ADDITIONAL S 2420A 1
RENDERING PROVIDER
NAME INFORMATION
N201 Name AN 1-60 R

REF RENDERING PROVIDER S 2420A 5

SECONDARY
IDENTIFICATION

Qualifier 1C,1D,1E,
1H,EI,G2,
G5,LU,SY,
TJ

1129
1130
1131
1132
1133
1134
1135
NM1 OTHER PAYER REFERRAL S 2420B 1
NUMBER
ORGANIZATION NAME

Qualifier

1147
1148
1149
1150
1151
1152
1153
1154
1155
REF OTHER PAYER REFERRAL S 2420B 1
NUMBER

Qualifier

1160
1161
1162
1163
1164
1165
1166
1167
1168
1169
1170
1171
1172
1173
1174
1175
1176
1177
1178
1179
1180
1181
1182
1183
1184
1185
1186
1187
1188
1189
1190
1191
1192
1193
1194
1195
1196
1197
1198
1199
1200
1201
1202
1203
1204
1205
1206
1207
1208
1209
1210
1211
1212
1213
1214
1215
1216
1217
1218
1219
1220
1221
1222
1223
1224
SVD LINE ADJUDICATION S 2430 1
INFORMATION
1225 SVD01 Identification Code AN 2-80 R
1226 SVD02 Monetary Amount R 1-18 R
1227 SVD03 COMPOSITE MEDICAL R
1228 SVD03 - 1 Product/Service ID ID 2-2 R AD,ZZ

Qualifier
1229 SVD03 - 2 Product/Service ID AN 1-48 R
1230 SVD03 - 3 Procedure Modifier AN 2-2 S
1234 SVD03 - 7 Description AN 1-80 S
1235
1236 SVD04 Product/Service ID AN 1-48 N/U
1237 SVD05 Quantity R 1-15 R
1238 SVD06 Assigned Number N0 1-6 S
1239
CAS SERVICE ADJUSTMENT S 2430 99
1240 CAS01 Claim Adjustment Group ID 1-2 R CO,CR,OA

Code ,PI,PR
1241 CAS02 Claim Adjustment ID 1-5 R
Reason Code
1242 CAS03 Monetary Amount R 1-18 R
Reason Code
Reason Code
Reason Code
Reason Code
Reason Code
1259
DTP LINE ADJUDICATION R 2430 1
DATE
Qualifier
1263
1264
1265
1266
1267
SE TRANSACTION SET R 1
TRAILER
1268 SE01 Number of Included N0 1-10 R
Segments
Number
1270
1271
1272
1273
1274
1275
1276
1277
1278
1279
1280
1281
1282
1283
1284
5010 5010 Description ID Min. Usage Loop Loop Values
Element Max. Reg. Repeat
Identifier
ISA INTERCHANGE 1 R
CONTROL HEADER
ISA01 Authorization ID 2-2 R 0,3
Information Qualifier
ISA02 Authorization AN 10-10 R
Information
ISA03 Security Information ID 2-2 R 00,01
Qualifier
ISA04 Security Information AN 10-10 R
ISA05 Interchange ID Qualifier ID 2-2 R 01,14,20,
27,28,29,
30,ZZ
ISA07 Interchange ID Qualifier ID 2-2 R 01,14,20,

27,28,29,
30,ZZ
ISA09 Interchange Date DT 6-6 R

ISA10 Interchange Time TM 4-4 R
ISA11 Repetition Separator 1-1 R
ISA12 Interchange Control ID 5-5 R 00501
Version Number
Number
ISA14 Acknowledgment ID 1-1 R 0,1
Requested
ISA15 Interchange Usage ID 1-1 R P,T
Indicator
Separator
HEADER
Code
GS02 Application Sender’s AN 2-15 R
Code
GS03 Application Receiver’s AN 2-15 R X
Code
GS04 Date DT 8-8 R
GS05 Time TM 4-8 R
GS07 Responsible Agency ID 1-2 R

Code
GS08 Version / Release / AN 1-12 R
ST TRANSACTION SET R 1
HEADER
ST01 Transaction Set Identifier ID 3-3 R 837
Code
Number
ST03 Implementation AN 1 - 35 R
BHT BEGINNING OF R 1
HIERARCHICAL
TRANSACTION
BHT01 Hierarchical Structure ID 4-4 R 0019
Code
BHT02 Transaction Set Purpose ID 2-2 R 00,18
Code
BHT03 Reference Identification AN 1-50 R
BHT04 Date DT 8-8 R

BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 R 31,CH,RP
NM1 SUBMITTER NAME R 1000A 1

NM102 Entity Type Qualifier ID 1-1 R 1,2
NM103 NAME LAST OR ID 1-60 R
ORGANIZATION NAME

NM107 Name Suffix AN 1-10 N/U
NM108 Identification Code ID 1-2 R 46
Qualifier
NM109 Identification Code AN 2-80 R

NM112 NAME LAST OR AN 1-60 N/U
ORGANIZATION NAME
PER SUBMITTER EDI R 1000A 2

CONTACT
INFORMATION
PER01 Contact Function Code ID 2-2 R IC

PER03 Communication Number ID 2-2 R EM,FX,T
Qualifier E
PER05 Communication Number ID 2-2 S EM,EX,F

Qualifier X,TE
PER07 Communication Number ID 2-2 S EM,EX,F

Qualifier X,TE
PER09 Contact Inquiry AN 1-20 N/U

Reference
NM1 RECEIVER NAME R 1000B 1

NM103 NAME LAST OR AN 1-60 R
ORGANIZATION NAME

NM108 Identification Code ID 1-2 R 46
Qualifier

ORGANIZATION NAME
HL BILLING PROVIDER R 2000A >1

HIERARCHICAL LEVEL
HL01 Hierarchical ID Number AN 1-12 R
HL02 Hierarchical Parent ID AN 1-12 N/U

Number
PRV BILLING PROVIDER S 2000A 1

SPECIALTY
INFORMATION
PRV01 Provider Code ID 1-3 R BI

PRV02 Reference Identification ID 2-3 R PXC
Qualifier
PRV03 Reference Identification AN 1-50 R


INFORMATION
Code
CUR FOREIGN CURRENCY S 2000A 1

INFORMATION
CUR01 Entity Identifier Code ID 2-3 R 85
CUR02 Currency Code ID 3-3 R
CUR03 Exchange Rate R 4-10 N/U
CUR04 Entity Identifier Code ID 2-3 N/U
CUR05 Currency Code ID 3-3 N/U
CUR06 Currency ID 3-3 N/U
Market/Exchange Code
CUR07 Date/Time Qualifier ID 3-3 N/U

CUR08 Date DT 8-8 N/U
CUR09 Time TM 4-8 N/U
NM1 BILLING PROVIDER R 2010AA 1

NAME
ORGANIZATION NAME

NM107 Name Suffix AN 1-10 S
NM108 Identification Code ID 1-2 S XX
Qualifier

ORGANIZATION NAME
N3 BILLING PROVIDER R 2010AA 1

ADDRESS
N4 BILLING PROVIDER R 2010AA 1

CITY, STATE, ZIP
CODE

Code
REF BILLING PROVIDER R 2010AA

TAX IDENTIFICATION
REF01 Reference Identification ID 2-3 R EI,SY

Qualifier

REF BILLING PROVIDER S 2010AA 2
UPIN/LICENSE
INFORMATION
REF01 Reference Identification ID 2-3 R OB,1G
Qualifier

PER BILLING PROVIDER S 2010AA 2

CONTACT
INFORMATION
PER01 Contact Function Code ID 2-2 R IC

PER03 Communication Number ID 2-2 R EM,FX,TE
Qualifier
PER05 Communication Number ID 2-2 S EM,EX,FX,

Qualifier TE
PER07 Communication Number ID 2-2 S EM,EX,FX,

Qualifier TE
PER09 Contact Inquiry AN 1-20 N/U

Reference
NM1 PAY-TO ADDRESS S 2010AB 1

NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
N3 PAY-TO ADDRESS - R 2010AB 1

ADDRESS
N4 PAY-TO ADDRESS R 2010AB 1

CITY, STATE, ZIP
CODE

Code
NM1 PAY-TO PLAN NAME S 2010AC 1

NM101 Entity Identifier Code ID 2-3 R PE
ORGANIZATION NAME

NM108 Identification Code ID 1-2 R PI,XV
Qualifier

ORGANIZATION NAME
N3 PAY-TO PLAN R 2010AC 1

ADDRESS
N4 PAY-TO PLAN CITY, R 2010AC 1

STATE, ZIP CODE

Code
REF PAY-TO PLAN S 2010AC 1

SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 2U,FY,NF
Qualifier

REF PAY-TO PLAN TAX R 2010AC 1

IDENTIFICATION
NUMBER
REF01 Reference Identification ID 2-3 R EI
Qualifier

HL SUBSCRIBER R 2000B >1

HIERARCHICAL LEVEL
HL02 Hierarchical Parent ID AN 1-12 R

Number
HL04 Hierarchical Child Code ID 1-1 R 0,1
SBR SUBSCRIBER R 2000B 1

INFORMATION
SBR01 Payer Responsibility ID 1-1 R A,B,C,D,
Sequence Number Code E,F,G,H,P
,S,T,U
SBR02 Individual Relationship ID 2-2 S 18

Code
SBR03 Reference Identification AN 1-50 S
SBR04 Name AN 1-60 S

SBR05 Insurance Type Code ID 1-3 S 12,13,14,
15,16,41,
42,43,47
SBR06 Coordination of Benefits ID 1-1 N/U
Code
SBR07 Yes/No Condition or ID 1-1 N/U
Response Code
SBR08 Employment Status Code ID 2-2 N/U
SBR09 Claim Filing Indicator ID 1-2 S 11,12,13,
Code 14,15,16,
17,AM,BL
,CH,CI,D
S,FI,HM,L
M,MA,MB
,MC,OF,T
V,VA,WC,
ZZ
NM1 SUBSCRIBER NAME R 2010BA 1

ORGANIZATION NAME

NM108 Identification Code ID 1-2 R II,MI
Qualifier

NM112 NAME LAST OR ID 1-60 N/U
ORGANIZATION NAME
N3 SUBSCRIBER ADDRESS S 2010BA 1

N4 SUBSCRIBER S 2010BA 1
CITY,STATE,ZIP CODE

Code
DMG SUBSCRIBER S 2010BA 1

DEMOGRAPHIC
INFORMATION
DMG01 Date Time Period Format ID 2-3 R D8

Qualifier
DMG02 Date Time Period AN 1 - 35 R
DMG03 Gender Code ID 1-1 R F,M,U
ETHNICITY

Code
REF SUBSCRIBER S 2010BA 1

SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R S,Y

Qualifier

REF PROPERTY AND S 2010BA 1

CASUALTY CLAIM
NUMBER
REF01 Reference Identification ID 2-3 R Y4

Qualifier

NM1 PAYER NAME R 2010BB 1

NM101 Entity Identifier Code ID 2-3 R PR
ORGANIZATION NAME

NM108 Identification Code ID 1-2 R PI,XV
Qualifier

ORGANIZATION NAME
N3 PAYER ADDRESS S 2010BB 1

N4 PAYER CITY, STATE, ZIP R 2010BB 1

CODE

Code
REF PAYER SECONDARY S 2010BB 3
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 2U,EI,FY,
Qualifier NF

REF BILLING PROVIDER S 2010BB 1

SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R G2,LU

Qualifier

HL PATIENT S 2000C >1
HIERARCHICAL LEVEL
HL02 Hierarchical Parent ID AN 1-12 R

Number
PAT PATIENT INFORMATION R 2000C 1
PAT01 Individual Relationship ID 2-2 R 01,19,20,

Code 21,39,40,
53,G8
PAT02 Patient Location Code ID 1-1 N/U

PAT03 Employment Status Code ID 2-2 N/U
PAT04 Student Status Code ID 1-1 N/U

PAT05 Date Time Period Format ID 2-3 N/U
Qualifier
PAT06 Date Time Period AN 1 - 35 N/U
PAT07 Unit or Basis for ID 2-2 N/U
Measurement Code
PAT08 Weight R 1-10 N/U
PAT09 Yes/No Condition or ID 1-1 N/U
Response Code
NM1 PATIENT NAME R 2010CA 1

NM101 Entity Identifier Code ID 2-3 R QC
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
N3 PATIENT ADDRESS R 2010CA 1

N4 PATIENT CITY, STATE, R 2010CA 1

ZIP CODE

Code
DMG PATIENT DEMOGRAPHIC R 2010CA 1

INFORMATION
DMG01 Date Time Period Format ID 2-3 R D8

Qualifier
DMG02 Date Time Period AN 1 - 35 R
DMG03 Gender Code ID 1-1 R F,M,U
ETHNICITY

Code
REF PROPERTY AND S 2010CA 1

CASUALTY CLAIM
NUMBER
REF01 Reference Identification ID 2-3 R Y4

Qualifier

CLM CLAIM INFORMATION R 2300 100

CLM01 Claim Submitter’s AN 1-38 R
Identifier
CLM02 Monetary Amount R 1-18 R
CLM03 Claim Filing Indicator ID 1-2 N/U
Code
CLM04 Non-Institutional Claim ID 1-2 N/U
Type Code
CLM05 HEALTH CARE SERVICE R
LOCATION
INFORMATION
CLM05 - 1 Facility Code Value AN 1-2 R
CLM05 - 2 Facility Code Qualifier ID 1-2 R B
CLM05 - 3 Claim Frequency Type ID 1-1 R

Code
CLM06 Yes/No Condition or ID 1-1 R N,Y
Response Code
CLM07 Provider Accept ID 1-1 R A,C
Assignment Code
CLM08 Yes/No Condition or ID 1-1 R N,W,Y
Response Code
CLM09 Release of Information ID 1-1 R I,Y
Code
CLM10 Patient Signature Source ID 1-1 N/U
Code
CLM11 RELATED CAUSES S
INFORMATION
CLM11 - 1 Related-Causes Code ID 2-3 R AA,EM,O
A
CLM11 - 2 Related-Causes Code ID 2-3 S AA,EM,O
A
CLM11 - 3 Related-Causes Code ID 2-3 N/U AA,EM,O
A
CLM11 - 4 State or Province Code ID 2-2 S
CLM11 - 5 Country Code ID 2-3 S
CLM12 Special Program Code ID 2-3 S 01,02,03,

05
CLM13 Yes/No Condition or ID 1-1 N/U
Response Code
CLM14 Level of Service Code ID 1-3 N/U
Response Code
CLM16 Provider Agreement ID 1-1 N/U
Code
CLM17 Claim Status Code ID 1-2 N/U
Response Code
CLM19 Claim Submission ID 2-2 S PB
Reason Code
CLM20 Delay Reason Code ID 1-2 S 1,2,3,4,5,
6,7,8,9,10
,11,15
DTP DATE - ACCIDENT S 2300 1

DTP01 Date/Time Qualifier ID 3-3 R 439
DTP02 Date Time Period Format ID 2-3 R D8
Qualifier

PLACEMENT
Qualifier
DTP DATE - SERVICE DATE S 2300 1

DTP02 Date Time Period Format ID 2-3 R D8,RD8
Qualifier
DTP DATE REPRICER S 2300 1

RECEIVED DATE
Qualifier
DN1 ORTHODONTIC TOTAL S 2300 1
MONTHS OF
TREATMENT
DN101 Quantity R 1-15 S

DN102 Quantity R 1-15 S
DN103 Yes/No Condition or ID 1-1 N/U
Response Code
DN104 Description AN 1-80 S
DN2 TOOTH STATUS S 2300 35

DN201 Reference Identification AN 1-50 R
DN202 Tooth Status Code ID 1-2 R E,M

DN203 Quantity R 1-15 N/U
DN204 Date Time Period Format ID 2-3 N/U
Qualifier
DN205 Date Time Period AN 1 - 35 N/U
DN206 Code List Qualifier Code ID 1-3 N/U
PWK CLAIMS SUPPLEMENTAL S 2300 10

INFORMATION
PWK01 Report Type Code ID 2-2 R B4,DA,DG

,EB,OZ,P6,
RB,RR
PWK02 Report Transmission ID 1-2 R AA,BM,EL

Code ,EM,FT,FX
PWK03 Report Copies Needed N0 1-2 N/U
PWK04 Entity Identifier Code ID 2-3 N/U

PWK05 Identification Code ID 1-2 S AC
Qualifier
PWK06 Identification Code AN 2-80 S
PWK07 Description AN 1-80 N/U
PWK08 ACTIONS INDICATED N/U
PWK09 Request Category Code ID 1-2 N/U
CN1 CONTRACT S 2300 1

INFORMATION
CN101 Contract Type Code ID 2-2 R 02,03,04,
05,06,09
CN102 Monetary Amount R 1-18 S
CN103 Percent, Decimal Format R 1-6 S
CN104 Reference Identification AN 1-50 S
CN105 Terms Discount Percent R 1-6 S
CN106 Version Identifier AN 1-30 S
AMT PATIENT AMOUNT PAID S 2300 1
AMT01 Amount Qualifier Code ID 1-3 R F5

REF PREDETERMINATION S 2300 1

IDENTIFICATION
REF01 Reference Identification ID 2-3 R G3
Qualifier


AUTHORIZATION
EXCEPTION CODE
REF01 Reference Identification ID 2-3 R 4N

Qualifier
REF02 Reference Identification AN 1-50 R 1,2,3,4,5,

6,7
REF PAYER CLAIM CONTROL S 2300 1

NUMBER
REF01 Reference Identification ID 2-3 R F8
Qualifier

REF01 Reference Identification ID 2-3 R 9F

Qualifier

REF PRIOR AUTHORIZATION S 2300 1

Qualifier

REF REPRICED CLAIM S 2300 1

NUMBER
REF01 Reference Identification ID 2-3 R 9A
Qualifier

REF ADJUSTRED REPRICED S 2300 1

CLAIM NUMBER
REF01 Reference Identification ID 2-3 R 9C
Qualifier

REF CLAIM IDENTIFIER FOR S 2300 1

TRANSMISSION
INTERMEDIARY
REF01 Reference Identification ID 2-3 R D9

Qualifier

KE FILE INFORMATION S 2300 10

K301 Fixed Format AN 1-80 R
Information
K302 Record Format Code ID 1-2 N/U
K303 COMPOSITE UNIT OF N/U
MEASURE
NTE CLAIM NOTE S 2300 5

NTE01 Note Reference Code ID 3-3 R ADD
NTE02 Description AN 1-80 R
HI HEALTH CARE S 2300 1

DIAGNOSIS CODE
INFORMATION
HI01 - 1 Code List Qualifier Code ID 1-3 R ABK,BK,T
Q
HI01 - 2 Industry Code AN 1-30 R
HI01 - 3 Date Time Period Format ID 2-3 N/U
Qualifier
HI01 - 4 Date Time Period AN 1 - 35 N/U
HI01 - 5 Monetary Amount R 1-18 N/U
HI01 - 6 Quantity R 1-15 N/U
HI01 - 7 Version Identifier AN 1-30 N/U
HI01 - 8 Industry Code AN 1-30 N/U
HI01 - 9 Yes/No Condition or ID 1-1 N/U
Response Code
INFORMATION
HI02 - 1 Code List Qualifier Code ID 1-3 R ABF,BF,T
Q
Qualifier
Response Code
INFORMATION
Q
Qualifier
Response Code
INFORMATION
Q
Qualifier
Response Code
INFORMATION
INFORMATION
INFORMATION
INFORMATION
INFORMATION
INFORMATION
INFORMATION
INFORMATION
HCP CLAIM PRICING / S 2300 1

REPRICING
INFORMATION
HCP01 Pricing Methodology ID 2-2 R 01,02,03,

04,05,06,
07,08,09,
10,11,12,
13,14
HCP02 Monetary Amount R 1-18 R

HCP03 Monetary Amount R 1-18 S
HCP04 Reference Identification AN 1-50 S
HCP05 Rate R 1-9 S

HCP07 Monetary Amount R 1-18 N/U

HCP08 Product/Service ID AN 1-48 N/U
HCP09 Product/Service ID ID 2-2 N/U
Qualifier
HCP11 Unit or Basis for ID 2-2 N/U
Measurement Code
HCP12 Quantity R 1-15 N/U
HCP13 Reject Reason Code ID 2-2 S T1,T2,T3,
T4,T5,T6
HCP14 Policy Compliance Code ID 1-2 S 1,2,3,4,5,
6
HCP15 Exception Code ID 1-2 S 1,2,3,4,5,
6
NM1 REFERRING R 2310A 2

PROVIDER NAME
NM101 Entity Identifier Code ID 2-3 R DN,P3
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
PRV REFERRING PROVIDER S 2310A 1

SPECIALTY
INFORMATION
PRV01 Provider Code ID 1-3 R RF

Qualifier

INFORMATION
Code
REF REFERRING PROVIDER S 2310A 3

SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 0B,1G,G2

Qualifier

NM1 RENDERING PROVIDER S 2310B 1

NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
PRV RENDERING PROVIDER R 2310B 1
SPECIALTY
INFORMATION
PRV01 Provider Code ID 1-3 R PE

Qualifier

INFORMATION
Code
REF RENDERING PROVIDER S 2310B 4

SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 0B,1G,G2,

Qualifier LU

NM1 SERVICE FACILITY S 2310C 1

LOCATION NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
N3 SERVICE FACILITY R 2310C 1

LOCATION ADDRESS
N4 SERVICE FACILITY R 2310C 1

LOCATION CITY, STATE,
ZIP CODE


Code
REF SERVICE FACILITY S 2310C 3

LOCATION SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 0B,G2,LU

Qualifier

NM1 ASSISTANT SURGEON S 2310D 1

NAME
NM101 Entity Identifier Code ID 2-3 R DD
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
PRV ASSISTANT SURGEON R 2310D 1

SPECIALTY
INFORMATION
PRV01 Provider Code ID 1-3 R AS

Qualifier

INFORMATION
Code
REF ASSISTANT SURGEON S 2310D 4

SECONDARY
IDENTIFICATION
Qualifier LU

NM1 SUPERVISING S 2310E 1

PROVIDER NAME
NM101 Entity Identifier Code ID 2-3 R DQ
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
REF SUPERVISING S 2310E 4

PROVIDER
SECONDARY
IDENTIFICATION
Qualifier LU

SBR OTHER SUBSCRIBER S 2320 10

INFORMATION
SBR01 Payer Responsibility ID 1-1 R A,B,C,D,E,
Sequence Number Code F,G,H,P,S,
T,U
SBR02 Individual Relationship ID 2-2 R 01,18,19,

Code 20,21,39,
40,53,G8
SBR03 Reference Identification AN 1-50 S
SBR04 Name AN 1-60 S

SBR05 Insurance Type Code ID 1-3 S 12,13,14,
15,16,41,
42,43,47
SBR06 Coordination of Benefits ID 1-1 N/U

Code
SBR07 Yes/No Condition or ID 1-1 N/U
Response Code
SBR09 Claim Filing Indicator ID 1-2 S 11,12,13,

Code 14,15,16,
17,AM,BL,
CH,CI,DS,
FI,HM,LM
,MA,MB,
MC,OF,TV
,VA,WC,Z
Z
CAS CLAIM LEVEL S 2320 5

ADJUSTMENTS
CAS01 Claim Adjustment Group ID 1-2 R CO,CR,OA
Code ,PI,PR
CAS02 Claim Adjustment ID 1-5 R
Reason Code
CAS03 Monetary Amount R 1-18 R
CAS04 Quantity R 1-15 S
CAS05 Claim Adjustment ID 1-5 S
Reason Code
CAS06 Monetary Amount R 1-18 S
Reason Code
Reason Code
Reason Code
Reason Code
AMT COORDINATION OF S 2320 1

BENEFITS (COB) PAYER
PAID AMOUNT
AMT01 Amount Qualifier Code ID 1-3 R D

AMT REMAINING PATIENT S 2320 1

LIABILITY
AMT01 Amount Qualifier Code ID 1-3 R EAF

AMT COORDINATION OF S 2320 1

BENEFITS (COB) TOTAL
NON-COVERED
AMOUNT
AMT01 Amount Qualifier Code ID 1-3 R A8

OI OTHER INSURANCE R 2320 1
COVERAGE
INFORMATION
OI01 Claim Filing Indicator ID 1-2 N/U

Code
OI02 Claim Submission ID 2-2 N/U
Reason Code
OI03 Yes/No Condition or ID 1-1 R N,W,Y
Response Code
OI04 Patient Signature Source ID 1-1 N/U
Code
OI05 Provider Agreement ID 1-1 N/U
Code
OI06 Release of Information ID 1-1 R I,Y
Code
MOA OUTPATIENT S 2320 1
ADJUDICATION
INFORMATION
MOA01 Percentage as Decimal R 1-10 S
MOA02 Monetary Amount R 1-18 S

MOA03 Reference Identification AN 1-50 S
MOA08 Monetary Amount R 1-18 N/U

MOA09 Monetary Amount R 1-18 S
NM1 OTHER SUBSCRIBER R 2330A 1

NAME
ORGANIZATION NAME

NM108 Identification Code ID 1-2 R II,MI
Qualifier

ORGANIZATION NAME
N3 OTHER SUBSCRIBER S 2330A 1
ADDRESS
N4 OTHER SUBSCRIBER R 2330A 1

CITY,STATE,ZIP CODE

Code
REF OTHER SUBSCRIBER S 2330A 2

SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R SY

Qualifier

NM1 OTHER PAYER NAME R 2330B 1

NM101 Entity Identifier Code ID 2-3 R PR
ORGANIZATION NAME

NM108 Identification Code ID 1-2 R PI,WV
Qualifier

ORGANIZATION NAME
N3 OTHER PAYER S 2330B 1

ADDRESS
N4 OTHER PAYER R 2330B 1

CITY,STATE,ZIP CODE

Code
DTP CLAIM CHECK OR S 2330B 1
REMITTANCE DATE
Qualifier
REF OTHER PAYER S 2330B S

SECONDARY IDENTIFIER
REF01 Reference Identification ID 2-3 R 2U,EI,FY,

Qualifier NF

REF OTHER PAYER PRIOR S 2330B 1

AUTHORIZATION
NUMBER

Qualifier

REF OTHER PAYER REFERRAL S 2330B 1

NUMBER
Qualifier

REF OTHER PAYER CLAIM S 2330B 1
ADJUSTMENT
INDICATOR
REF01 Reference Identification ID 2-3 R T4

Qualifier

REF OTHER PAYER S 2330B 1

PREDETERMINATION
IDENTIFICATION

Qualifier

REF OTHER PAYER CLAIM S 2330B 1

CONTROL NUMBER
REF01 Reference Identification ID 2-3 R F8
Qualifier

NM1 OTHER PAYER S 2330C 2

REFERRING PROVIDER
NM101 Entity Identifier Code ID 2-3 R DN,P3

ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
REF OTHER PAYER R 2330C 3

REFERRING
PROVIDER
SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 0B,1G,G2
Qualifier

NM1 OTHER PAYER S 2330D 1

RENDERING PROVIDER

NM102 Entity Type Qualifier1-1 ID R 1
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
REF OTHER PAYER R 2330D 3
RENDERING
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier LU

NM1 OTHER PAYER S 2330E 1

SUPERVISING PROVIDER

ORGANIZATION NAME

Qualifier
NM111 Entity Identifier Code

ID 2-3 N/U
ORGANIZATION NAME
REF OTHER PAYER R 2330E 3

SUPERVISING
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier LU

NM1 OTHER PAYER BILLING S 2330F 1

PROVIDER
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
REF OTHER PAYER R 2330F 2

BILLING PROVIDER
SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R G2,LU
Qualifier

NM1 OTHER PAYER SERVICE S 2330G 1

FACILITY LOCATION

ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
REF OTHER PAYER R 2330G 3

SERVICE FACILITY
LOCATION
SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 0B,G2,LU
Qualifier

NM1 OTHER PAYER S 2330H 1

ASSISTANT SURGEON
ORGANIZATION NAME

Qualifier
ORGANIZATION NAME
REF OTHER PAYER 4 2330H 3

ASSISTANT SURGEON
SECONDARY
IDENTIFIER

Qualifier LU

LX01 SERVICE LINE NUMBER R 2400 50
SV3 DENTAL SERVICE R 2400 1

PROCEDURE
SV301 - 1 Product/Service ID ID 2-2 R AD

Qualifier
SV301 - 2 Product/Service ID AN 1-48 R
SV301 - 3 Procedure Modifier AN 2-2 S
SV301 - 7 Description O AN 1-80 S
SV301 - 8 Product/Service ID AN 1-48 N/U
SV302 Monetary Amount R 1-18 R
SV303 Facility Code Value AN 1-2 S
SV304 ORAL CAVITY S

DESIGNATION
SV304 - 1 Oral Cavity Designation ID 1-3 R
Code
SV304 - 2 Oral Cavity Designation ID 1-3 S
Code

Code

Code

Code
SV305 Prosthesis, Crown or ID 1-1 S I,R

Inlay Code
SV306 Quantity R 1-15 S
SV307 Description AN 1-80 N/U
SV308 Copay Status Code ID 1-1 N/U
SV309 Provider Agreement ID 1-1 N/U
Code
SV310 Yes/No Condition or ID 1-1 N/U
Response Code
SV311 COMPOSITE DIAGNOSIS S
CODE POINTER
SV311 - 1 Diagnosis Code Pointer N0 1-2 R
SV311 - 2 Diagnosis Code Pointer N0 1-2 S
TOO TOOTH INFORMATION S 2400 32
TOO01 Code List Qualifier Code ID 1-3 R JP
TOO02 Industry Code AN 1-30 R

TOO03 - 1 Tooth Surface Code ID 1-2 R B,D,F,I,L,
M,O
TOO03 - 2 Tooth Surface Code ID 1-2 S B,D,F,I,L,
M,O
M,O
M,O
M,O
DTP DATE - SERVICE DATE S 2400 1

Qualifier
DTP DATE - PRIOR S 2400 1

PLACEMENT
Qualifier

PLACEMENT
Qualifier
DTP DATE - REPLACEMENT S 2400 1

Qualifier
DTP DATE - TREATMENT S 2400 1

START
Qualifier
DTP DATE - TREATMENT S 2400 1

COMPLETION
Qualifier
CN1 CONTRACT S 2400 1
INFORMATION
CN101 Contract Type Code ID 2-2 R 02,03,04,
05,06,09
CN102 Monetary Amount R 1-18 S
CN103 Percent, Decimal Format R 1-6 S
CN104 Reference Identification AN 1-50 S
CN106 Version Identifier AN 1-30 S

PREDETERMINATION
IDENTIFICATION

Qualifier

REF04 - 1 Reference Identification ID 2-3 R 2U

Qualifier
REF04 - 2 Reference Identification AN 1-50 R
REF04 - 3 Reference Identification ID 2-3 N/U

Qualifier
REF04 - 4 Reference Identification AN 1-50 N/U

Qualifier
REF PRIOR AUTHORIZATION S 2400 5

Qualifier


Qualifier

Qualifier

Qualifier
REF LINE ITEM CONTROL S 2400 1

NUMBER
REF01 Reference Identification ID 2-3 R 6R
Qualifier

REF REPRICED CLAIM S 2400 1

NUMBER
REF01 Reference Identification ID 2-3 R 9A
Qualifier

REF ADJUSTED REPRICED S 2400 1

CLAIM NUMBER
REF01 Reference Identification ID 2-3 R 9C
Qualifier


Qualifier


Qualifier

Qualifier

Qualifier

AMT SALES TAX AMOUNT S 2400 1
AMT01 Amount Qualifier Code ID 1-3 R T

K3 FILE INFORMATION S 2400 10

K301 Fixed Format
Information
K302 Record Format Code
K303 Composite Unit of
Measure
HCP LINE S 2400 1

PRICING/REPRICING
INFORMATION
HCP01 Pricing Methodology ID 2-2 R 00,01,02,

03,04,05,
06,07,08,
09,10,11,
12,13,14
HCP02 Monetary Amount R 1-18 R

HCP03 Monetary Amount R 1-18 S
HCP05 Rate R 1-9 S

HCP06 Reference Identification AN 1-50 N/U
HCP07 Monetary Amount R 1-18 N/U

HCP09 Product/Service ID ID 2-2 S AD
Qualifier
HCP10 Product/Service ID AN 1-48 S
HCP11 Unit or Basis for ID 2-2 S UN
Measurement Code
HCP12 Quantity R 1-15 S
HCP13 Reject Reason Code ID 2-2 S T1,T2,T3,
T4,T5,T6
HCP14 Policy Compliance Code ID 1-2 S 1,2,3,4,5
HCP15 Exception Code ID 1-2 S 1,2,3,4,5,

6
NM1 RENDERING PROVIDER S 2420A 1

NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
PRV RENDERING PROVIDER R 2420A 1

SPECIALTY
INFORMATION
PRV01 Provider Code ID 1-3 R PE

Qualifier

INFORMATION
Code
REF RENDERING PROVIDER S 2420A 20
SECONDARY
IDENTIFICATION

Qualifier LU


Qualifier

Qualifier

Qualifier
NM1 ASSISTANT SURGEON S 2420B 1

NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
PRV ASSISTANT SURGEON S 2420B 1

SPECIALTY
INFORMATION
PRV01 Provider Code ID 1-3 R AS

Qualifier

INFORMATION
Code
REF ASSISTANT SURGEON S 2420B 20

SECONDARY
IDENTIFICATION

Qualifier LU


Qualifier

Qualifier

Qualifier
NM1 SUPERVISING PROVIDER S 2420C 1

NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
REF SUPERVISING S 2420C 20

PROVIDER
SECONDARY
IDENTIFICATION
Qualifier LU

REF04 - 1 Reference Identification ID 2-3 R

Qualifier
REF04 - 2 Reference Identification AN 1-50 R 2U

Qualifier

Qualifier
NM1 SERVICE FACILITY S 2420D 1

LOCATION NAME
ORGANIZATION NAME

Qualifier

ORGANIZATION NAME
N3 SERVICE FACILITY R 2420D 1

LOCATION ADDRESS
N4 SERVICE FACILITY R 2420D 1

LOCATION
CITY,STATE,ZIP CODE


Code
REF SERVICE FACILITY S 2420D 20

LOCATION SECONDARY
IDENTIFICATION
REF01 Reference Identification ID 2-3 R 1G, G2,

Qualifier LU


Qualifier

Qualifier

Qualifier
SVD LINE ADJUDICATION S 2430 1

INFORMATION
SVD01 Identification Code AN 2-80 R
SVD02 Monetary Amount R 1-18 R
SVD03 COMPOSITE MEDICAL R
PROCEDURE
SVD03 - 1 Product/Service ID ID 2-2 R AD,ER

Qualifier
SVD03 - 2 Product/Service ID AN 1-48 R
SVD03 - 3 Procedure Modifier AN 2-2 S
SVD03 - 7 Description AN 1-80 S
SVD03 - 8 Product/Service ID AN 1-48 N/U
SVD04 Product/Service ID AN 1-48 N/U
SVD05 Quantity R 1-15 R
SVD06 Assigned Number N0 1-6 S
CAS LINE ADJUSTMENT S 2430 5
CAS01 Claim Adjustment Group ID 1-2 R CO,CR,OA

Code ,PI,PR
CAS02 Claim Adjustment ID 1-5 R
Reason Code
CAS03 Monetary Amount R 1-18 R
Reason Code
Reason Code
Reason Code
Reason Code
Reason Code
DTP LINE CHECK OR R 2430 1

REMITTANCE DATE
Qualifier
AMT REMAINING PATIENT S 2430 1
LIABILITY
AMT01 Amount Qualifier Code ID 1-3 R EAF

SE TRANSACTION SET R 1
TRAILER
SE01 Number of Included N0 1-10 R
Segments
Number

Code
GS02 Application Sender’s AN 2-15 R
Code
GS03 Application Receiver’s AN 2-15 R
Code
GS04 Date DT 8-8 R
GS05 Time TM 4-8 R
GS07 Responsible Agency ID 1-2 R

Code
GS08 Version / Release / AN 1-12 R

Sets Included

Functional Groups
Number
4010A1 837I Institutional Claim
ISA INTERCHANGE 1 R ___ 1

CONTROL HEADER
Qualifier



11 ISA11 Interchange Control Standards 1-1 R
ID
Number

GS FUNCTIONAL GROUP 1 R ___ 1

HEADER

ST TRANSACTION SET 1 R ___ >1

HEADER

Number
27 1
BHT BEGINNING OF 1 R ___ 1
HIERARCHICAL
TRANSACTION
30 BHT03 Originator Application AN 1 - 30 R

Transaction ID
32 BHT05 Transaction Set Creation Time TM 4-8 R
33 1 BHT06 Claim or Encounter ID ID 2-2 R
REF TRANSMISSION TYPE 1 S

IDENTIFICATION

Qualifier
37 1 REF04 Reference Identifier N/U
NM1 SUBMITTER NAME 1 R 1000A 1

40 1 NM103 Submitter Last or Organization AN 1 - 35 R
Name
41 1 NM104 Submitter First Name AN 1 - 25 S
42 NM105 Submitter Middle Name AN 1 - 25 S
46 NM109 Submitter Identifier AN 2 - 80 R
49 1
PER SUBMITTER EDI 2 R 1000A

CONTACT
INFORMATION
51 PER02 Submitter Contact Name AN 1 - 60 R
Qualifier
Qualifier
Qualifier
NM1 RECEIVER NAME 1 R 1000B 1

61 1 NM103 Receiver Name AN 1 - 35 R
67 NM109 Receiver Primary Identifier AN 2 - 80 R
70 1
HL BILLING/PAY-TO 1 R 2000A >1

PROVIDER
HIERARCHICAL LEVEL


PRV BILLING/PAY-TO 1 S 2000A

PROVIDER SPECIALTY
INFORMATION
75 1 PRV01 Provider Code ID 1-3 R

Qualifier
77 1 PRV03 Provider Taxonomy Code AN 1 - 30 R
INFORMATION
80 PRV06 Provider Organization Code ID 3-3 N/U
CUR FOREIGN CURRENCY 1 S 2000A

INFORMATION
81 CUR01 Entity Identifier Code ID 2-3 R
83 CUR03 Exchange Rate R 4 - 10 N/U
86 CUR06 Currency Market/Exchange ID 3-3 N/U
Code
NM1 Billing Provider Name 1 R 2010AA 1

104 1 NM103 Billing Provider Last or AN 1 - 35 R
Organizational Name

110 NM109 Billing Provider Identifier AN 2 - 80 S
113 1
N3 BILLING PROVIDER 1 R 2010AA

ADDRESS
114 N301 Billing Provider Address Line AN 1 - 55 R
115 N302 Billing Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
116 N401 Billing Provider City Name AN 2 - 30 R

117 N402 Billing Provider State or ID 2-2 R
Province Code
118 N403 Billing Provider Postal Zone or ID 3 - 15 R
ZIP Code
121 N406 Location Identifier AN 1 - 30 N/U
122
REF BILLING PROVIDER 8 R 2010AA

TAX IDENTIFICATION

Qualifier
124 1 REF02 Billing Provider Additional AN 1 - 30 R

Identifier
REF CREDIT/DEBIT CARD 8 S 2010AA
BILLING
INFORMATION
Qualifier
Identifier
PER BILLING PROVIDER 2 S 2010AA

CONTACT
INFORMATION
132 PER02 Billing Provider Contact Name AN 1 - 60 R
133 PER03 Communication Number ID 2-2 R

Qualifier
Qualifier
Qualifier
NM1 PAY-TO PROVIDER 1 S 2010AB 1

NAME
142 1 NM103 Pay-to Provider Last or AN 1 - 35 N/U
Organization Name

147 1 NM108 Identification Code Qualifier ID 1-2 N/U

148 NM109 Pay-to Provider Identifier AN 2 - 80 N/U
151 1
N3 PAY-TO PROVIDER 1 R 2010AB

ADDRESS
152 N301 Pay-to Provider Address Line AN 1 - 55 R
153 N302 Pay-to Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
154 N401 Pay-to Provider City Name AN 2 - 30 R

155 N402 Pay-to Provider State Code ID 2-2 R
156 N403 Pay-to Provider Postal Zone or ID 3 - 15 R
ZIP Code
157 N404 Pay-to Provider Country Code ID 2-3 S

160 1
REF PAY-TO PROVIDER 5 S 2010AB

SECONDARY
IDENTIFICATION

Qualifier
Identifier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HL SUBSCRIBER 1 R 2000B >1

HIERARCHICAL LEVEL


SBR SUBSCRIBER 1 R 2000B

INFORMATION
169 1 SBR01 Payer Responsibility Sequence ID 1-1 R
Number Code
170 SBR02 Individual Relationship Code ID 2-2 S
171 1 SBR03 Insured Group or Policy AN 1 - 30 S

Number
172 SBR04 Insured Group Name AN 1 - 60 S
174 SBR06 Coordination of Benefits Code ID 1-1 N/U
175 SBR07 Yes/No Condition or Response ID 1-1 N/U

Code
177 1 SBR09 Claim Filing Indicator Code ID 1-2 S
NM1 SUBSCRIBER NAME 1 R 2010BA 1

186 NM109 Subscriber Primary Identifier AN 2 - 80 S

189 1
N3 SUBSCRIBER 1 S 2010BA
ADDRESS
190 N301 Subscriber Address Line AN 1 - 55 R
191 N302 Subscriber Address Line AN 1 - 55 S
CITY/STATE/ZIP CODE
192 N401 Subscriber City Name AN 2 - 30 R

193 N402 Subscriber State Code ID 2-2 R
194 N403 Subscriber Postal Zone or ZIP ID 3 - 15 R
Code
195 N404 Subscriber Country Code ID 2-3 S
198
DMG SUBSCRIBER 1 S 2010BA

DEMOGRAPHIC
INFORMATION
Qualifier
208 1
209 1
REF SUBSCRIBER 4 S 2010BA

SECONDARY
IDENTIFICATION
Qualifier
211 1 REF02 Subscriber Supplemental AN 1 - 30 R
Identifier
REF CASUALTY CLAIM 1 S 2010BA

NUMBER
Qualifier
215 1 REF02 Property Casualty Claim AN 1 - 30 R
Number
NM1 CREDIT/DEBIT CARD 1 S 2010BB 1
ACCOUNT HOLDER
NAME
219 1 NM102 Entity Type Qualifier ID 1-1 R
220 1 NM103 Credit or Debt Card Holder Last AN 1 - 35 R
or Organization Name
221 1 NM104 Credit or Debt Card Holder First AN 1 - 25 S
Name
222 1 NM105 Credit or Debt Card Holder AN 1 - 25 S
Middle Name
223 1 NM106 Name Prefix AN 1 - 10 N/U
224 1 NM107 Credit or Debt Card Holder AN 1 - 10 S
Name Suffix
226 1 NM109 Payer Identifier AN 2 - 80 R
228 1 NM111 Entity Identifier Code ID 2-3 N/U
REF CREDIT/DEBT CARD 2 S 2010BB

INFORMATION
Qualifier
230 1 REF02 Credit or Debt Card AN 1 - 30 R
Authorization Number
NM1 PAYER NAME 1 R 2010BC 1

244 1
N3 PAYER ADDRESS 1 S 2010BC
245 N301 Payer Address Line AN 1 - 55 R

246 N302 Payer Address Line AN 1 - 55 S
N4 PAYER 1 R 2010BC
CITY/STATE/ZIP CODE
247 N401 Payer City Name AN 2 - 30 R

248 N402 Payer State Code ID 2-2 R
249 N403 Payer Postal Zone or ZIP Code ID 3 - 15 R
250 N404 Payer Country Code ID 2-3 S

253
REF PAYER SECONDARY 3 S 2010BC

IDENTIFICATION
Qualifier
255 1 REF02 Payer Additional Identifier AN 1 - 30 R
1
1
1
NM1 RESPONSIBLE PARTY 1 S 2010BD 1

NAME
262 1 NM105 Name Middle AN 1 - 25 S
264 1 NM107 Name Suffix AN 1 - 10 S
266 1 NM109 Identification Code AN 2 - 80 N/U
N3 RESPONSIBLE PARTY 1 S 2010BC

ADDRESS
269 1 N301 Responsible Party Address AN 1 - 55 R
Line
270 1 N302 Responsible Party Address AN 1 - 55 S
Line
N4 RESPONSIBLE PARTY 1 R 2010BC

CITY/STATE/ZIP CODE
271 1 N401 Responsible Party City Name AN 2 - 30 R
272 1 N402 Responsible Party State Code ID 2-2 R
273 1 N403 Responsible Party ZIP Code ID 3 - 15 R

274 1 N404 Responsible Party Country ID 2-3 S
Code
275 1 N405 Location Qualifier ID 1-2 N/U
276 1 N406 Location Identifier AN 1 - 30 N/U
HL PATIENT 1 S 2000C >1
HIERARCHICAL LEVEL


PAT PATIENT 1 R 2000C

INFORMATION
281 1 PAT01 Individual Relationship Code ID 2-2 R

284 PAT04 Student Status Code ID 1-1 N/U
285 PAT05 Date Time Period Format ID 2-3 N/U
Qualifier
286 PAT06 Patient Death Date AN 1 - 35 N/U
287 PAT07 Measurement Code ID 2-2 N/U
288 PAT08 Patient Weight R 1 - 10 N/U
289 PAT09 Pregnancy Indicator ID 1-1 N/U
NM1 PATIENT NAME 1 R 2010CA 1

293 1 NM104 Patient First Name AN 1 - 25 R
301 1
N3 PATIENT ADDRESS 1 R 2010CA
302 N301 Patient Address Line AN 1 - 55 R

303 N302 Patient Address Line AN 1 - 55 S
N4 PATIENT 1 R 2010CA
CITY/STATE/ZIP CODE
304 N401 Patient City Name AN 2 - 30 R

305 N402 Patient State Code ID 2-2 R
306 N403 Patient Postal Zone or ZIP ID 3 - 15 R
Code
307 N404 Patient Country Code ID 2-3 S
310 1
DMG PATIENT 1 R 2010CA
DEMOGRAPHIC
INFORMATION
Qualifier
313 DMG03 Patient Gender Code ID 1-1 R
320 1
321 1
REF PATIENT SECONDARY 5 S 2010CA

IDENTIFICATION
NUMBER

Qualifier
323 1 REF02 Patient Secondary Identifier AN 1 - 30 R
REF PROPERTY AND 1 S 2010CA

CASUALTY CLAIM
NUMBER
Qualifier
Number
CLM CLAIM INFORMATION 1 R 2300 100
330 CLM01 Patient Account Number AN 1 - 38 R

331 CLM02 Total Claim Charge Amount R 1 - 18 R
332 CLM03 Claim Filing Indicator Code ID 1-2 N/U
333 CLM04 Non-Institutional Claim Type ID 1-2 N/U
Code
LOCATION INFORMATION
335 CLM05-1 Facility Type Code AN 1-2 R
336 CLM05-2 Facility Code Qualifier ID 1-2 R
337 CLM05-3 Claim Frequency Code ID 1-1 R
338 CLM06 Provider or Supplier Signature ID 1-1 N/U
Indicator
339 1 CLM07 Medicare Assignment Code ID 1-1 R
340 1 CLM08 Benefits Assignment ID 1-1 R
Certification Indicator
341 1 CLM09 Release of Information Code ID 1-1 R
342 1 CLM10 Patient Signature Source Code ID 1-1 N/U
343 CLM11 RELATED CAUSES N/U

INFORMATION
344 1 CLM12 Special Program Indicator ID 2-3 N/U
345 CLM13 Yes/No Condition or Response ID 1-1 N/U
Code
Code
348 CLM16 Participation Agreement ID 1-1 N/U
350 1 CLM18 Yes/No Condition or Response ID 1-1 R
Code
351 CLM19 Claim Submission Reason ID 2-2 N/U
Code
352 1 CLM20 Delay Reason Code ID 1-2 S
DTP DATE -DISCHARGE 1 S 2300

HOUR
Qualifier
355 DTP03 Discharge Hour AN 1 - 35 R
DTP DATE -STATEMENT 1 R 2300

DATES
Qualifier
358 1 DTP03 Statement From or To Date AN 1 - 35 R
DTP DATE -ADMISSION 1 S 2300

DATE/HOUR
Qualifier
361 1 DTP03 Admission Date and Hour AN 1 - 35 R
1
1
CL1 INSTITUTIONAL CLAIM 1 S 2300

CODE
362 CL101 Admission Type Code ID 1-1 S
363 CL102 Admission Source Code ID 1-1 S
364 CL103 Patient Status Code ID 1-2 S
365 CL104 Nursing Home Code ID 1-1 NU
PWK CLAIM 10 S 2300
SUPPLEMENTAL
INFORMATION
366 1 PWK01 Attachment Report Type Code ID 2-2 R
367 1 PWK02 Attachment Transmission Code ID 1-2 R

370 PWK05 Identification Code Qualifier ID 1-2 S
371 PWK06 Attachment Control Number AN 2 - 80 S
372 PWK07 Description AN 1 - 80 S
CN1 CONTRACT 1 S 2300

INFORMATION
375 CN101 Contract Type Code ID 2-2 R
376 CN102 Contract Amount R 1 - 18 S

377 CN103 Contract Percentage R 1-6 S
378 CN104 Contract Code AN 1 - 30 S
379 CN105 Terms Discount Percent R 1-6 S
380 CN106 Contract Version Identifier AN 1 - 30 S
AMT PAYER ESTIMATED 1 S 2300

AMOUNT DUE
381 1 AMT01 Amount Qualifier Code ID 1-3 R
382 1 AMT02 Patient Responsibility Amount R 1 - 18 R
383 1 AMT03 Credit/Debit Flag Code ID 1-1 N/U
AMT PATIENT ESTIMATED 1 S 2300

AMOUNT DUE

385 AMT02 Patient Responsibility Amount R 1 - 18 R
AMT PATIENT PAID 1 S 2300

AMOUNT
388 1 AMT02 Patient Paid Amount R 1 - 18 R
AMT CREDIT/DEBIT CARD 1 S 2300
MAXIMUM AMOUNT
391 1 AMT02 Credit or Debit Card Maximum R 1 - 18 R
Amount
REF SERVICE 1 S 2300

AUTHORIZATION
EXCEPTION CODE
Qualifier
394 1 REF02 Service Authorization Exception AN 1 - 30 R
Code
1
1
REF PRIOR 2 S 2300

AUTHORIZATION
Qualifier
398 1 REF02 Prior Authorization Number AN 1 - 30 R

REF ORIGINAL 1 S 2300

REFERENCE NUMBER
(ICN/DCN)
Qualifier
402 1 REF02 Claim Original Reference AN 1 - 30 R
Number
REF REPRICED CLAIM 1 S 2300

NUMBER
Qualifier
406 1 REF02 Repriced Claim Reference AN 1 - 30 R
Number
REF ADJUSTED REPRICED 1 S 2300

CLAIM NUMBER
Qualifier
410 1 REF02 Adjusted Repriced Claim AN 1 - 30 R
Reference Number
REF INVESTIGATIONAL 1 S 2300

DEVICE EXEMPTION
NUMBER
Qualifier
414 1 REF02 Investigational Device AN 1 - 30 R
Exemption Number
REF CLAIM IDENTIFIER 1 S 2300

FOR TRANSMISSION
INTERMEDIARIES
Qualifier
418 1 REF02 Value Added Network Trace AN 1 - 30 R
Number
REF DOCUMENT 2 S 2300

IDENTIFICATION CODE

Qualifier
422 1 REF02 Document ControlIdentifier AN 1 - 30 R
1
1
REF MEDICAL RECORD 1 S 2300

NUMBER
Qualifier
REF DEMONSTRATION 1 S 2300

PROJECT IDENTIFIER
Qualifier
430 1 REF02 Demonstration Project Identifier AN 1 - 30 R

REF PEER REVIEW 1 S 2300

ORGANIZARION (PRO)
APPROVAL NUMBER

Qualifier
434 1 REF02 PRO Number AN 1 - 30 R
K3 FILE INFORMATION 10 S 2300

437 K301 Fixed Format Information AN 1 - 80 R
438 K302 Record Format Code ID 1-2 N/U
439 K303 COMPOSITE UNIT OF N/U
MEASURE
NTE CLAIM NOTE 10 S 2300

440 NTE01 Note Reference Code ID 3-3 R
441 NTE02 Claim Note Text AN 1 - 80 R
NTE BILLING NOTE 1 S 2300

442 NTE01 Note Reference Code ID 3-3 R
443 NTE02 Billing Note Text AN 1 - 80 R
CR6 HOME HEALTH CARE 1 S 2300

INFORMATION
444 1 CR601 Prognosis Indicator ID 1-1 R
445 1 CR602 Service From Date DT 8-8 R
446 1 CR603 Date Time Period Format ID 2-3 S
Qualifier
447 1 CR604 Home Health Certification AN 1 - 35 S
Period
448 1 CR605 Diagnosis Date DT 8-8 R
449 1 CR606 Skilled Nursing Facility Indicator ID 1-1 R
450 1 CR607 Medicare Coverage Indicator ID 1-1 R
451 1 CR608 Certification Type Indicator ID 1-1 R

452 1 CR609 Surgery Date DT 8-8
453 1 CR610 Product or Service ID Qualifier ID 2-2 S
454 1 CR611 Surgical Procedure Code AN 1 - 15 S

455 1 CR612 Physician Order Date DT 8-8 S
456 1 CR613 Last Visit Date DT 8-8 S
457 1 CR614 Physician Contact Date DT 8-8 S
458 1 CR615 Date Time Period Format ID 2-3 S
Qualifier
459 1 CR616 Last Admission Period AN 1 - 35 S
460 1 CR617 Patient Discharge Facility Type ID 1-1 R
Code
461 1 CR618 Diagnosis Date DT 8-8 S
CRC HOME HEALTH 3 S 2300

FUNCTIONAL
LIMITATIONS
465 1 CRC01 Code Category ID 2-2 R
466 1 CRC02 Certification Condition Indicator ID 1-1 R
467 1 CRC03 Functional Limitations Code ID 2-2 R
468 1 CRC04 Functional Limitations Code ID 2-2 S


FUNCTIONAL
LIMITATIONS
474 1 CRC03 Activities Permitted Code ID 2-2 R
475 1 CRC04 Activities Permitted Code ID 2-2 S


MENTAL STATUS
479 1 CRC01 Certification Condition Indicator ID 2-2 R

481 1 CRC03 Mental Status Code ID 2-2 R
482 1 CRC04 Mental Status Code ID 2-2 S

1
1
1
1
1
1
1
HI PRINCIPAL DIAGNOSIS 1 S 2300

486 HI01 HEALTH CARE CODE R
INFORMATION
487 1 HI01-1 Code List Qualifier Code ID 1-3 R
488 HI01-2 Industry Code AN 1 - 30 R
489 HI01-3 Date Time Period Format ID 2-3 N/U
Qualifier
490 HI01-4 Date Time Period AN 1 - 35 N/U
491 HI01-5 Monetary Amount R 1 - 18 N/U
492 HI01-6 Quantity R 1 - 15 N/U
493 HI01-7 Version Identifier AN 1 - 30 N/U
494 1
495 1
496 1 HI02 HEALTH CARE CODE S

INFORMATION
Qualifier
504 1
505 1
506 1 HI03 HEALTH CARE CODE S

INFORMATION
Qualifier
514 1
515 1
516 HI04 HEALTH CARE CODE N/U

INFORMATION
517 1
518 1
519 1
520 1
521 1
522 1
523 1
524 1
525 1

INFORMATION
527 1
528 1
529 1
530 1
531 1
532 1
533 1
534 1
535 1

INFORMATION
537 1
538 1
539 1
540 1
541 1
542 1
543 1
544 1
545 1

INFORMATION
547 1
548 1
549 1
550 1
551 1
552 1
553 1
554 1
555 1

INFORMATION
557 1
558 1
559 1
560 1
561 1
562 1
563 1
564 1
565 1

INFORMATION
567 1
568 1
569 1
570 1
571 1
572 1
573 1
574 1
575 1

INFORMATION
577 1
578 1
579 1
580 1
581 1
582 1
583 1
584 1
585 1

INFORMATION
587 1
588 1
589 1
590 1
591 1
592 1
593 1
594 1
595 1

INFORMATION
597 1
598 1
599 1
600 1
601 1
602 1
603 1
604 1
605 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HI DIAGNOSIS RELATED 1 R 2300

GROUP (DRG)
INFORMATION
INFORMATION
607 HI01-1 Code List Qualifier Code ID 1-3 R
608 HI01-2 DRG Code AN 1 - 30 R
Qualifier
614 1
615 1
616 HI02 HEALTH CARE CODE S

INFORMATION
617 1
618 1
619 1
620 1
621 1
622 1
623 1
624 1
625 1

INFORMATION
627 1
628 1
629 1
630 1
631 1
632 1
633 1
634 1
635 1

INFORMATION
637 1
638 1
639 1
640 1
641 1
642 1
643 1
644 1
645 1

INFORMATION
647 1
648 1
649 1
650 1
651 1
652 1
653 1
654 1
655 1

INFORMATION
657 1
658 1
659 1
660 1
661 1
662 1
663 1
664 1
665 1

INFORMATION
667 1
668 1
669 1
670 1
671 1
672 1
673 1
674 1
675 1

INFORMATION
677 1
678 1
679 1
680 1
681 1
682 1
683 1
684 1
685 1

INFORMATION
687 1
688 1
689 1
690 1
691 1
692 1
693 1
694 1
695 1

INFORMATION
697 1
698 1
699 1
700 1
701 1
702 1
703 1
704 1
705 1
INFORMATION
707 1
708 1
709 1
710 1
711 1
712 1
713 1
714 1
715 1

INFORMATION
717 1
718 1
719 1
720 1
721 1
722 1
723 1
724 1
725 1
HI OTHER DIAGNOSIS 2 R 2300

INFORMATION
INFORMATION
728 HI01-2 Other Diagnosis AN 1 - 30 R
Qualifier
734 1
735 1

INFORMATION
Qualifier
744 1
745 1

INFORMATION
Qualifier
754 1
755 1

INFORMATION
Qualifier
764 1
765 1

INFORMATION
Qualifier
774 1
775 1

INFORMATION
Qualifier
784 1
785 1

INFORMATION
Qualifier
794 1
795 1

INFORMATION
Qualifier
804 1
805 1

INFORMATION
Qualifier
814 1
815 1

INFORMATION
Qualifier
824 1
825 1

INFORMATION
Qualifier
834 1
835 1

INFORMATION
Qualifier
844 1
845 1
HI PRINCIPAL 1 R 2300
PROCEDURE
INFORMATION
INFORMATION
848 HI01-2 Principal Procedure Code AN 1 - 30 R
849 1 HI01-3 Date Time Period Format ID 2-3 S
Qualifier
850 1 HI01-4 Date Time Period AN 1 - 35 S
854 1
855 1

INFORMATION
857 1
858 1
859 1
860 1
861 1
862 1
863 1
864 1
865 1

INFORMATION
867 1
868 1
869 1
870 1
871 1
872 1
873 1
874 1
875 1

INFORMATION
877 1
878 1
879 1
880 1
881 1
882 1
883 1
884 1
885 1

INFORMATION
887 1
888 1
889 1
890 1
891 1
892 1
893 1
894 1
895 1

INFORMATION
897 1
898 1
899 1
900 1
901 1
902 1
903 1
904 1
905 1

INFORMATION
907 1
908 1
909 1
910 1
911 1
912 1
913 1
914 1
915 1

INFORMATION
917 1
918 1
919 1
920 1
921 1
922 1
923 1
924 1
925 1

INFORMATION
927 1
928 1
929 1
930 1
931 1
932 1
933 1
934 1
935 1

INFORMATION
937 1
938 1
939 1
940 1
941 1
942 1
943 1
944 1
945 1

INFORMATION
947 1
948 1
949 1
950 1
951 1
952 1
953 1
954 1
955 1

INFORMATION
957 1
958 1
959 1
960 1
961 1
962 1
963 1
964 1
965 1
HI OTHER PROCEDURE 2 R 2300

INFORMATION
INFORMATION
968 HI01-2 Procedure Code AN 1 - 30 R
Qualifier
970 HI01-4 Date Time Period AN 1 - 35 S
974 1
975 1

INFORMATION
Qualifier
984 1
985 1

INFORMATION
Qualifier
994 1
995 1

INFORMATION
999 HI04-3 Date Time Period Format ID 2-3 S
Qualifier
1002 HI04-6 Quantity R 1 - 15 N/U
1004 1
1005 1

INFORMATION
1009 HI05-3 Date Time Period Format ID 2-3 S
Qualifier
1012 HI05-6 Quantity R 1 - 15 N/U
1014 1
1015 1

INFORMATION
Qualifier
1022 HI06-6 Quantity R 1 - 15 N/U
1024 1
1025 1

INFORMATION
Qualifier
1032 HI07-6 Quantity R 1 - 15 N/U
1034 1
1035 1

INFORMATION
Qualifier
1042 HI08-6 Quantity R 1 - 15 N/U
1044 1
1045 1

INFORMATION
Qualifier
1052 HI09-6 Quantity R 1 - 15 N/U
1054 1
1055 1

INFORMATION
Qualifier
1062 HI10-6 Quantity R 1 - 15 N/U
1064 1
1065 1

INFORMATION
Qualifier
1072 HI11-6 Quantity R 1 - 15 N/U
1074 1
1075 1

INFORMATION
Qualifier
1082 HI12-6 Quantity R 1 - 15 N/U
1084 1
1085 1
HI OCCURRENCE SPAN 2 S 2300

INFORMATION
INFORMATION
1088 HI01-2 Occurrence Span Code AN 1 - 30 R
1089 HI01-3 Date Time Period Format ID 2-3 R
Qualifier
1090 HI01-4 Date Time Period AN 1 - 35 R

1092 HI01-6 Quantity R 1 - 15 N/U
1094 1
1095 1

INFORMATION
Qualifier

1102 HI02-6 Quantity R 1 - 15 N/U
1104 1
1105 1
INFORMATION
Qualifier

1112 HI03-6 Quantity R 1 - 15 N/U
1114 1
1115 1

INFORMATION
Qualifier

1122 HI04-6 Quantity R 1 - 15 N/U
1124 1
1125 1

INFORMATION
Qualifier

1132 HI05-6 Quantity R 1 - 15 N/U
1134 1
1135 1

INFORMATION
Qualifier

1142 HI06-6 Quantity R 1 - 15 N/U
1144 1
1145 1

INFORMATION
Qualifier

1152 HI07-6 Quantity R 1 - 15 N/U
1154 1
1155 1

INFORMATION
Qualifier

1162 HI08-6 Quantity R 1 - 15 N/U
1164 1
1165 1

INFORMATION
Qualifier

1172 HI09-6 Quantity R 1 - 15 N/U
1174 1
1175 1

INFORMATION
Qualifier

1182 HI10-6 Quantity R 1 - 15 N/U
1184 1
1185 1

INFORMATION
Qualifier
1192 HI11-6 Quantity R 1 - 15 N/U
1194 1
1195 1

INFORMATION
Qualifier

1202 HI12-6 Quantity R 1 - 15 N/U
1204 1
1205 1
HI OCCURRENCE 2 R 2300
INFORMATION
INFORMATION
1208 HI01-2 Occurrence Code AN 1 - 30 R
Qualifier
1212 HI01-6 Quantity R 1 - 15 N/U
1214 1
1215 1

INFORMATION
Qualifier
1222 HI02-6 Quantity R 1 - 15 N/U
1224 1
1225 1

INFORMATION
Qualifier
1232 HI03-6 Quantity R 1 - 15 N/U
1234 1
1235 1

INFORMATION
Qualifier
1242 HI04-6 Quantity R 1 - 15 N/U
1244 1
1245 1

INFORMATION
Qualifier
1252 HI05-6 Quantity R 1 - 15 N/U
1254 1
1255 1

INFORMATION
Qualifier
1262 HI06-6 Quantity R 1 - 15 N/U
1264 1
1265 1

INFORMATION
Qualifier
1272 HI07-6 Quantity R 1 - 15 N/U
1274 1
1275 1

INFORMATION
Qualifier
1282 HI08-6 Quantity R 1 - 15 N/U
1284 1
1285 1

INFORMATION
Qualifier
1292 HI09-6 Quantity R 1 - 15 N/U
1294 1
1295 1

INFORMATION
Qualifier
1302 HI10-6 Quantity R 1 - 15 N/U
1304 1
1305 1

INFORMATION
Qualifier
1312 HI11-6 Quantity R 1 - 15 N/U
1314 1
1315 1

INFORMATION
Qualifier
1322 HI12-6 Quantity R 1 - 15 N/U
1324 1
1325 1
HI VALUE INFORMATION 2 R 2300

INFORMATION
1328 HI01-2 Value Code AN 1 - 30 R
Qualifier
1331 HI01-5 Value Code Associated Amount R 1 - 18 R
1332 HI01-6 Quantity R 1 - 15 N/U

1334 1
1335 1

INFORMATION
Qualifier
1342 HI02-6 Quantity R 1 - 15 N/U

1344 1
1345 1

INFORMATION
Qualifier
1352 HI03-6 Quantity R 1 - 15 N/U

1354 1
1355 1

INFORMATION
Qualifier
1362 HI04-6 Quantity R 1 - 15 N/U

1364 1
1365 1

INFORMATION
Qualifier
1372 HI05-6 Quantity R 1 - 15 N/U

1374 1
1375 1

INFORMATION
Qualifier
1382 HI06-6 Quantity R 1 - 15 N/U

1384 1
1385 1

INFORMATION
Qualifier
1392 HI07-6 Quantity R 1 - 15 N/U

1394 1
1395 1

INFORMATION
Qualifier
1402 HI08-6 Quantity R 1 - 15 N/U

1404 1
1405 1

INFORMATION
Qualifier
1412 HI09-6 Quantity R 1 - 15 N/U

1414 1
1415 1

INFORMATION
Qualifier
1422 HI10-6 Quantity R 1 - 15 N/U

1424 1
1425 1

INFORMATION
Qualifier
1432 HI11-6 Quantity R 1 - 15 N/U

1434 1
1435 1

INFORMATION
Qualifier
1442 HI12-6 Quantity R 1 - 15 N/U

1444 1
1445 1
HI CONDITION 2 R 2300
INFORMATION
INFORMATION
1448 HI01-2 Condition Code AN 1 - 30 R
Qualifier
1452 HI01-6 Quantity R 1 - 15 N/U
1454 1
1455 1

INFORMATION
Qualifier
1462 HI02-6 Quantity R 1 - 15 N/U
1464 1
1465 1

INFORMATION
Qualifier
1472 HI03-6 Quantity R 1 - 15 N/U
1474 1
1475 1

INFORMATION
Qualifier
1482 HI04-6 Quantity R 1 - 15 N/U
1484 1
1485 1

INFORMATION
Qualifier
1492 HI05-6 Quantity R 1 - 15 N/U
1494 1
1495 1

INFORMATION
Qualifier
1502 HI06-6 Quantity R 1 - 15 N/U
1504 1
1505 1

INFORMATION
Qualifier
1512 HI07-6 Quantity R 1 - 15 N/U
1514 1
1515 1

INFORMATION
Qualifier
1522 HI08-6 Quantity R 1 - 15 N/U
1524 1
1525 1

INFORMATION
Qualifier
1532 HI09-6 Quantity R 1 - 15 N/U
1534 1
1535 1

INFORMATION
Qualifier
1542 HI10-6 Quantity R 1 - 15 N/U
1544 1
1545 1

INFORMATION
Qualifier
1552 HI11-6 Quantity R 1 - 15 N/U
1554 1
1555 1

INFORMATION
Qualifier
1562 HI12-6 Quantity R 1 - 15 N/U
1564 1
1565 1
HI TREATMENT CODE 2 R 2300

INFORMATION
INFORMATION
1568 HI01-2 Treatment Code AN 1 - 30 R
Qualifier
1572 HI01-6 Quantity R 1 - 15 N/U
1574 1
1575 1

INFORMATION
Qualifier
1582 HI02-6 Quantity R 1 - 15 N/U
1584 1
1585 1

INFORMATION
Qualifier
1592 HI03-6 Quantity R 1 - 15 N/U
1594 1
1595 1

INFORMATION
Qualifier
1602 HI04-6 Quantity R 1 - 15 N/U
1604 1
1605 1

INFORMATION
Qualifier
1612 HI05-6 Quantity R 1 - 15 N/U
1614 1
1615 1

INFORMATION
Qualifier
1622 HI06-6 Quantity R 1 - 15 N/U
1624 1
1625 1

INFORMATION
Qualifier
1632 HI07-6 Quantity R 1 - 15 N/U
1634 1
1635 1

INFORMATION
Qualifier
1642 HI08-6 Quantity R 1 - 15 N/U
1644 1
1645 1

INFORMATION
Qualifier
1652 HI09-6 Quantity R 1 - 15 N/U
1654 1
1655 1

INFORMATION
Qualifier
1662 HI10-6 Quantity R 1 - 15 N/U
1664 1
1665 1

INFORMATION
Qualifier
1672 HI11-6 Quantity R 1 - 15 N/U
1674 1
1675 1

INFORMATION
Qualifier
1682 HI12-6 Quantity R 1 - 15 N/U
1684 1
1685 1
QTY CLAIM QUANTITY 4 S 2300

1686 1 QTY01 Quantity Qualifier ID 2-2 R
1687 1 QTY02 Claim Days Count R 1 - 15 R
1688 1 QTY03 COMPOSITE UNIT OF R
MEASURE
1689 1 QTY03-1 Unit or Basis for Measurement ID 2-2 R
Code
1690 1 QTY03-2 Exponent R 1 - 15 N/U
1691 1 QTY03-3 Multiplier R 1 - 10 N/U
1692 1 QTY03-4 Unit or Basis for Measurement ID 2-2 N/U
Code
1693 1 QTY03-5 Exponent R 1 - 15 N/U
Code
1696 1 QTY03-8 Exponent R 1 - 15 N/U
Code
1699 1 QTY03-11 Exponent R 1 - 15 N/U
Code
1702 1 QTY03-14 Exponent R 1 - 15 N/U
1704 1 QTY04 Free-Form Message AN 1 - 30 N/U
HCP CLAIM 1 S 2300

PRICING/REPRICING
INFORMATION
1705 HCP01 Pricing Methodology ID 2-2 R
1706 HCP02 Repriced Allowed Amount R 1 - 18 R

1707 HCP03 Repriced Saving Amount R 1 - 18 S
1708 1 HCP04 Repricing Organization AN 1 - 30 S
Identifier
1709 HCP05 Repricing Per Diem or Flat Rate R 1-9 S
Amount
1710 1 HCP06 Repriced Approved DRG Code AN 1 - 30 S
1711 HCP07 Repriced Approved Amount R 1 - 18 S
1712 HCP08 Product/Service ID AN 1 - 48 S

1713 1 HCP09 Product/Service ID Qualifier ID 2-2 S
1715 HCP11 Unit or Basis for Measurement ID 2-2 S
Code
1716 HCP12 Quantity R 1 - 15 S
1717 HCP13 Reject Reason Code ID 2-2 S
1718 HCP14 Policy Compliance Code ID 1-2 S
1719 HCP15 Exception Code ID 1-2 S
CR7 HOME HEALTH CARE 1 S 2305 6

PLAN INFORMATION
1720 1 CR701 Disipline Type Code ID 2-2 R
1721 1 CR702 Vsits Prior to Recertification NO 1-9 R
Date Count
1722 1 CR703 Total Visits Projected This NO 1-9 R
Certification Count
HSD HOME CARE 12 S 2305

SERVICES DELIVERY
1723 1 HSD01 Visits ID 2-2 S
1724 1 HSD02 Number of Visits R 1 - 15 S
1725 1 HSD03 Frequency Period ID 2-2 S
1726 1 HSD04 Frequency Count R 1-6 S
1727 1 HSD05 Duration of Visits Units ID 1-2 S
1728 1 HSD06 Duration of Visits, Number of NO 1-3 S
Units
1729 1 HSD07 Ship, Delivery or Caledar ID 1-2 S
Pattern Code
1730 1 HSD08 Delivery Pattern Time Code ID 1-1 S
NM1 ATTENDING 1 S 2310A 1

PHYSICIAN NAME
1733 1 NM103 Name Last AN 1 - 35 R
1734 1 NM104 NameFirst AN 1 - 25 S
1739 NM109 Provider Identifier AN 2 - 80 R
1742 1
PRV ATTENDING 1 S 2310A

PHYSICIAN
SPECIALTY
INFORMATION
Qualifier
INFORMATION
REF ATTENDING 5 S 2310A
PHYSICIAN
SECONDARY
IDENTIFICATION
Qualifier
1750 1 REF02 Attending Physician Secondary AN 1 - 30 R
Identifier
NM1 OPERATING 1 S 2310B 1

PHYSICIAN NAME
1755 1 NM103 Last or Organization Name AN 1 - 35 R
1756 1 NM104 Name First AN 1 - 25 R
1757 NM105 Middle Name AN 1 - 25 S
1761 NM109 Identifier AN 2 - 80 R
1764 1
REF OPERATING 5 S 2310B

PHYSICIAN
SECONDARY
IDENTIFICATION
Qualifier
1766 1 REF02 Secondary Identifier AN 1 - 30 R
NM1 OTHER PROVIDER 1 S 2310C 1

NAME
1771 1 NM103 Last or Organization Name AN 1 - 35 R
1772 1 NM104 First Name AN 1 - 25 R
1777 NM109 Identifier AN 2 - 80 S
1780 1
REF OTHER PROVIDER 5 S 2310C

SECONDARY
IDENTIFICATION
Qualifier
1782 1 REF02 Rendering Provider Secondary AN 1 - 30 R
Identifier
1
1
1
1
1
1
1
1
1
1
1
1
NM1 SERVICE FACILITY 1 S 2310E 1

NAME
1787 1 NM103 Laboratory or Facility Name AN 1 - 35 R
1793 NM109 Laboratory or Facility Primary AN 2 - 80 S
Identifier
1796 1
N3 SERVICE FACILITY 1 R 2310E
ADDRESS
1797 N301 Laboratory or Facility Address AN 1 - 55 R

Line
1798 N302 Laboratory or Facility Address AN 1 - 55 S
Line
N4 SERVICE FACILITY 1 R 2310E

CITY/STATE/ZIP CODE
1799 N401 Laboratory or Facility City AN 2 - 30 R

Name
1800 N402 Laboratory or Facility State or ID 2-2 R
Province Code
1801 N403 Laboratory or Facility Postal ID 3 - 15 R
Zone or ZIP Code
1802 N404 Laboratory/Facility Country ID 2-3 S
Code
1805 1
REF SERVICE FACILITY 5 S 2310E

SECONDARY
IDENTIFICATION

Qualifier
1807 1 REF02 Laboratory or Facility AN 1 - 30 R
Secondary Identifier
1
1
1
1
1
1
1
1
1
1
1
1
1
SBR OTHER SUBSCRIBER 1 S 2320 10

INFORMATION
Number Code
1811 1 SBR02 Individual Relationship Code ID 2-2 R

Number
1813 SBR04 Other Insured Group Name AN 1 - 60 S

Code
CAS CLAIM LEVEL 5 S 2320

ADJUSTMENTS
1819 CAS01 Claim Adjustment Group Code ID 1-2 R
1820 CAS02 Adjustment Reason Code ID 1-5 R

1821 CAS03 Adjustment Amount R 1 - 18 R
1822 CAS04 Adjustment Quantity R 1 - 15 S
1823 CAS05 Adjustment Reason Code ID 1-5 S
1824 CAS06 Adjustment Amount R 1 - 18 S
AMT PAYER PRIOR 1 S 2320
PAYMENT
1839 1 AMT02 Other Payer Patient Paid R 1 - 18 R
Amount
1
1
1
AMT COORDINATION OF 1 S 2320

BENEFITS (COB)
TOTAL ALLOWED
AMOUNT
1842 1 AMT02 Allowed Amount R 1 - 18 R

BENEFITS (COB)
TOTAL SUBMITED
CHARGES
1845 1 AMT02 Coordination of Benefits Total R 1 - 18 R
Submitted Charge Amount
AMT DIAGNOSTIC RELATED 1 S 2320

GROUP (DRG)
OUTLIER AMOUNT

1848 1 AMT02 Claim DRG Outlier Amount R 1 - 18 R

BENEFITS (COB)
TOTAL MEDICARE
PAID AMOUNT
1851 1 AMT02 Total Medicare Paid Amout R 1 - 18 R
AMT MEDICARE PAID 1 S 2320

AMOUNT 100%
1854 1 AMT02 Medicare Paid at 100% Amount R 1 - 18 R

AMT MEDICARE PAID 1 S 2320
AMOUNT 80%
1857 1 AMT02 Medicare Paid at 80% Amount R 1 - 18 R

BENEFITS (COB)
MEDICARE A TRUST
FUND PAID AMOUNT
1860 1 AMT02 Paid From Part A Medicare R 1 - 18 R
Trust Fund Amount

BENEFITS (COB)
MEDICARE B TRUST
FUND PAID AMOUNT
1863 1 AMT02 Paid From Part B Medicare R 1 - 18 R
Trust Fund Amount

BENEFITS (COB)
TOTAL NON-COVERED
AMOUNT
1866 AMT02 Non-Covered Charge Amount R 1 - 18 R

BENEFITS (COB)
TOTAL DENIED
AMOUNT
1869 1 AMT02 Claim Total Denied Charge R 1 - 18 R
Amount
1
1
DMG OTHER SUBSCRIBER 1 S 2320

DEMOGRAPHIC
INFORMATION
Qualifier
1872 1 DMG02 Other Insured Birth Date AN 1 - 35 R
1873 1 DMG03 Gender Code ID 1-1 R
1878 1 DMG08 Basis of Veification Code ID 1-2 N/U
OI OTHER INSURANCE 1 R 2320

COVERAGE
INFORMATION
1880 OI01 Claim Filing Indicator Code ID 1-2 N/U
1881 OI02 Claim Submission Reason ID 2-2 N/U
Code
1882 1 OI03 Benefits Assignment ID 1-1 R
1883 OI04 Patient Signature Source Code ID 1-1 N/U
1884 OI05 Provider Agreement Code ID 1-1 N/U

1885 1 OI06 Release of Information Code ID 1-1 R
MIA MEDICARE INPATIENT 1 S 2320

ADJUDICATION
INFORMATION
1886 MIA01 Covered Days or Visits Count R 1 - 15 R
1887 MIA02 Lifetime Reserve Days Count R 1 - 15 S
1888 MIA03 Lifetime Psychiatric Days R 1 - 15 S

1889 MIA04 Claim DRG Amount R 1 - 18 S
1890 1 MIA05 Remark Code AN 1 - 30 S
1891 MIA06 Claim Disproportionate Share R 1 - 18 S

Amount
1892 MIA07 Claim MSP Pass-through R 1 - 18 S
Amount
1893 MIA08 Claim PPS Capital Amount R 1 - 18 S
1894 MIA09 PPS-Capital FSP DRG Amount R 1 - 18 S
1895 MIA10 PPS-Capital HSP DRG Amount R 1 - 18 S
1896 MIA11 PPS-Capital DSH DRG Amount R 1 - 18 S
1897 MIA12 Old Capital Amount R 1 - 18 S

1898 MIA13 PPS-Capital IME Amount R 1 - 18 S
1899 MIA14 PPS-Operating Hospital R 1 - 18 S
Specific DRG Amount
1900 MIA15 Cost Report Day Count R 1 - 15 S
1901 MIA16 PPS-Operating Federal Specific R 1 - 18 S
DRG Amount
1902 MIA17 Claim PPS Capital Outlier R 1 - 18 S
Amount
1903 MIA18 Claim Indirect Teaching R 1 - 18 S
Amount
1904 MIA19 Non-Payable Professional R 1 - 18 S
Component Amount
1909 MIA24 PPS-Capital Exception Amount R 1 - 18 S
MOA MEDICARE 1 S 2320

OUTPATIENT
ADJUDICATION
INFORMATION
1910 MOA01 Reimbursement Rate R 1 - 10 S
1911 MOA02 Claim HCPCS Payable Amount R 1 - 18 S
1912 1 MOA03 Remark Code AN 1 - 30 S

1917 MOA08 Claim ESRD Payment Amount R 1 - 18 S
1918 MOA09 Non-Payable Professional R 1 - 18 S

Component Amount
NM1 OTHER SUBSCRIBER 1 R 2330A 1

NAME
1921 1 NM103 Other Insured Last Name AN Dec-99 R
1922 1 NM104 Other Insured First Name AN 1 - 25 S
1923 NM105 Other Insured Middle Name AN 1 - 25 S
1925 NM107 Other Insured Name Suffix AN 1 - 10 S
1927 NM109 Other Insured Identifier AN 2 - 80 R
1930 1
N3 OTHER SUBSCRIBER 1 S 2330A

ADDRESS
1931 N301 Other Insured Address Line AN 1 - 55 R
1932 N302 Other Insured Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
1933 N401 Other Insured City Name AN 2 - 30 R

1934 N402 Other Insured State Code ID 2-2 R
1935 N403 Other Insured Postal Zone or ID 3 - 15 R
ZIP Code
1939 1
REF OTHER SUBSCRIBER 3 S 2330A

SECONDARY
IDENTIFICATION
Qualifier
1941 1 REF02 Other Insured Additional AN 1 - 30 R
Identifier
NM1 OTHER PAYER NAME 1 R 2330B 1

1946 1 NM103 Other Payer Last or AN 1 - 35 R
Organization Name
1952 NM109 Other Payer Primary Identifier AN 2 - 80 R

1955 1
N3 OTHER PAYER 1 S 2330B

ADDRESS
1956 N301 Other Payer Address Line AN 1 - 55 R
1957 N302 Other Payer Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
1958 N401 Other Payer City Name AN 2 - 30 R

1959 N402 Other Payer State Code ID 2-2 R
1960 N403 Other Payer Postal Zone or ZIP ID 3 - 15 R
Code
1964 1
DTP CLAIM ADJUDICATION 1 S 2330B

DATE

Qualifier
1967 DTP03 Adjudication or Payment Date AN 1 - 35 R
REF OTHER PAYER 2 S 2330B

SECONDARY
IDENTIFICATION AND
REFERENCE NUMBER
Qualifier
1969 1 REF02 Other Payer Secondary AN 1 - 30 R
Identifier
REF OTHER PAYER PRIOR 1 S 2330B

AUTHORIZATION
NUMBER OR
REFERRAL NUMBER
Qualifier
1973 1 REF02 Authorization or Referral AN 1 - 30 R
Number
1
1
1
1
1
1
NM1 OTHER PAYER 1 S 2330C 1
PATIENT
INFORMATION
1978 1 NM103 Name Last or Organization AN 1 - 35 N/U
Name
1980 1 NM105 Name Middle AN 1 - 25 N/U
1982 1 NM107 Name Suffix AN 1 - 10 N/U
1984 1 NM109 Other Payer Patient Primary AN 2 - 80 R
Identifier
REF OTHER PAYER 3 S 2330C

PATIENT
IDENTIFICATION
NUMBER
Qualifier
1988 1 REF02 Other Payer Patient Secondary AN 1 - 30 R
Identifier
NM1 OTHER PAYER 1 S 2330D 1

ATTENDING
PROVIDER
Name
1998 NM108 Identification Code Qualifier ID 1-2 N/U

2002 1
REF OTHER PAYER 3 R 2330D

ATTENDING
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
NM1 OTHER PAYER 1 S 2330E 1
OPERATING
PROVIDER
Name
2015 NM109 Other Payer Primary Identifier AN 2 - 80 N/U

2018 1
REF OTHER PAYER 3 R 2330E

OPERATING
PROVIDER
IDENTIFICATION

Qualifier
NM1 OTHER PAYER OTHER 1 S 2330F 1

PROVIDER

Name

2034 1
REF OTHER PAYER OTHER 3 R 2330F

PROVIDER
IDENTIFICATION

Qualifier
NM1 OTHER PAYER 1 S 2330H 1

SERVICE FACILITY
PROVIDER
Name

2050 1
REF OTHER PAYER 3 R 2330H

SERVICE FACILITY
PROVIDER
IDENTIFICATION

Qualifier
2052 1 REF02 Other Payer Service Facility AN 1 - 30 R
Location Secondary Identifier

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
LX SERVICE LINE 1 R 2400 999

NUMBER
2055 LX01 Assigned Number N0 1-6 R
SV2 INSTITUTIONAL 1 R 2400

SERVICE LINE
2056 SV201 Revenue Code AN 1 - 48 R
2057 SV202 COMPOSITE S
2058 1 SV202-1 Product or Service ID Qualifier ID 2-2 R
2059 SV202-2 Procedure Code AN 1 - 48 R

2060 SV202-3 Procedure Modifier AN 2-2 S
2064 SV202-7 Description AN 1 - 80 N/U
2065 1
2066 SV203 Line Item Charge Amount R 1 - 18 R
2067 1 SV204 Unit or Basis for Measurement ID 2-2 R
Code
2068 SV205 Service Unit Count R 1 - 15 R
2069 SV206 Unit Rate ID 1 - 10 S
2070 SV207 Monetary Amount R 1 - 18 S
2071 SV208 Y/N ID 1-1 N/U
2072 SV209 NHRSC ID 1-1 N/U
2073 SV210 Level of Care Code ID 1-1 N/U
PWK LINE SUPPLEMENTAL 5 S 2400

INFORMATION

2079 PWK06 Identification Code AN 2 - 80 S
2080 PWK07 Description AN 1 - 80 N/U

Qualifier
2085 DTP03 Service Date AN 1 - 35 R
DTP ASSESSMENT DATE 1 S 2400

2086 1 DTP01 Date Time Qualifier ID 3-3 R
Qualifier
2088 1 DTP03 Assessment Date AN 1 - 35 R
1
1
1
1
1
1
1
1
AMT SERVICE TAX 1 S 2400

AMOUNT
2090 AMT02 Service Tax Amount R 1 - 18 R
AMT FACILITY TAX 1 S 2400

AMOUNT
2093 AMT02 Facility Tax Amount R 1 - 18 R
1
1
HCP LINE 1 S 2400

PRICING/REPRICING
INFORMATION

Identifier
Amount
2100 1 HCP06 Ambulatory Patient Group Code AN 1 - 30 S
2101 HCP07 Ambulatory Patient Group R 1 - 18 S

Amount
2103 1 HCP09 Product or Service ID Qualifier ID 2-2 S
2104 HCP10 Procedure Code AN 1 - 48 S

2105 HCP11 Measurement Code ID 2-2 S
2106 HCP12 Repriced Approved Service R 1 - 15 S
Unit Count "DA" "UN"

LIN DRUG IDENTIFICATION 1 S 2410 25

2110 LIN01 Assigned Identification AN 1 - 20 N/U
2111 LIN02 Product or Service ID Qualifier ID 2-2 R
2112 LIN03 National Drug Code AN 1 - 48 R

2113 LIN04 Product/Service ID Qualifier ID 2-2 N/U
2114 LIN05 Product/Service ID AN 1 - 48 N/U
CTP DRUG QUANTITY 1 S 2410

2141 CTP01 Class of Trade Code ID 2-2 N/U
2142 CTP02 Price Identifier Code ID 3-3 N/U
2143 CTP03 Unit Price R 1 - 17 R
2144 CTP04 National Drug Unit Count R 1 - 15 R
2145 CTP05 COMPOSITE UNIT OF R
MEASURE
2146 1 CTP05-1 Unit or Basis For Measurement ID 2-2 R
Code
2147 CTP05-2 Exponent R 1 - 15 N/U
2148 CTP05-3 Multiplier R 1 - 10 N/U
2149 CTP05-4 Unit or Basis For Measurement ID 2-2 N/U
Code
Code
Code
Code
2161 CTP06 Price Multiplier Qualifier ID 3-3 N/U
2162 CTP07 Multiplier R 1 - 10 N/U
2163 CTP08 Monetary Amount R 1 - 18 N/U
2164 CTP09 Basis of Unit Price Code ID 2-2 N/U
2165 CTP10 Condition Value AN 1 - 10 N/U
2166 CTP11 Multiple Price Quantity N0 1-2 N/U
REF PRESCRIPTION 1 S 2410

NUMBER

Qualifier
2168 1 REF02 Prescription Number AN 1 - 30 R
2169 REF03 Desciption AN 1 - 80 N/U
NM1 ATTENDING 1 S 2420A 1

PHYSICIAN NAME
2173 1 NM103 Last Name AN 1 - 35 R
2174 1 NM104 First Name AN 1 - 25 S
2175 1 NM105 Middle Name AN 1 - 25 S
2179 1 NM109 Identifier AN 2 - 80 S
REF ATTENDING 1 S 2420A

PHYSICIAN
SECONDARY
IDENTIFICATION
Qualifier
2185 1 REF04 REFERENCE IDENTIFIER S
NM1 OPERATING 1 S 2420B 1

PHYSICIAN NAME
2188 1 NM103 Last Name AN 1 - 35 R
2189 1 NM104 First Name AN 1 - 25 S
2194 NM109 Identifier AN 2 - 80 S
2197 1
REF OPERATING 1 S 2420B
PHYSICIAN
SECONDARY
IDENTIFICATION
Qualifier
2202 1
2203 1
2204 1
2205 1
2206 1
2207 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM1 OTHER PROVIDER 1 S 2420C 1

NAME
2210 1 NM103 Other Physician Last Name AN 1 - 35 R
2211 1 NM104 Other Physician First Name AN 1 - 25 S
2212 1 NM105 Middle Name AN 1 - 25 S
2216 1 NM109 Identifier AN 2 - 80 R
REF OTHER PROVIDER 1 S 2420B

SECONDARY
IDENTIFICATION
Qualifier
2222 1 REF04 REFERENCE IDENTIFIER S
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
SVD LINE ADJUDICATION 1 S 2430 25

INFORMATION
2223 SVD01 Payer Identifier AN 2 - 80 R
2224 SVD02 Service Line Paid Amount R 1 - 18 R

2226 1 SVD03-1 Product or Service ID Qualifier ID 2-2 R
2227 SVD03-2 Procedure Code AN 1 - 48 R

2228 SVD03-3 Procedure Modifier AN 2-2 S
2232 SVD03-7 Procedure Code Description AN 1 - 80 S
2233 1
2234 1 SVD04 Product or Service ID AN 1 - 48 R
2235 SVD05 Paid Service Unit Count R 1 - 15 R
2236 SVD06 Bundled or Unbundled Line N0 1-6 S
Number
CAS LINE ADJUSTMENT 99 S 2430


2239 CAS03 Adjustment Amount R 1 - 18 R
DTP SERVICE 1 S 2430

ADJUDICATION DATE
Qualifier
1
1
SE TRANSACTION SET 1 R ___ >1

TRAILER

Number
GE FUNCTION GROUP 1 R ___ 1

TRAILER
Included
IEA INTERCHANGE 1 R ___ 1

CONTROL TRAILER
Groups
1514
al Claim 5010 837I Institutional Claim
Values Element Description ID Min. Usa Loop Loop
Identifier Max. ge Repe
Reg. at

CONTROL HEADER
Qualifier

ZZ
ZZ
ISA11 Interchange Control Standards 1-1 R
ID
ISA12 Interchange Control Version ID 5-5 R
Number


HEADER
GS01 Functional Identifier Code ID 2-2 R
HHMM, HHMMSS, HHMMSSD, GS05 Time TM 4-8 R
HHMMSSDD


HEADER

Number
Reference
HIERARCHICAL
TRANSACTION
00, 18 BHT02 Transaction Set Purpose Code ID 2-2 R

Transaction ID
HHMM, HHMMSS, HHMMSSD, BHT05 Transaction Set Creation Time TM 4-8 R

HHMMSSDD
CH, RP BHT06 Claim or Encounter ID ID 2-2 R
87
NM1 SUBMITTER NAME 1 R 1000 1

A
NM103 Submitter Last or Organization AN 1 - 60 R
Name
NM104 Submitter First Name AN 1 - 35 S
NM105 Submitter Middle Name AN 1 - 25 S
NM109 Submitter Identifier AN 2 - 80 R
NM112 Name Last or Organization AN 1 - 60 N/U
Name
PER SUBMITTER EDI 2 R 1000

CONTACT A
INFORMATION
PER02 Submitter Contact Name AN 1 - 60 S
ED, EM, FX. TE PER03 Communication Number ID 2-2 R
Qualifier
Qualifier
Qualifier
NM1 RECEIVER NAME 1 R 1000 1
B
NM103 Receiver Name AN 1 - 60 R
NM109 Receiver Primary Identifier AN 2 - 80 R
Name
HL BILLING PROVIDER 1 R 2000 >1

HIERARCHICAL A
LEVEL


PRV BILLING PROVIDER 1 S 2000

SPECIALTY A
INFORMATION
BI, PT PRV01 Provider Code ID 1-3 R

ZZ PRV02 Reference Identification ID 2-3 R
Qualifier
PRV03 Provider Taxonomy Code AN 1 - 50 R
INFORMATION
PRV06 Provider Organization Code ID 3-3 N/U
CUR FOREIGN CURRENCY 1 S 2000

INFORMATION A
CUR03 Exchange Rate R 4 - 10 N/U
CUR06 Currency Market/Exchange ID 3-3 N/U
Code
NM1 Billing Provider Name 1 R 2010 1

AA
NM103 Billing Provider Last or AN 1 - 60 R
Organizational Name
NM104 Billing Provider First Name AN 1 - 35 N/U
NM105 Billing Provider Middle Name AN 1 - 25 N/U

NM107 Billing Provider Name Suffix AN 1 - 10 N/U
24, 34, XX NM108 Identification Code Qualifier ID 1-2 S
NM109 Billing Provider Identifier AN 2 - 80 S
Name
N3 BILLING PROVIDER 1 R 2010

ADDRESS AA
N301 Billing Provider Address Line AN 1 - 55 R
N302 Billing Provider Address Line AN 1 - 55 S
N4 BILLING PROVIDER 1 R 2010

CITY/STATE/ZIP CODE AA
N401 Billing Provider City Name AN 2 - 30 R

N402 Billing Provider State or ID 2-2 S
Province Code
N403 Billing Provider Postal Zone or ID 3 - 15 S
ZIP Code
N406 Location Identifier AN 1 - 30 N/U
REF BILLING PROVIDER 1 R 2010

TAX IDENTIFICATION AA
0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, REF01 Reference Identification ID 2-3 R
B3, BQ, EI, FH, G2, G5, LU, Qualifier
SY, X5
REF02 Billing Provider Additional AN 1 - 50 R
Identifier
06, 8U, EM, IJ, LU, RB, ST, TT
PER BILLING PROVIDER 2 S 2010

CONTACT AA
INFORMATION
PER02 Billing Provider Contact Name AN 1 - 60 S
EM, FX, TE PER03 Communication Number ID 2-2 R

Qualifier
EM, EX, FX, TE PER05 Communication Number ID 2-2 S
Qualifier
Qualifier
NM1 PAY-TO ADDRESS 1 S 2010 1

NAME AB
NM103 Pay-to Provider Last or AN 1 - 60 N/U
Organization Name
NM104 Pay-to Provider First Name AN 1 - 35 N/U
NM105 Pay-to Provider Middle Name AN 1 - 25 N/U

NM107 Pay-to Provider Name Suffix AN 1 - 10 N/U
24, 34, XX NM108 Identification Code Qualifier ID 1-2 N/U

NM109 Pay-to Provider Identifier AN 2 - 80 N/U
Name
N3 PAY-TO PROVIDER 1 R 2010

ADDRESS AB
N301 Pay-to Provider Address Line AN 1 - 55 R
N302 Pay-to Provider Address Line AN 1 - 55 S
N4 PAY-TO PROVIDER 1 R 2010

CITY/STATE/ZIP CODE AB
N401 Pay-to Provider City Name AN 2 - 30 R

N402 Pay-to Provider State Code ID 2-2 S
N403 Pay-to Provider Postal Zone or ID 3 - 15 S
ZIP Code
N404 Pay-to Provider Country Code ID 2-3 S

0B, 1A, 1B, 1C, 1D, 1G,

1H, 1J, B3, BQ, EI, FH,
G2, G5, LU, SY, X5
NM1 PAY TO PLAN NAME 1 S 2010 1

AC
NM103 Pay to Plan Organizational AN 1 - 60 R
Name
NM108 Identification Code Qualifier ID 1-2 R
Name
N3 PAY-TO PLAN 1 R 2010

ADDRESS AC
N301 Pay-to Plan Address Line AN 1 - 55 R
N302 Pay-to Plan Address Line AN 1 - 55 S
N4 PAY-TO PLAN 1 R 2010

CITY/STATE/ZIP CODE AC
N401 Pay-to Plan City Name AN 2 - 30 R

N402 Pay-to Plan State Code ID 2-2 S
N403 Pay-to Plan Postal Zone or ZIP ID 3 - 15 S
Code
N404 Pay-to Plan Country Code ID 2-3 S
REF SECONDARY 1 S 2010

IDENTIFICATION AC
Qualifier
REF PAY-TO PLAN TAX 1 R 2010

IDENTIFICATION AC
Qualifier
HL SUBSCRIBER 1 R 2000 >1

HIERARCHICAL B
LEVEL

SBR SUBSCRIBER 1 R 2000

INFORMATION B
P, S, T SBR01 Payer Responsibility ID 1-1 R
SBR03 Insured Group or Policy AN 1 - 50 S

Number
SBR04 Insured Group Name AN 1 - 60 S
SBR05 Insurance Type Code ID 1-3 N/U
SBR06 Coordination of Benefits Code ID 1-1 N/U
SBR07 Yes/No Condition or Response ID 1-1 N/U

Code
09, 10, 11, 12, 13, 14, 15, 16, SBR09 Claim Filing Indicator Code ID 1-2 S
AM, BL, CH, CI, DS, HM, LI,
LM, MA, MB, MC, OF, TV, VA,
WC, ZZ
NM1 SUBSCRIBER NAME 1 R 2010 1

BA
MI, ZZ NM108 Identification Code Qualifier ID 1-2 R
NM109 Subscriber Primary Identifier AN 2 - 80 R

Name
N3 SUBSCRIBER 1 S 2010
ADDRESS BA
N301 Subscriber Address Line AN 1 - 55 R
N302 Subscriber Address Line AN 1 - 55 S
N4 SUBSCRIBER 1 S 2010
CITY/STATE/ZIP CODE BA
N401 Subscriber City Name AN 2 - 30 R

N402 Subscriber State Code ID 2-2 S
N403 Subscriber Postal Zone or ZIP ID 3 - 15 S
Code
N404 Subscriber Country Code ID 2-3 S

DEMOGRAPHIC BA
INFORMATION
Qualifier
F, M, U DMG03 Subscriber Gender Code ID 1-1 R
REF SUBSCRIBER 1 S 2010

SECONDARY BA
IDENTIFICATION
1W, 23, IG, SY REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Subscriber Supplemental AN 1 - 50 R
Identifier
REF CASUALTY CLAIM 1 S 2010

NUMBER BA
Y4 REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Property Casualty Claim AN 1 - 50 R
Number
AO
1, 2
MI
AB, BB
NM1 PAYER NAME 1 R 2010 1

BB
PI, XV NM108 Identification Code Qualifier ID 1-2 R
Name
N3 PAYER ADDRESS 1 S 2010

BB
N301 Payer Address Line AN 1 - 55 R
N302 Payer Address Line AN 1 - 55 S
N4 PAYER 1 R 2010
CITY/STATE/ZIP CODE BB
N401 Payer City Name AN 2 - 30 R

N402 Payer State Code ID 2-2 S
N403 Payer Postal Zone or ZIP ID 3 - 15 S
Code
N404 Payer Country Code ID 2-3 S
REF PAYER SECONDARY 3 S 2010

IDENTIFICATION BB
2U, FY, NF, TJ REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Payer Additional Identifier AN 1 - 50 R
REF BILLING PROVIDER 1 S 2010

SECONDARY BB
IDENTIFICATION
Qualifier
QD
HL PATIENT 1 S 2000 >1
HIERARCHICAL C
LEVEL

PAT PATIENT 1 R 2000

INFORMATION C
01, 04, 05, 07, 10, 15, 17, 19, PAT01 Individual Relationship Code ID 2-2 R
20, 21, 22, 23, 24, 29, 32, 33,
36, 39, 40, 41, 43, 53, G8

PAT05 Date Time Period Format ID 2-3 N/U
Qualifier
PAT06 Patient Death Date AN 1 - 35 N/U
PAT07 Measurement Code ID 2-2 N/U
PAT08 Patient Weight R 1 - 10 N/U
PAT09 Pregnancy Indicator ID 1-1 N/U
NM1 PATIENT NAME 1 R 2010 1

CA
NM107 Patient Name Suffix AN 1 - 10 S
Name
N3 PATIENT ADDRESS 1 R 2010

CA
N301 Patient Address Line AN 1 - 55 R
N302 Patient Address Line AN 1 - 55 S
N4 PATIENT 1 R 2010
CITY/STATE/ZIP CODE CA
N401 Patient City Name AN 2 - 30 R

N402 Patient State Code ID 2-2 S
N403 Patient Postal Zone or ZIP ID 3 - 15 S
Code
N404 Patient Country Code ID 2-3 S
DMG PATIENT 1 R 2010
DEMOGRAPHIC CA
INFORMATION
Qualifier
F, M, U DMG03 Patient Gender Code ID 1-1 R
1W, 23, IG, SY
REF PROPERTY AND 1 S 2010

CASUALTY CLAIM CA
NUMBER
Qualifier
Number
CLM01 Patient Account Number AN 1 - 38 R

CLM02 Total Claim Charge Amount R 1 - 18 R
CLM03 Claim Filing Indicator Code ID 1-2 N/U
CLM04 Non-Institutional Claim Type ID 1-2 N/U
Code
CLM05-1 Facility Type Code AN 1-2 R
A CLM05-2 Facility Code Qualifier ID 1-2 R
CLM05-3 Claim Frequency Code ID 1-1 R
N, Y CLM06 Provider or Supplier Signature ID 1-1 N/U
Indicator
A, C CLM07 Medicare Assignment Code ID 1-1 R
N CLM08 Benefits Assignment ID 1-1 R
A, I, M, N, O, Y CLM09 Release of Information Code ID 1-1 R
CLM10 Patient Signature Source Code ID 1-1 S
CLM11 RELATED CAUSES N/U

INFORMATION
CLM12 Special Program Indicator ID 2-3 S
CLM13 Yes/No Condition or Response ID 1-1 N/U
Code
Code
CLM16 Participation Agreement ID 1-1 N/U
N, Y CLM18 Yes/No Condition or Response ID 1-1 N/U
Code
CLM19 Claim Submission Reason ID 2-2 N/U
Code
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 CLM20 Delay Reason Code ID 1-2 S

HOUR
TM DTP02 Date Time Period Format ID 2-3 R
Qualifier
HHMM DTP03 Discharge Time AN 1 - 35 R
DTP DATE -STATEMENT 1 S 2300

DATES
Qualifier
CCYYMMDDCCY YMMDD DTP03 Statement From and To Date AN 1 - 35 R

DATE/HOUR
DT DTP02 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDDHHM M DTP03 Admission Date and Hour AN 1 - 35 R
DTP DATE -REPRICER 1 S 2300

RECEIVED DATE
DTP02 Date Time Period Format ID 2-3 R
Qualifier
DTP03 Order Date AN 1 - 35 R
CL1 INSTITUTIONAL 1 S 2300

CLAIM CODE
CL101 Admission Type Code ID 1-1 S
CL102 Admission Source Code ID 1-1 S
CL103 Patient Status Code ID 1-2 R
CL104 Nursing Home Code ID 1-1 NU
PWK CLAIM 10 S 2300
SUPPLEMENTAL
INFORMATION
AS, B2, B3, B4, CT, DA, DG, PWK01 Attachment Report Type Code ID 2-2 R
DS, EB, MT, NN, OB, OZ, PN,
PO, PZ, RB, RR, RT
AA, BM, EL, EM, FX PWK02 Attachment Transmission ID 1-2 R

Code
AC PWK05 Identification Code Qualifier ID 1-2 S
PWK06 Attachment Control Number AN 2 - 80 S
PWK07 Description AN 1 - 80 N/U

INFORMATION
01, 02, 03, 04, 05, 06, 09 CN101 Contract Type Code ID 2-2 R
CN102 Contract Amount R 1 - 18 S

CN103 Contract Percentage R 1-6 S
CN104 Contract Code AN 1 - 50 S
CN106 Contract Version Identifier AN 1 - 30 S
C5
AMT PATIENT ESTIMATED 1 S 2300

AMOUNT DUE
F3 AMT01 Amount Qualifier Code ID 1-3 R

AMT02 Patient Responsibility Amount R 1 - 18 R
F5
MA

AUTHORIZATION
EXCEPTION CODE
4N REF01 Reference Identification ID 2-3 R
Qualifier
1, 2, 3, 4, 5, 6, 7 REF02 Service Authorization AN 1 - 50 R
Exception Code
REF REFERRAL NUMBER 1 S 2300

Qualifier
REF02 Prior Authorization or Referral AN 1 - 50 R
Number
REF PRIOR 1 S 2300

AUTHORIZATION
9F, G1 REF01 Reference Identification ID 2-3 R
Qualifier
Number

CONTROL NUMBER
F8 REF01 Reference Identification ID 2-3 R

Qualifier
REF02 Claim Original Reference AN 1 - 50 R
Number

NUMBER
9A REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Repriced Claim Reference AN 1 - 50 R
Number

CLAIM NUMBER
9C REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Adjusted Repriced Claim AN 1 - 50 R
Reference Number

DEVICE EXEMPTION
NUMBER
LX REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Investigational Device AN 1 - 50 R
Exemption Number

FOR TRANSMISSION
INTERMEDIARIES
D9 REF01 Reference Identification ID 2-3 R
Qualifier

DD
REF AUTO ACCIDENT 1 S 2300

STATE
Qualifier
REF02 Auto Accident State or AN 1 - 50 R
Province

NUMBER
EA REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Medical Record Number AN 1 - 50 R

PROJECT IDENTIFIER
P4 REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Demonstration Project AN 1 - 50 R
Identifier
REF PEER REVIEW 1 S 2300

ORGANIZARION (PRO)
APPROVAL NUMBER
G4 REF01 Reference Identification ID 2-3 R

Qualifier
REF02 PRO Number AN 1 - 50 R

K301 Fixed Format Information AN 1 - 80 R
MEASURE

ALG, DCP, DGN, DME, MED, NTE01 Note Reference Code ID 3-3 R
NTR, ODT, RHB, RLH, RNH,
SET, SFM, SPT, UPI
NTE02 Claim Note Text AN 1 - 80 R
NTE BILLING NOTE 1 S 2300

ADD NTE01 Note Reference Code ID 3-3 R
NTE02 Billing Note Text AN 1 - 80 R
1, 2, 3, 4, 5, 6, 7, 8
CCYYMMDD
RD8
CCYYMMDD
N, U, Y
N, Y
I, R, S
CCYYMMDD
HC, ID
CCYYMMDD
CCYYMMDD
CCYYMMDD
RD8
A, B, C, D, E, F, G, H, L, M, O,
R, S, T
CCYYMMDD
CCYYMMDD
CCYYMMDD
CCYYMMDD
75
N, Y
AA, AL, BL, CO, DY, EL, HL,

LB, OL, PA, SL
76
N, Y
BR, CA, CB, CR, EP, IH, NR,
PW, TR, UT, WA, WR
77
N, Y
AG, CM, DI, DP, FO, LE, MC,
OT
CRC EPSDT REFERRAL 1 S 2300

CRC01 Code Category ID 2-2 R
CRC02 Certification Condition ID 1-1 R
Indicator
CRC03 Condition Code ID 2-3 R
CRC04 Condition Code ID 2-3 S
CRC05 Condition Code ID 2-3 S
CRC06 Condition Indicator ID 2-3 N/U
DIAGNOSIS
INFORMATION
BK HI01-1 Diagnosis Type Code ID 1-3 R
HI01-2 Principal Diagnosis Code AN 1 - 30 R
HI01-3 Date Time Period Format ID 2-3 N/U
Qualifier
HI01-4 Date Time Period AN 1 - 35 N/U
HI01-5 Monetary Amount R 1 - 18 N/U
HI01-6 Quantity R 1 - 15 N/U
HI01-7 Version Identifier AN 1 - 30 N/U
HI01-8 Industry code AN 1 - 30 N/U
HI01-9 Present on Admission indicator ID 1-1 S

INFORMATION
BJ, ZZ HI02-1 Diagnosis Type Code ID 1-3 N/U
HI02-2 Principal Diagnosis Code AN 1 - 30 N/U
Qualifier
HI02-9 Present on Admission indicator ID 1-1 N/U

INFORMATION
BN HI03-1 Diagnosis Type Code ID 1-3 N/U
Qualifier

INFORMATION
HI04-1 Diagnosis Type Code ID 1-3 N/U
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier
HI ADMITTING 1 R 2300
DISGNOSIS
INFORMATION
HI01-1 Diagnosis Type Code ID 1-3 R
HI01-2 Admitting Diagnosis Code AN 1 - 30 R
Qualifier
HI01-9 Yes/No Condition or response ID 1-1 N/U
Code
INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier
HI PATIENT REASON 1 R 2300

FOR VISIT
INFORMATION
HI01-2 Patient Reason For Visit AN 1 - 30 R
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier
HI EXTERNAL CAUSE OF 1 R 2300

INJURY
INFORMATION
HI01-2 External Cause of Injury Code AN 1 - 30 R

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION
HI05-2 Diagnosis Code AN 1 - 30 R
Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier

INFORMATION

Qualifier
HI DIAGNOSIS RELATED 1 R 2300

GROUP (DRG)
INFORMATION
INFORMATION
DR HI01-1 Qualifier ID 1-3 R
HI01-2 DRG Code AN 1 - 30 R
Qualifier
Code
INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier
INFORMATION
Qualifier

INFORMATION
Qualifier
HI OTHER DIAGNOSIS 2 R 2300

INFORMATION
INFORMATION
BF HI01-1 Diagnosis Type Code ID 1-3 R
HI01-2 Other Diagnosis AN 1 - 30 R
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier
PROCEDURE
INFORMATION
INFORMATION
BP HI01-1 Qualifier ID 1-3 R
HI01-2 Principal Procedure Code AN 1 - 30 R
D8 HI01-3 Date Time Period Format ID 2-3 N/U
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier

INFORMATION
Qualifier
HI OTHER PROCEDURE 2 R 2300

INFORMATION
INFORMATION
BO, BQ HI01-1 Qualifier Code ID 1-3 R
HI01-2 Procedure Code AN 1 - 30 R
D8 HI01-3 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDD HI01-4 Date Time Period AN 1 - 35 R
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
HI OCCURRENCE SPAN 2 R 2300

INFORMATION
INFORMATION
BI HI01-1 Qualifier ID 1-3 R
HI01-2 Occurrence Span Code AN 1 - 30 R
RD8 HI01-3 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDDCCYYMMDD HI01-4 Date Time Period AN 1 - 35 R

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier

Code
HI OCCURRENCE 2 R 2300
INFORMATION
INFORMATION
BH HI01-1 Qualifier ID 1-3 R
HI01-2 Occurrence Code AN 1 - 30 R
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
HI VALUE INFORMATION 2 R 2300

INFORMATION
BE HI01-1 Qualifier ID 1-3 R
HI01-2 Value Code AN 1 - 30 R
Qualifier
HI01-5 Value Code Amount R 1 - 18 R

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
INFORMATION
Qualifier

Code
HI CONDITION 2 R 2300
INFORMATION
INFORMATION
BG HI01-1 Qualifier ID 1-3 R
HI01-2 Condition Code AN 1 - 30 R
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
HI TREATMENT CODE 2 R 2300

INFORMATION
INFORMATION
TC HI01-1 Qualifier ID 1-3 R
HI01-2 Treatment Code AN 1 - 30 R
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
CA, CD, LA, NA
DA
HCP CLAIM 1 S 2300

PRICING/REPRICING
INFORMATION
00, 01, 02, 03, 04, 05, 06, 07, HCP01 Pricing Methodology ID 2-2 R
08, 09, 10 ,11, 12, 13, 14
HCP02 Repriced Allowed Amount R 1 - 18 R

HCP03 Repriced Saving Amount R 1 - 18 S
HCP04 Repricing Organization AN 1 - 50 S
Identifier
HCP05 Repricing Per Diem or Flat R 1-9 S
Rate Amount
HCP06 Ambulatory Patient Group AN 1 - 50 S
Code
HCP07 Ambulatory Patient Group R 1 - 18 S
Amount
HCP08 Product/Service ID AN 1 - 48 S
HC HCP09 Product/Service ID Qualifier ID 2-2 N/U
HCP10 Product/Service ID AN 1 - 48 N/U
DA, UN HCP11 Unit or Basis for Measurement ID 2-2 S
Code
HCP12 Quantity R 1 - 15 S
T1, T2, T3, T4, T5, T6 HCP13 Reject Reason Code ID 2-2 S
1, 2, 3, 4, 5 HCP14 Policy Compliance Code ID 1-2 S
1, 2, 3, 4, 5, 6 HCP15 Exception Code ID 1-2 S
AI, MS, OT, PT, SN, ST
DA, MO, Q1, WK
7, 35
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C,
D, E, F, G, J, K, L, N, O, S, SA,
SB, SC, SD, SG, SL, SP, SX,
SY, SZ, W,
D, E, F
NM1 ATTENDING 1 S 2310 1

PROVIDER NAME A
NM103 Last Name AN 1 - 60 R
NM104 First Name AN 1 - 35 S
NM105 Middle Name AN 1 - 25 S
NM109 Provider Identifier AN 2 - 80 S
Name
PRV ATTENDING 1 S 2310

PROVIDER A
SPECIALTY
INFORMATION
AT, SU PRV01 Provider Code ID 1-3 R
Qualifier
INFORMATION
REF ATTENDING 4 S 2310
PROVIDER A
SECONDARY
IDENTIFICATION
0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, REF01 Reference Identification ID 2-3 R
G2, LU, N5, SY, X5 Qualifier
REF02 Secondary Identifier AN 1 - 50 R

NM1 OPERATING 1 S 2310 1

PHYSICIAN NAME B
NM103 Last or Organization Name AN 1 - 60 R
NM109 Identifier AN 2 - 80 S
Name
REF OPERATING 4 S 2310

PHYSICIAN B
SECONDARY
IDENTIFICATION
0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, REF01 Qualifier ID 2-3 R
G2, LU, N5, SY, X5
NM1 OTHER OPERATING 1 S 2310 1

PHYSICIAN NAME C
NM103 Last or Organization Name AN 1 - 60 R
Name

PHYSICIAN C
SECONDARY
IDENTIFICATION
REF02 Rendering Provider Secondary AN 1 - 50 R
Identifier
NM1 RENDERING 1 S 2310 1

PHYSICIAN NAME D
NM103 Rendering Provider Last or AN 1 - 60 R
Organization Name
NM104 Rendering Provider First AN 1 - 35 S
Name
NM105 Rendering Provider Middle AN 1 - 25 S
Name
NM107 Rendering Provider Name AN 1 - 10 S
Suffix
NM109 Rendering Provider Identifier AN 2 - 80 S

Name
REF RENDERING 4 S 2310

PHYSICIAN D
SECONDARY
IDENTIFICATION
Qualifier
Identifier
NM1 SERVICE FACILITY 1 S 2310 1

LOCATION E
FA NM101 Entity Identifier Code ID 2-3 R
NM103 Laboratory or Facility Name AN 1 - 60 R
NM109 Laboratory or Facility Primary AN 2 - 80 S
Identifier
Name
N3 SERVICE FACILITY 1 R 2310
LOCATION ADDRESS E
N301 Laboratory or Facility Address AN 1 - 55 R

Line
N302 Laboratory or Facility Address AN 1 - 55 S
Line
N4 SERVICE FACILITY 1 R 2310

LOCATION E
CITY/STATE/ZIP
N401 Laboratory or Facility City AN 2 - 30 R
Name
N402 Laboratory or Facility State or ID 2-2 S
Province Code
N403 Laboratory or Facility Postal ID 3 - 15 S
Zone ZIP Code
N404 Laboratory/Facility Country ID 2-3 S
Code
REF SERVICE FACILITY 3 S 2310

LOCATION E
SECONDARY
IDENTIFICATION
REF02 Laboratory or Facility AN 1 - 50 R
NM1 REFERRING 1 S 2310 1

PROVIDER NAME F
NM103 Referring Provider Last Name AN 1 - 60 R
NM104 Referring Provider First Name AN 1 - 35 S
NM105 Referring Provider Middle AN 1 - 25 S

Name
NM107 Referring Provider Name AN 1 - 10 S
Suffix
NM109 Referring Provider Identifier AN 2 - 80 S
Name
REF REFERRING 3 S 2310
PROVIDER F
SECONDARY
IDENTIFICATION
Qualifier
REF02 Referring Provider Secondary AN 1 - 50 R
Identifier

INFORMATION
P, S, T SBR01 Payer Responsibility ID 1-1 R
01, 04, 05, 07, 10, 15, 17, 18, SBR02 Individual Relationship Code ID 2-2 R
19, 20, 21, 22, 23, 24, 29, 32,
33, 36, 39, 40, 41, 43, 53, G8

Number
SBR04 Other Insured Group Name AN 1 - 60 S
SBR05 Insurance Type Code ID 1-3 N/U

Code
LM, MA, MB, MC, OF, TV, VA,
WC, ZZ

ADJUSTMENTS
CO, CR, OA, PI, PR CAS01 Claim Adjustment Group Code ID 1-2 R
CAS02 Adjustment Reason Code ID 1-5 R

CAS03 Adjustment Amount R 1 - 18 R
CAS04 Adjustment Quantity R 1 - 15 S
CAS05 Adjustment Reason Code ID 1-5 S
CAS06 Adjustment Amount R 1 - 18 S
AMT COB PAYER PAID 1 S 2320
AMOUNT
C4 AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Payer Paid Amount R 1 - 18 R

AMOUNT
AMT02 Payer Paid Amount R 1 - 18 R
B6
T3
ZZ
N1
KF
PG
AA
B1
AMT COB TOTAL NON 1 S 2320

COVERED AMOUNT
A8 AMT01 Amount Qualifier Code ID 1-3 R

AMT02 Non-Covered Amount R 1 - 18 R
AMT REMAINING PATIENT 1 S 2320

LIABILITY
YT AMT01 Amount Qualifier Code ID 1-3 R

AMT02 Remaining Patient Liability R 1 - 18 R
Amount

LIABILITY
Amount
D8
F, M, U

COVERAGE
INFORMATION
OI01 Claim Filing Indicator Code ID 1-2 N/U
OI02 Claim Submission Reason ID 2-2 N/U
Code
N, Y OI03 Benefits Assignment ID 1-1 R
OI04 Patient Signature Source Code ID 1-1 N/U
OI05 Provider Agreement Code ID 1-1 N/U

A, I, M, N, O, Y OI06 Release of Information Code ID 1-1 R
MIA INPATIENT 1 S 2320

ADJUDICATION
INFORMATION
MIA01 Covered Days or Visits Count R 1 - 15 S
MIA02 Amount R 1 - 15 N/U
MIA03 Lifetime Psychiatric Days R 1 - 15 S

MIA04 Remaining Patient Liability R 1 - 18 S
Amount
MIA05 Claim Payment Remark Code AN 1 - 50 S
MIA06 Claim Disproportionate Share R 1 - 18 S

Amount
MIA07 Claim MSP Pass-through R 1 - 18 S
Amount
MIA08 Claim PPS Capital Amount R 1 - 18 S
MIA09 PPS-Capital FSP DRG R 1 - 18 S
Amount
MIA10 PPS-Capital HSP DRG R 1 - 18 S
Amount
MIA11 PPS-Capital DSH DRG R 1 - 18 S
Amount
MIA12 Old Capital Amount R 1 - 18 S
MIA13 PPS-Capital IME Amount R 1 - 18 S
MIA14 PPS-Operating Hospital R 1 - 18 S
Specific DRG Amount
MIA15 Cost Report Day Count R 1 - 15 S
MIA16 PPS-Operating Federal R 1 - 18 S
Specific DRG Amount
MIA17 Claim PPS Capital Outlier R 1 - 18 S
Amount
MIA18 Claim Indirect Teaching R 1 - 18 S
Amount
MIA19 Non-Payable Professional R 1 - 18 S
Component Billed Amount
MIA24 PPS-Capital Exception R 1 - 18 S

Amount

OUTPATIENT
ADJUDICATION
INFORMATION
MOA01 Reimbursement Rate R 1 - 10 S
MOA02 HCPCS Payable Amount R 1 - 18 S
MOA03 Remark Code AN 1 - 50 S

MOA08 End Stage Renal Disease R 1 - 18 S
Payment Amount
MOA09 Non-Payable Professional R 1 - 18 S
NM1 OTHER SUBSCRIBER 1 R 2330 1

NAME A
NM103 Other Insured Last Name AN 1 - 60 R
NM104 Other Insured First Name AN 1 - 35 S
NM105 Other Insured Middle Name AN 1 - 25 S
NM107 Other Insured Name Suffix AN 1 - 10 S
NM109 Other Insured Identifier AN 2 - 80 R
Name
N3 OTHER SUBSCRIBER 1 S 2330

ADDRESS A
N301 Other Insured Address Line AN 1 - 55 R
N302 Other Insured Address Line AN 1 - 55 S
N4 OTHER SUBSCRIBER 1 R 2330

CITY/STATE/ZIP CODE A
N401 Other Insured City Name AN 2 - 30 R

N402 Other Insured State Code ID 2-2 S
N403 Other Insured Postal Zone or ID 3 - 15 S
ZIP Code
REF OTHER SUBSCRIBER 2 S 2330

SECONDARY A
IDENTIFICATION
1W, 23, !G, SY REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Other Insured Additional AN 1 - 50 R
Identifier
NM1 OTHER PAYER NAME 1 R 2330 1

B
NM103 Other Payer Last or AN 1 - 60 R
Organization Name
NM109 Other Payer Primary Identifier AN 2 - 80 R

Name
N3 OTHER PAYER 1 S 2330

ADDRESS B
N301 Other Payer Address Line AN 1 - 55 R
N302 Other Payer Address Line AN 1 - 55 S
N4 OTHER PAYER 1 R 2330

CITY/STATE/ZIP CODE B
N401 Other Payer City Name AN 2 - 30 R

N402 Other Payer State Code ID 2-2 S
N403 Other Payer Postal Zone or ID 3 - 15 S
ZIP Code
N404 Other Payer Country Code ID 2-3 S
DTP DATE -CLAIM CHECK 1 S 2330

OR REMITTANCE B
DATE
D8 DTP02 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDD DTP03 Adjudication or Payment Date AN 1 - 35 R
REF OTHER PAYER 2 S 2330

SECONDARY B
IDENTIFICATION
2U, F8, FY, NF, TJ REF01 Reference Identification ID 2-3 R

Qualifier
REF02 Other Payer Secondary AN 1 - 50 R
Identifier
REF OTHER PAYER PRIOR 1 S 2330

AUTHORIZATION B
NUMBER

Qualifier
REF02 Other Payer Prior AN 1 - 50 R
REF OTHER PAYER 1 S 2330

REFERRAL NUMBER B
Qualifier
REF02 Other Payer Referral Number AN 1 - 50 R

REF OTHER PAYER CLAIM 1 S 2330

ADJUSTMENT B
INDICATOR
Qualifier
REF02 Other Payer Claim Adjustment AN 1 - 50 R
Indicator
REF OTHER PAYER CLAIM 1 S 2330

CONTROL NUMBER B

Qualifier
REF02 Other Payer Claim Control AN 1 - 50 R
Number
QC
1
EI, MI
1W, IG, SY
NM1 OTHER PAYER 1 S 2330 1

ATTENDING C
PROVIDER
Name
NM109 Other Payer Primary Identifier AN 2 - 80 N/U

Name
REF OTHER PAYER 4 R 2330

ATTENDING C
PROVIDER
SECONDARY
IDENTIFICATION
1A, 1B, 1C, 1D, 1G, 1H, EI, G2, REF01 Reference Identification ID 2-3 R
LU, N5 Qualifier
OPERATING D
PROVIDER
Name

Name

OPERATING D
PROVIDER
SECONDARY
IDENTIFICATION
LU, N5 Qualifier

OTHER OPERATING E
PROVIDER
Name

Name

OTHER OPERATING E
PROVIDER
SECONDARY
IDENTIFICATION
LU, N5, SY Qualifier

SERVICE FACILITY F
LOCATION
FA NM101 Entity Identifier Code ID 2-3 R
Name

Name

SERVICE FACILITY F
LOCATION
SECONDARY
IDENTIFIER
1B, 1C, 1D, EI, G2, LU, N5 REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Other Payer Service Facility AN 1 - 50 R


RENDERING G
PROVIDER
Name

Name
RENDERING G
PROVIDER
SECONDARY
IDENTIFIER
Qualifier
REF02 Other Payer Rendering AN 1 - 50 R
Provider Secondary Identifier


REFERRING H
PROVIDER
Name

Name

REFERRING H
PROVIDER
SECONDARY
IDENTIFIER
Qualifier
REF02 Other Payer Referring Provider AN 1 - 50 R

NM1 OTHER PAYER 1 S 2330I 1

BILLING PROVIDER
Name

Name
REF OTHER PAYER 2 R 2330I

BILLING PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
REF02 Other Payer Billing Provider AN 1 - 50 R
Secondary Identification
SV2 INSTITUTIONAL 1 R 2400

SERVICE LINE
SV201 Revenue Code AN 1 - 48 R
SV202 COMPOSITE R
HC, IV, ZZ SV202-1 Product or Service ID Qualifier ID 2-2 R
SV202-2 Procedure Code AN 1 - 48 R

SV202-3 Procedure Modifier AN 2-2 S
SV202-7 Description AN 1 - 80 S
SV202-8 Product/Service ID AN 1 - 48 N/U
SV203 Line Item Charge Amount R 1 - 18 R
DA, F2, UN SV204 Unit or Basis for Measurement ID 2-2 R
Code
SV205 Service Units/Days R 1 - 15 R
SV206 Unit Rate ID 1 - 10 N/U
SV207 Monetary Amount R 1 - 18 S
SV208 Y/N ID 1-1 N/U
SV209 NHRSC ID 1-1 N/U
SV210 Level of Care Code ID 1-1 N/U

INFORMATION
AS, B2, B3, B4, CT, D2, DA, PWK01 Attachment Report Type Code ID 2-2 R
DG, DS, EB, MT, NN, OB, OZ,
PN, PO, PZ, RB, RR, RT
AA, AB, AD, AF, AG, BM, EL, PWK02 Attachment Transmission ID 1-2 R
EM, FX Code
PWK06 Identification Code AN 2 - 80 S
DTP DATE -SERVICE DATE 1 R 2400

Qualifier
CYYMMDD, CCYYMMDD DTP03 Service Date AN 1 - 35 R
CCYYMMDD
866
D8
CCYYMMDD
REF LINE ITEM CONTROL 1 S 2400

NUMBER
Qualifier
REF REPRICED LINE ITEM 1 S 2400

REFERENCE NUMBER

Qualifier
REF02 Repriced Line Item Reference AN 1 - 50 R
Number
REF ITEM REFERENCE 1 S 2400
NUMBER
Qualifier
REF02 Adjusted Repriced Line Item AN 1 - 50 R
Reference Number
AMT SERVICE TAX 1 S 2400

AMOUNT
GT AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Tax Amount R 1 - 18 R
AMT FACILITY TAX 1 S 2400

AMOUNT
N8 AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Facility Tax Amount R 1 - 18 R
NTE THIRD PARTY 1 S 2400

ORGANIZATION
NOTES
NTE01 Note Reference Code ID 3-3 R
HCP LINE 1 S 2400

PRICING/REPRICING
INFORMATION
08, 09, 10, 11, 12, 13, 14

Identifier
HCP05 Repricing Per Diem or Flat R 1-9 S
Rate Amount
HCP06 Ambulatory Patient Group AN 1 - 50 S
Code
HCP07 Ambulatory Patient Group R 1 - 18 S
Amount
HC HCP09 Product or Service ID Qualifier ID 2-2 S
HCP10 Procedure Code AN 1 - 48 S

DA, UN HCP11 Measurement Code ID 2-2 S
HCP12 Repriced Approved Service R 1 - 15 S
Unit Count "DA" "UN"
LIN DRUG 1 S 2410 1

IDENTIFICATION
LIN01 Assigned Identification AN 1 - 20 N/U
N4 LIN02 Product or Service ID Qualifier ID 2-2 R
LIN03 National Drug Code AN 1 - 48 R

LIN04 Product/Service ID Qualifier ID 2-2 N/U
LIN05 Product/Service ID AN 1 - 48 N/U
CTP DRUG QUANTITY 1 R 2410

CTP01 Class of Trade Code ID 2-2 N/U
CTP02 Price Identifier Code ID 3-3 N/U
CTP03 Unit Price R 1 - 17 N/U
CTP04 National Drug Unit Count R 1 - 15 R
CTP05 COMPOSITE UNIT OF R
MEASURE
F2, GR, ML, UN CTP05-1 Unit or Basis For ID 2-2 R
Measurement Code
CTP05-2 Exponent R 1 - 15 N/U
CTP05-3 Multiplier R 1 - 10 N/U
CTP05-4 Unit or Basis For ID 2-2 N/U
Measurement Code
Measurement Code
Measurement Code
Measurement Code
CTP06 Price Multiplier Qualifier ID 3-3 N/U
CTP07 Multiplier R 1 - 10 N/U
CTP08 Monetary Amount R 1 - 18 N/U
CTP09 Basis of Unit Price Code ID 2-2 N/U
CTP10 Condition Value AN 1 - 10 N/U
CTP11 Multiple Price Quantity N0 1-2 N/U
REF PRESCRIPTION OR 1 S 2410

COMPOUND DRUG
ASSOCIATION
NUMBER
XZ REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Prescription Number AN 1 - 50 R
REF03 Desciption AN 1 - 80 N/U
71
1, 2
24, 34, XX
OB, 1A, 1B, 1C, 1D, 1G, 1H, EI,

G2, LU, N5, SY, X5
NM1 OPERATING 1 S 2420 1

PHYSICIAN NAME A
Name
PHYSICIAN A
SECONDARY
IDENTIFICATION
OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, REF01 Reference Identification ID 2-3 R
REF04-1 Reference Identifier Qualifier ID 2-3 R
REF04-2 Idenitifer AN 1 - 50 R
REF04-3 Reference Identification ID 2-3 N/U
Qualifier
REF04-4 Reference Identification AN 1 - 50 N/U
Qualifier
NM1 OTHER OPERATING 1 S 2420 1

PHYSICIAN NAME B
Name
REF OTHER OPERATING 20 S 2420

PHYSICIAN B
SECONDARY
IDENTIFICATION
Qualifier
REF04-2 Idenitifer AN 1 - 50 R
Qualifier
Qualifier
73
1, 2
24, 34, XX
OB, 1A, 1B, 1C, 1D, 1G, 1H, EI,

G2, LU, N5, SY, X5
NM1 RENDERING 1 S 2420 1

PROVIDER NAME C
Organization Name
NM104 Rendering Provider First AN 1 - 35 S
Name
Name
Suffix

Name
REF RENDERING 20 S 2420

PROVIDER C
SECONDARY
IDENTIFICATION
Qualifier
Identifier
REF04-2 Other Payer Primary Idenitifer AN 1 - 50 R

Qualifier
Qualifier
NM1 REFERRING 1 S 2420 1

PROVIDER NAME D

Name or Initial
NM107 Referring Provider Name AN 1 - 10 S
Suffix
NM109 Other Payer Primary Identifier AN 2 - 80 S

Name
REF REFERRING 20 S 2420

PROVIDER D
SECONDARY
IDENTIFICATION
Qualifier
Identifier

Qualifier
Qualifier

INFORMATION
SVD01 Other Payer Primary Identifier AN 2 - 80 R
SVD02 Service Line Paid Amount R 1 - 18 R

HC, IV, ZZ SVD03-1 Product or Service ID Qualifier ID 2-2 R
SVD03-2 Procedure Code AN 1 - 48 R

SVD03-3 Procedure Modifier AN 2-2 S
SVD03-7 Procedure Code Description AN 1 - 80 S
SVD03-8 Product/Service ID AN N/U

SVD04 Product or Service ID AN 1 - 48 N/U
SVD05 Paid Service Unit Count R 1 - 15 R
SVD06 Bundled or Unbundled Line N0 1-6 S
Number


CAS03 Adjustment Amount R 1 - 18 R
DTP LINE CHECK OR 1 R 2430

REMITTANCE DATE
Qualifier

LIABILITY
Amount

TRAILER

Number

TRAILER
Included

CONTROL TRAILER
Groups
itutional Claim
Values
00, 03
00, 01
01, 14, 20, 27, 28, 29,

30, 33, ZZ
01, 14, 20, 27, 28, 29,

30, 33, ZZ
YYMMDD
HHMM
501
0, 1
P, T
CCYYMMDD
HHMM, HHMMSS,
HHMMSSD,
HHMMSSDD
X
005010X223
837
19
00, 18
CCYYMMDD
HHMM, HHMMSS,
HHMMSSD,
HHMMSSDD
31, CH, RP
41
1, 2
46
IC
EM, FX. TE
EM, EX, FX, TE
EM, EX, FX, TE

40
2
46
20
1
BI
PXC
85
85
2
XX
EI
IC
EM, FX, TE
EM, EX, FX, TE
EM, EX, FX, TE
87
2
PE
2
PI, XV
2U, FY, NF
EI
22
0, 1
A, B, C, D, E, F, G, H, P,
S, T, U
18
11, 12, 13, 14, 15, 16,

17, AM, BL, CH, CI, DS,
FI, HM, LM, MA, MB,
MC, OF, TV, VA, WC,
ZZ
IL
1, 2
II, MI
D8
CCYYMMDD
F, M, U
SY
Y4
PR
2
PI, XV
2U, EI, FY, NF
G2, LU
23
0
01, 19, 20, 21, 39, 40,

53, G8
QC
1
D8
CCYYMMDD
F, M, U
Y4
N, Y
A, B, C
N, W, Y
I, Y
P
02, 03, 05, 09
1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 15
96
TM
HHMM
434
RD8
CCYYMMDDCCY
YMMDD
435
D8, DT
CCYYMMDD,
CCYYMMDDHHMM
50
D8
CCYYMMDD
03, 04, 05, 06, 07, 08,
09, 10, 11, 13, 15, 21,
A3, A4, AM, AS, B2, B3,
B4, BR, BS, BT, CB,
CK, CT, D2, DA, DB,
DG, DJ, DS, EB, HC,
HR, I5, IR, LA, M1, MT,
NN, OB, OC, OD, OE,
OX, OZ, P4, P5, PE,
PN, PO, PQ, PY, PZ,
RB, RR, RT, RX, SG,
V5, XP
AA, BM, EL, EM, FT, FX
AC
01, 02, 03, 04, 05, 06,

09
F3
4N
1, 2, 3, 4, 5, 6, 7
9F
G1
F8
9A
9C
LX
D9
LU
EA
P4
G4
ALG, DCP, DGN, DME,

MED, NTR, ODT, RHB,
RLH, RNH, SET, SFM,
SPT, UPI
ADD
ZZ
N, Y
AV, NU, S2, ST

AV, NU, S2, ST
AV, NU, S2, ST
ABK, BK
N, U, W, Y
ABJ, BJ
APR, PR
APR, PR
APR, PR
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
ABN, BN
N, U, W, Y
DR
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
ABF, BF
N, U, W, Y
BBR, BR
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BBQ, BQ
D8
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDDCCY
YMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BI
RD8
CCYYMMDD
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BH
D8
CCYYMMDD
BE
BE
BE
BE
BE
BE
BE
BE
BE
BE
BE
BE
BG
BG
BG
BG
BG
BG
BG
BG
BG
BG
BG
BG
TC
TC
TC
TC
TC
TC
TC
TC
TC
TC
TC
TC
00, 01, 02, 03, 04, 05,
06, 07, 08, 09, 10 ,11,
12, 13, 14
DA, UN
T1, T2, T3, T4, T5, T6
1, 2, 3, 4, 5
1, 2, 3, 4, 5, 6
71
1
XX
AT
PXC
0B, 1G, G2, LU
72
1
XX
0B, 1G, G2, LU
ZZ
1
XX
0B, 1G, G2, LU
82
1
XX
0B, 1G, G2, LU
77
2
XX
0B, G2, LU
DN
1
XX
0B, 1G, G2
A, B, C, D, E, F, G, H, P,
S, T, U
01, 18, 19, 20, 21, 39,
40, 53, G8
11, 12, 13, 14, 15, 16,

17, AM, BL, CH, CI, DS,
FI, HM, LM, MA, MB,
MC, OF, TV, VA, WC,
ZZ
CO, CR, OA, PI, PR

D
NM
NM
A8
EAF
EAF
N, W, Y
I, Y
IL
1, 2
II, MI
SY
PR
2
PI, XV
573
D8
CCYYMMDD
2U, EI, FY, NF
G1
9F
T4
F8
71
1
0B, 1G, G2, LU

72
1
0B, 1G, G2, LU
ZZ
1
0B, 1G, G2, LU

77
2
0B, G2, LU
82
1
0B, 1G, G2, LU
DN
1
0B, 1G, G2
85
2
G2, LU
ER, HC, HP, IV, WK
DA, UN
03, 04, 05, 06, 07, 08,
09, 10, 11, 13, 15, 21,
A3, A4, AM, AS, B2,
B3, B4, BR, BS, BT,
CB, CK, CT, D2, DA,
DB, DG, DJ, DS, EB,
HC, HR, I5, IR, LA, M1,
MT, NN, OB, OC, OD,
OE, OX, OZ, P4, P5,
PE, PN, PO, PQ, PY,
PZ, RB, RR, RT, RX,
SG, V5, XP
AC
472
D8, RD8
CYYMMDD,
CCYYMMDD
CCYYMMDD
6R
9B
9D
GT
N8
TPO
00, 01, 02, 03, 04, 05,

06, 07, 08, 09, 10, 11,
12, 13, 14
ER, HC, HP, IV, WK
DA, UN
T1, T2, T3, T4, T5, T6

1, 2, 3, 4, 5
1, 2, 3, 4, 5, 6
N4
F2, GR, ME, ML, UN

VY, XZ
72
1
XX
OB, 1G, G2, LU
2U
ZZ
1
XX
OB, 1G, G2, LU
2U
82
1
XX
OB, 1G, G2, LU
2U
DN
1
XX
OB, 1G, G2
2U
ER, HC, HP, IV, WK

CO, CR, OA, PI, PR
573
D8
CCYYMMDD
EAF
4010A1 837P Professional Claim

CONTROL HEADER
Qualifier



ID
Number

GS FUNCTIONAL GROUP 1 R ___ >1

HEADER
21 1 GS05 Time TM 4-8 R

HEADER

Number
27 1

HIERARCHICAL
TRANSACTION
30 BHT03 Originator Application AN 1 - 30 R

Transaction ID
32 BHT05 Transaction Set Creation Time TM 4-8 R
33 1 BHT06 Claim or Encounter ID ID 2-2 R
REF TRANSMISSION TYPE 1 R ___ 1

IDENTIFICATION

Qualifier
35 1 REF02 Transmission Type Code AN 1 - 30 R


40 1 NM103 Submitter Last or Organization AN 1 - 35 R
Name
41 1 NM104 Submitter First Name AN 1 - 25 S
42 NM105 Submitter Middle Name AN 1 - 25 S
46 NM109 Submitter Identifier AN 2 - 80 R
49 1

CONTACT
INFORMATION
51 PER02 Submitter Contact Name AN 1 - 60 R
Qualifier
53 PER04 Communication Number AN 1 - 80 R
Qualifier
Qualifier

61 1 NM103 Receiver Name AN 1 - 35 R
67 NM109 Receiver Primary Identifier AN 2 - 80 R
70 1
HL BILLING/PAY-TO 1 R 2000A >1

PROVIDER
HIERARCHICAL LEVEL


PRV BILLING/PAY-TO 1 S 2000A

PROVIDER SPECIALTY
INFORMATION

Qualifier
77 PRV03 Provider Taxonomy Code AN 1 - 30 R
INFORMATION

INFORMATION
83 CUR03 Exchange Rate R 4 - 10 N/U
86 CUR06 Currency Market/Exchange ID 3-3 N/U
Code
Suffix
104 1 NM103 Billing Provider Last or AN 1 - 35 R
Organizational Name
105 1 NM104 Billing Provider First Name AN 1 - 25 S
106 NM105 Billing Provider Middle Name AN 1 - 25 S
108 NM107 Billing Provider Name Suffix AN 1 - 10 S
110 NM109 Billing Provider Identifier AN 2 - 80 R
113 1

ADDRESS
114 N301 Billing Provider Address Line AN 1 - 55 R
115 N302 Billing Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
116 N401 Billing Provider City Name AN 2 - 30 R

117 N402 Billing Provider State or ID 2-2 R
Province Code
118 N403 Billing Provider Postal Zone or ID 3 - 15 R
ZIP Code
122 1
REF BILLING PROVIDER 8 S 2010AA

SECONDARY
IDENTIFICATION
Qualifier

Identifier
127 1
128 1
129 1
130 1
131 1
132 1
REF CREDIT/DEBIT CARD 8 S 2010AA
BILLING
INFORMATION
Qualifier
134 1 REF02 Billing Provider Credit Card AN 1 - 30 R
Identifier
1
1
1
1
1

CONTACT
INFORMATION
138 PER02 Billing Provider Contact Name AN 1 - 60 R

Qualifier
Qualifier
Qualifier
NM1 PAY-TO PROVIDER 1 S 2010AB 1

NAME
148 1 NM103 Pay-to Provider Last or AN 1 - 35 R
Organization Name
149 1 NM104 Pay-to Provider First Name AN 1 - 25 S
150 NM105 Pay-to Provider Middle Name AN 1 - 25 S

152 NM107 Pay-to Provider Name Suffix AN 1 - 10 S
154 NM109 Pay-to Provider Identifier AN 2 - 80 R
157 1

ADDRESS
158 N301 Pay-to Provider Address Line AN 1 - 55 R
159 N302 Pay-to Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
160 N401 Pay-to Provider City Name AN 2 - 30 R

161 N402 Pay-to Provider State Code ID 2-2 R
162 N403 Pay-to Provider Postal Zone or ID 3 - 15 R
ZIP Code
163 N404 Pay-to Provider Country Code ID 2-3 S

166 1
REF PAY-TO PROVIDER 5 S 2010AB

SECONDARY
IDENTIFICATION
Qualifier
168 1 REF02 Pay-to Provider Identifier AN 1 - 30 R

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

HIERARCHICAL LEVEL


INFORMATION
Number Code
Number
178 SBR04 Insured Group Name AN 1 - 60 S
179 SBR05 Insurance Type Code ID 1-3 S

Code
PAT PATIENT 1 S 2000B

INFORMATION
184 PAT01 Individual Relationship Code ID 2-2 N/U
188 PAT05 Date Time Period Format ID 2-3 S
Qualifier
189 PAT06 Insured Individual Death Date AN 1 - 35 S
190 PAT07 Unit or Basis for Measurement ID 2-2 S

Code
191 PAT08 Patient Weight 9(6)V99 R 1 - 10 S
192 PAT09 Pregnancy Indicator ID 1-1 S

201 NM109 Subscriber Primary Identifier AN 2 - 80 S
204 1
ADDRESS
205 N301 Subscriber Address Line AN 1 - 55 R
206 N302 Subscriber Address Line AN 1 - 55 S
CITY/STATE/ZIP CODE
207 N401 Subscriber City Name AN 2 - 30 R

208 N402 Subscriber State Code ID 2-2 R
209 N403 Subscriber Postal Zone or ZIP ID 3 - 15 R
Code
213 1

DEMOGRAPHIC
INFORMATION
Qualifier
223 1
224 1

SECONDARY
IDENTIFICATION
Qualifier
226 1 REF02 Subscriber Supplemental AN 1 - 30 R
Identifier
229 1
230 1
231 1
232 1
233 1
234 1
REF PROPERTY AND 1 S 2010BA

CASUALTY CLAIM
NUMBER
Qualifier
Number
239 1
240 1
241 1
242 1
243 1
244 1
1
1
1
1
1
1
1
1
NM1 PAYER NAME 1 R 2010BB 1

257 1
N3 PAYER ADDRESS 1 S 2010BB

258 N301 Payer Address Line AN 1 - 55 R
259 N302 Payer Address Line AN 1 - 55 S
N4 PAYER 1 S 2010BB
CITY/STATE/ZIP CODE
260 N401 Payer City Name AN 2 - 30 R

261 N402 Payer State Code ID 2-2 R
262 N403 Payer Postal Zone or ZIP Code ID 3 - 15 R

266 1
REF PAYER SECONDARY 3 S 2010BB

IDENTIFICATION
Qualifier
268 1 REF02 Payer Additional Identifier AN 1 - 30 R
271 1
272 1
273 1
274 1
275 1
276 1
1
1
1
1
1
1
NM1 RESPONSIBLE PARTY 1 S 2010BC 1

NAME
279 1 NM103 Responsible Party Last or AN 1 - 35 R
Organization Name
280 1 NM104 Responsible Party First Name AN 1 - 25 S
281 1 NM105 Responsible Party Middle AN 1 - 25 S

Name
283 1 NM107 Responsible Party Suffix Name AN 1 - 10 S

ADDRESS
288 1 N301 Responsible Party Address AN 1 - 55 R
Line
289 1 N302 Responsible Party Address AN 1 - 55 S
Line

CITY/STATE/ZIP CODE
290 1 N401 Responsible Party City Name AN 2 - 30 R
291 1 N402 Responsible Party State Code ID 2-2 R
292 1 N403 Responsible Party Postal Zone ID 3 - 15 R

or ZIP Code
293 1 N404 Responsible Party Country ID 2-3 S
Code
294 1 N405 Location Qualifier ID 1-2 N/U
295 1 N406 Location Identifier AN 1 - 30 N/U
NM1 CREDIT/DEBIT CARD 1 S 2010BD 1

HOLDER NAME
298 1 NM103 Credit or Debit Card Holder AN 1 - 35 R
Last or Organizational Name
299 1 NM104 Credit or Debit Card Holder AN 1 - 25 S
First Name
Middle Name
Name Suffix
304 1 NM109 Credit or Debit Card Number AN 2 - 80 R
REF CREDIT/DEBIT CARD 2 S 2010BD

INFORMATION
Qualifier
308 1 REF02 Credit or Debit Card AN 1 - 30 R

HIERARCHICAL LEVEL


INFORMATION
315 1 PAT01 Individual Relationship Code ID 2-2 R

319 PAT05 Date Time Period Format ID 2-3 S
Qualifier
320 PAT06 Patient Death Date AN 1 - 35 S
Code
322 PAT08 Patient Weight 9(6)V99 R 1 - 10 S
323 PAT09 Pregnancy Indicator ID 1-1 S

327 1 NM104 Patient First Name AN 1 - 25 R
335 1

336 N301 Patient Address Line AN 1 - 55 R
337 N302 Patient Address Line AN 1 - 55 S
CITY/STATE/ZIP CODE
338 N401 Patient City Name AN 2 - 30 R

339 N402 Patient State Code ID 2-2 R
340 N403 Patient Postal Zone or ZIP ID 3 - 15 R
Code
341 N404 Patient Country Code ID 2-3 S
344 1

DEMOGRAPHIC
INFORMATION
Qualifier
347 DMG03 Patient Gender Code ID 1-1 R
354 1
355 1
REF PATIENT SECONDARY 5 S 2010CA

IDENTIFICATION

Qualifier
357 1 REF02 Patient Secondary Identifier AN 1 - 30 R

CASUALTY CLAIM
NUMBER
Qualifier
Number
364 1
365 1
366 1
367 1
368 1
369 1
1
1
1
1
1
1
1
1

370 CLM01 Patient Account Number AN 1 - 38 R
371 CLM02 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
372 CLM03 Claim Filing Indicator Code ID 1-2 N/U
373 CLM04 Non-Institutional Claim Type ID 1-2 N/U
Code
375 1 CLM05-1 Facility Type Code AN 1-2 R
376 1 CLM05-2 Facility Code Qualifier ID 1-2 N/U

377 1 CLM05-3 Claim Frequency Code ID 1-1 R
378 CLM06 Provider or Supplier Signature ID 1-1 R
Indicator
379 1 CLM07 Medicare Assignment Code ID 1-1 R
380 1 CLM08 Benefits Assignment ID 1-1 R
381 1 CLM09 Release of Information Code ID 1-1 R
382 1 CLM10 Patient Signature Source Code ID 1-1 S
383 CLM11 RELATED CAUSES S

INFORMATION
384 1 CLM11-1 Related Causes Code ID 2-3 R
385 1 CLM11-2 Related Causes Code ID 2-3 S
386 1 CLM11-3 Related Causes Code ID 2-3 S
387 CLM11-4 Auto Accident State or Province ID 2-2 S
Code
388 CLM11-5 Country Code ID 2-3 S
389 1 CLM12 Special Program Indicator ID 2-3 S
Code
Code
393 1 CLM16 Participation Agreement ID 1-1 S
Code
396 CLM19 Claim Submission Reason ID 2-2 N/U
Code
397 1 CLM20 Delay Reason Code ID 1-2 S
1
1
DTP DATE -INITIAL 1 S 2300

TREATMENT
Qualifier
400 DTP03 Initial Treatment Date AN 1 - 35 R
DTP DATE -DATE LAST 1 S 2300

SEEN
Qualifier
403 DTP03 Last Seen Date AN 1 - 35 R
DTP DATE -ONSET OF 1 S 2300

CURRENT
ILLNESS/SYMPTOM
Qualifier
406 1 DTP03 Onset of Current Illness or AN 1 - 35 R
Injury Date
DTP DATE -ACUTE 5 S 2300

MANIFESTATION
Qualifier
409 DTP03 Acute Manifestation Date AN 1 - 35 R
DTP DATE -SIMILAR 10 S 2300

ILLNESS/SYMPTOM
ONSET
Qualifier
412 1 DTP03 Similar Illness or Symptom AN 1 - 35 R
Date
DTP DATE -ACCIDENT 10 S 2300

Qualifier
416 1 DTP03 Accident Date AN 1 - 35 R
DTP DATE -LAST 1 S 2300

MENSTRUAL PERIOD
Qualifier
419 DTP03 Last Menstrual Period Date AN 1 - 35 R
DTP DATE -LAST X-RAY 1 S 2300

Qualifier
422 DTP03 Last X-Ray Date AN 1 - 35 R
DTP DATE -HEARING AND 1 S 2300
VISION PRESCRIPTION
DATE
Qualifier
425 DTP03 Prescription Date AN 1 - 35 R
DTP DATE -DISABILITY 5 S 2300

BEGIN
Qualifier
428 DTP03 Disability From Date AN 1 - 35 R
DTP DATE -DISABILITY END 5 S 2300

Qualifier
431 1 DTP03 Disability To Date AN 1 - 35 R
DTP DATE -LAST WORKED 1 S 2300

Qualifier
434 DTP03 Last Worked Date AN 1 - 35 R
DTP DATE -AUTHORIZED 1 S 2300

RETURN TO WORK
Qualifier
437 DTP03 Work Return Date AN 1 - 35 R

Qualifier
440 DTP03 Related Hospitalization AN 1 - 35 R
Admission Date

Qualifier
443 DTP03 Related Hospitalization AN 1 - 35 R
Discharge Date
DTP DATE -ASSUMED AND 2 S 2300

RELINQUISHED CARE
DATES
Qualifier
446 DTP03 Assumed or Relinquished Care AN 1 - 35 R
Date
1
1
1
1
PWK CLAIM 10 S 2300

SUPPLEMENTAL
INFORMATION

452 PWK06 Attachment Control Number AN 2 - 80 S

INFORMATION
456 1 CN101 Contract Type Code ID 2-2 R
457 CN102 Contract Amount S9(7)V99 R 1 - 18 S
458 CN103 Contract Percentage 9(2)V99 R 1-6 S
459 1 CN104 Contract Code AN 1 - 30 S

9(2)V99
461 1 CN106 Contract Version Identifier AN 1 - 30 S
AMT CREDIT/DEBIT CARD 1 S 2300

MAXIMUM AMOUNT
463 1 AMT02 Credit or Debit Card Maximum R 1 - 18 R
Amount S9(7)V99
AMT PATIENT AMOUNT 1 S 2300

PAID
466 AMT02 Patient Amount Paid S9(7)V99 R 1 - 18 R
AMT TOTAL PURCHASED 1 S 2300

SERVICE AMOUNT
469 1 AMT02 Total Purchased Service R 1 - 18 R
Amount S9(7)V99

AUTHORIZATION
EXCEPTION CODE
Qualifier
472 1 REF02 Service Authorization Exception AN 1 - 30 R
Code
475 1
476 1
477 1
478 1
479 1
480 1
REF MANDATORY 1 S 2300

MEDICARE (SECTION
4081) CROSSOVER
INDICATOR
Qualifier
482 1 REF02 Medicare Section 4081 AN 1 - 30 R
Indicator
485 1
486 1
487 1
488 1
489 1
490 1
REF MAMMOGRAPHY 1 S 2300
CERTIFICATION
NUMBER
491 REF01 Mammography Certification ID 2-3 R
Number
492 1 REF02 Mammography Certification AN 1 - 30 R
Number
495 1
496 1
497 1
498 1
499 1
500 1
REF PRIOR 2 S 2300

AUTHORIZATION OR
REFERRAL NUMBER
Qualifier
502 1 REF02 Prior Authorization or Referral AN 1 - 30 R
Number
505 1
506 1
507 1
508 1
509 1
510 1
1
1
1
1
1
1
REF ORIGINAL 1 S 2300

REFERENCE NUMBER
(ICN/DCN)
Qualifier
512 1 REF02 Claim Original Reference AN 1 - 30 R
Number
515 1
516 1
517 1
518 1
519 1
520 1
REF CLINICAL 3 S 2300

LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
NUMBER
Qualifier
522 1 REF02 Clinical Laboratory AN 1 - 30 R
Improvement Amendment
Number

525 1
526 1
527 1
528 1
529 1
530 1

NUMBER
Qualifier
532 1 REF02 Repriced Claim Reference AN 1 - 30 R
Number
535 1
536 1
537 1
538 1
539 1
540 1

CLAIM NUMBER

Qualifier
542 1 REF02 Adjusted Repriced Claim AN 1 - 30 R
Reference Number
545 1
546 1
547 1
548 1
549 1
550 1

DEVICE EXEMPTION
NUMBER
Qualifier
552 1 REF02 Investigational Device AN 1 - 30 R
Exemption Number
555 1
556 1
557 1
558 1
559 1
560 1
REF CLAIM 1 S 2300

IDENTIFICATION
NUMBER FOR
CLEARING HOUSES
AND OTHER
TRANSMISSION
INTERMEDIARIES

Qualifier
562 1 REF02 Clearinghouse Trace Number AN 1 - 30 R
565 1
566 1
567 1
568 1
569 1
570 1
REF AMBULATORY 4 S 2300

PATIENT GROUP
(APG)
Qualifier
572 1 REF02 Ambulatory Patient Group AN 1 - 30 R
Number

NUMBER
Qualifier
579 1
580 1
581 1
582 1
583 1
584 1

PROJECT IDENTIFIER
Qualifier
586 1 REF02 Demonstration Project Identifier AN 1 - 30 R

589 1
590 1
591 1
592 1
593 1
594 1
1
1
1
1
1
1

595 K301 Fixed Format Information AN 1 - 80 R
596 K302 Record Format Code ID 1-2 N/U
597 K303 COMPOSITE UNIT OF N/U
MEASURE

598 1 NTE01 Note Reference Code ID 3-3 R
599 NTE02 Claim Note Text AN 1 - 80 R
CR1 AMBULANCE 1 S 2300

TRANSPORT
INFORMATION
600 CR101 Unit or Basis for Measurement ID 2-2 S
Code
601 CR102 Patient Weight 9(3) R 1 - 10 S
602 1 CR103 Ambulance Transport Code ID 1- 1 R
603 CR104 Ambulance Transport Reason ID 1- 1 R
Code
604 CR105 Unit or Basis for Measurement ID 2-2 R
Code
605 CR106 Transport Distance 9(4) R 1 - 15 R
606 CR107 Address Information AN 1 - 55 N/U
608 CR109 Round Trip Purpose AN 1 - 80 S
Description
609 CR110 Stretcher Purpose Description AN 1 - 80 S
CR2 SPINAL 1 S 2300

MANIPULATION
SERVICE
INFORMATION
610 CR201 Treatment Series Number 9(3) N0 1-9 N/U
611 CR202 Treatment Count 9(3) R 1 - 15 N/U

612 1 CR203 Subluxation Level Code ID 2-3 N/U
614 1 CR205 Unit or Basis for Measurement ID 2-2 N/U

Code
615 CR206 Treatment Period Count 9(3) R 1 - 15 N/U
616 CR207 Monthly Treatment Count 9(2) R 1 - 15 N/U
617 CR208 Patient Condition Code ID 1- 1 R

618 1 CR209 Complication Indicator ID 1- 1 N/U
619 CR210 Patient Condition Description AN 1 - 80 S
620 CR211 Patient Condition Description AN 1 - 80 S
621 1 CR212 X-ray Availability Indicator ID 1- 1 S
CRC AMBULANCE 3 S 2300

CERTIFICATION
622 CRC01 Code Category ID 2-2 R
623 CRC02 Certification Condition Indicator ID 1- 1 R
624 1 CRC03 Condition Code ID 2-2 R
625 1 CRC04 Condition Code ID 2-2 S
CRC PATIENT CONDITION 3 S 2300

INFORMATION: VISION

631 CRC03 Condition Code ID 2-2 R

632 CRC04 Condition Code ID 2-2 S
CRC HOMEBOUND 1 S 2300

INDICATOR
638 CRC03 Homebound Indicator ID 2-2 R

639 CRC04 Condition Indicator ID 2-2 N/U

645 CRC03 Condition Code ID 2-2 R

HI HEALTH CARE 1 S 2300

DIAGNOSIS CODE
INFORMATION
651 1 HI01-1 Diagnosis Type Code ID 1-3 R
652 HI01-2 Diagnosis Code AN 1 - 30 R
Qualifier
658 1
659 1

INFORMATION
Qualifier
668 1
669 1

INFORMATION
Qualifier
678 1
679 1

INFORMATION
Qualifier
688 1
689 1

INFORMATION
Qualifier
698 1
699 1

INFORMATION
Qualifier
708 1
709 1

INFORMATION
Qualifier
718 1
719 1

INFORMATION
Qualifier
728 1
729 1

INFORMATION
731 1
732 1
733 1
734 1
735 1
736 1
737 1
738 1
739 1

INFORMATION
741 1
742 1
743 1
744 1
745 1
746 1
747 1
748 1
749 1

INFORMATION
751 1
752 1
753 1
754 1
755 1
756 1
757 1
758 1
759 1

INFORMATION
761 1
762 1
763 1
764 1
765 1
766 1
767 1
768 1
769 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HCP CLAIM 1 S 2300

PRICING/REPRICING
INFORMATION

S9(7)V99
S9(7)V99
773 HCP04 Repricing Organization AN 1 - 30 S
Identifier
Amount S9(5)V99
775 1 HCP06 Repriced Approved Ambulatory AN 1 - 30 S
Patient Group Code
776 HCP07 Repriced Approved Ambulatory R 1 - 18 S

Patient Group Amount
S9(7)V99
777 HCP08 Product/Service ID AN 1 - 48 N/U
778 HCP09 Product/Service ID Qualifier ID 2-2 N/U
780 HCP11 Unit or Basis for Measurement ID 2-2 N/U
Code
781 HCP12 Quantity 9(3)V9 R 1 - 15 N/U
CR7 HOME HEALTH CARE 1 S 2305 6
PLAN INFORMATION
785 1 CR701 Discipline Type Code ID 2-2 R
786 1 CR702 Total Visits Rendered Count N0 1-9 R
787 1 CR703 Certification Period Projected N0 1-9 R
Visit Count
HSD HEALTH CARE 3 S 2305

SERVICES DELIVERY
789 1 HSD02 Number of Visits 9(3) R 1 - 15 S
791 1 HSD04 Frequency Count 9(2)V9 R 1-6 S
793 1 HSD06 Duration of Visits, Number of N0 1-3 S
Units
794 1 HSD07 Ship, Delivery or Calendar ID 1-2 S
Pattern Code
NM1 REFERRING 1 S 2310A 2

PROVIDER NAME
798 1 NM103 Referring Provider Last Name AN 1 - 35 R
799 1 NM104 Referring Provider First Name AN 1 - 25 S
800 NM105 Referring Provider Middle AN 1 - 25 S

Name
802 NM107 Referring Provider Name Suffix AN 1 - 10 S

804 NM109 Referring Provider Identifier AN 2 - 80 S
807 1
PRV REFERRING 1 S 2310A

PROVIDER SPECIALTY
INFORMATION
808 1 PRV01 Provider Code ID 3-Jan R

809 1 PRV02 Reference Identification ID 3-Feb R
Qualifier
810 1 PRV03 Provider Taxonomy Code AN 30-Jan R
811 1 PRV04 State or Province Code ID 2-Feb N/U
812 1 PRV05 PROVIDER SPECIALTY N/U
INFORMATION
813 1 PRV06 Provider Organization Code ID 3-Mar N/U
REF REFERRING 5 S 2310A
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
815 1 REF02 Referring Provider Secondary AN 1 - 30 R
Identifier
818 1
819 1
820 1
821 1
822 1
823 1
NM1 RENDERING 1 S 2310B 1

PROVIDER NAME
826 1 NM103 Rendering Provider Last or AN 1 - 35 R
Organization Name
827 1 NM104 Rendering Provider First Name AN 1 - 25 S
828 NM105 Rendering Provider Middle AN 1 - 25 S

Name
830 NM107 Rendering Provider Name AN 1 - 10 S
Suffix
832 NM109 Rendering Provider Identifier AN 2 - 80 R
835 1
PRV RENDERING 1 S 2310B

PROVIDER SPECIALTY
INFORMATION

Qualifier
INFORMATION
REF RENDERING 5 S 2310B
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
Identifier
846 1
847 1
848 1
849 1
850 1
851 1
NM1 PURCHASED SERVICE 1 S 2310C 1

PROVIDER NAME

854 1 NM103 Name Last or Organization AN 1 - 35 R
Name
856 1 NM105 Name Middle AN 1 - 25 S
860 1 NM109 Purchased Service Provider AN 2 - 80 S
Identifier
REF PURCHASED SERVICE 5 S 2310C

PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
864 1 REF02 Purchased Service Provider AN 1 - 30 R

NM1 SERVICE FACILITY 1 S 2310D 1

LOCATION
869 1 NM103 Laboratory or Facility Name AN 1 - 35 S
Identifier
878 1
N3 SERVICE FACILITY 1 R 2310D

LOCATION ADDRESS
Line
Line
N4 SERVICE FACILITY 1 R 2310D

LOCATION
CITY/STATE/ZIP
Name
Province Code
Zone ZIP Code
884 N404 Laboratory/Facility Country ID 2-3 S
Code
887 1
REF SERVICE FACILITY 5 S 2310D

LOCATION
SECONDARY
IDENTIFICATION
Qualifier
889 1 REF02 Laboratory or Facility AN 1 - 30 R

892 1
893 1
894 1
895 1
896 1
897 1
1
1
1
1
1
1
1
1
1
NM1 SUPERVISING 1 S 2310E 1

PROVIDER NAME
900 1 NM103 Supervising Provider Last AN 1 - 35 R
Name
901 1 NM104 Supervising Provider First AN 1 - 25 R
Name
902 NM105 Supervising Provider Middle AN 1 - 25 S
Name
904 NM107 Supervising Provider Name AN 1 - 10 S
Suffix
906 NM109 Supervising Provider Identifier AN 2 - 80 S

909 1
REF SUPERVISING 5 S 2310E

PROVIDER
SECONDARY
IDENTIFIER
Qualifier
911 1 REF02 Supervising Provider AN 1 - 30 R

914 1
915 1
916 1
917 1
918 1
919 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

INFORMATION
Number Code
921 1 SBR02 Individual Relationship Code ID 2-2 R

Number
923 SBR04 Other Insured Group Name AN 1 - 60 S
924 1 SBR05 Insurance Type Code ID 1-3 R

Code

ADJUSTMENTS

931 CAS03 Adjustment Amount S9(7)V99 R 1 - 18 R
932 CAS04 Adjustment Quantity 9(7) R 1 - 15 S

934 CAS06 Adjustment Amount S9(7)V99 R 1 - 18 S





AMOUNT
949 AMT02 Payer Paid Amount S9(7)V99 R 1 - 18 R
AMT COB APPROVED 1 S 2320

AMOUNT
952 1 AMT02 Approved Amount S9(7)V99 R 1 - 18 R
AMT COB ALLOWED 1 S 2320

AMOUNT
955 1 AMT02 Allowed Amount S9(7)V99 R 1 - 18 R
1
1
1
1
1
AMT COB PATIENT 1 S 2320

RESPONSIBILITY
AMOUNT
958 1 AMT02 Other Payer Patient R 1 - 18 R
Responsibility Amount
S9(7)V99
AMT COB COVERED 1 S 2320

AMOUNT
961 1 AMT02 Other Payer Covered Amount R 1 - 18 R
S9(7)V99
AMT COB DISCOUNT 1 S 2320

AMOUNT
964 1 AMT02 Other Payer Discount Amount R 1 - 18 R
S9(7)V99
AMT COB PER DAY LIMIT 1 S 2320

AMOUNT
967 1 AMT02 Other Payer Per Day Limit R 1 - 18 R
Amount S9(7)V99
AMT COB PATIENT PAID 1 S 2320

AMOUNT
970 1 AMT02 Other Payer Patient Paid R 1 - 18 R
Amount S9(7)V99
AMT COB TAX AMOUNT 1 S 2320

973 1 AMT02 Other Payer Tax Amount R 1 - 18 R
S9(7)V99
AMT COB TOTAL CLAIM 1 S 2320

BEFORE TAXES
AMOUNT
976 1 AMT02 Other Payer Pre-Tax Claim R 1 - 18 R
Total Amount S9(7)V99
DEMOGRAPHIC
INFORMATION
Qualifier
979 1 DMG02 Other Insured Birth Date AN 1 - 35 R
980 1 DMG03 Other Insured Gender Code ID 1=1 R
981 1 DMG04 Marital Status Code ID 1=1 N/U
982 1 DMG05 Race or Ethnicity Code ID 1=1 N/U

COVERAGE
INFORMATION
987 OI01 Claim Filing Indicator Code ID 1-2 N/U
988 OI02 Claim Submission Reason ID 2-2 N/U
Code
989 1 OI03 Benefits Assignment ID 1=1 R
990 1 OI04 Patient Signature Source Code ID 1=1 S
991 OI05 Provider Agreement Code ID 1=1 N/U

992 1 OI06 Release of Information Code ID 1=1 R
993

OUTPATIENT
ADJUDICATION
INFORMATION
994 MOA01 Reimbursement Rate 9(3)V99 R 1 - 10 S
995 MOA02 HCPCS Payable Amount R 1 - 18 S

S9(7)V99
996 MOA03 Remark Code AN 1 - 30 S
1001 MOA08 End Stage Renal Disease R 1 - 18 S
Payment Amount S9(7)V99
1002 MOA09 Non-Payable Professional R 1 - 18 S
S9(7)V99

NAME
1005 1 NM103 Other Insured Last Name AN 1 - 35 R
1006 1 NM104 Other Insured First Name AN 1 - 25 S
1007 NM105 Other Insured Middle Name AN 1 - 25 S
1009 NM107 Other Insured Name Suffix AN 1 - 10 S
1011 NM109 Other Insured Identifier AN 2 - 80 R
1014 1

ADDRESS
1015 N301 Other Insured Address Line AN 1 - 55 R
1016 N302 Other Insured Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
1017 N401 Other Insured City Name AN 2 - 30 S

1018 N402 Other Insured State Code ID 2-2 S
1019 N403 Other Insured Postal Zone or ID 3 - 15 S
ZIP Code
1023 1

SECONDARY
IDENTIFICATION
Qualifier
1025 1 REF02 Other Insured Additional AN 1 - 30 R
Identifier
1028 1
1029 1
1030 1
1031 1
1032 1
1033 1

1036 1 NM103 Other Payer Last or AN 1 - 35 R
Organization Name
1042 NM109 Other Payer Primary Identifier AN 2 - 80 R

1045 1
1
1
1
1
1
1
1
1
1
PER OTHER PAYER 2 S 2330B

CONTACT
INFORMATION
1046 1 PER01 Contact Function Code ID 2-Feb R
1047 1 PER02 Other Payer Contact Name AN Jan-60 R
1048 1 PER03 Communication Number ID 2-Feb R
Qualifier
1049 1 PER04 Communication Number AN Jan-80 R
1050 1 PER05 Communication Number ID 2-Feb S
Qualifier
1051 1 PER06 Communication Number AN Jan-80 S
1052 1 PER07 Communication Number ID 2-Feb S
Qualifier
1053 1 PER08 Communication Number AN Jan-80 S
1054 1 PER09 Contact Inquiry Reference AN 20-Jan N/U
DTP CLAIM ADJUDICATION 1 S 2330B

DATE

Qualifier

SECONDARY
IDENTIFIER
Qualifier
1059 1 REF02 Other Payer Secondary AN 1 - 30 R
Identifier
1062 1
1063 1
1064 1
1065 1
1066 1
1067 1

AUTHORIZATION OR
REFERRAL NUMBER
Qualifier
1069 1 REF02 Other Payer Prior Authorization AN 1 - 30 R
Number
1072 1
1073 1
1074 1
1075 1
1076 1
1077 1
1
1
1
1
1
REF OTHER PAYER CLAIM 2 S 2330B

ADJUSTMENT
INDICATOR
Qualifier
1079 1 REF02 Other Payer Claim Adjustment AN 1 - 30 R
Indicator
1082 1
1083 1
1084 1
1085 1
1086 1
1087 1
1
1
1
1
1

PATIENT
INFORMATION
1090 1 NM103 Patient Last Name AN 1 - 35 N/U
1096 1 NM109 Other Payer Patient Primary AN 2 - 80 R
Identifier
REF OTHER PAYER 3 S 2330C

PATIENT
IDENTIFICATION
Qualifier
1100 1 REF02 Other Payer Patient Secondary AN 1 - 30 R
Identifier

REFERRING
PROVIDER
1105 1 NM103 Referring Provider Last Name AN 1 - 35 N/U


1114 1

REFERRING
PROVIDER
IDENTIFICATION

Qualifier
1116 1 REF02 Other Payer Referring Provider AN 1 - 30 R

Identification

1119 1
1120 1
1121 1
1122 1
1123 1
1124 1

RENDERING
PROVIDER
1127 1 NM103 Rendering Provider Last or AN 1 - 35 N/U
Organization Name

1136 1
RENDERING
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
1138 1 REF02 Other Payer Rendering AN 1 - 30 R


1141 1
1142 1
1143 1
1144 1
1145 1
1146 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM1 OTHER PAYER 1 S 2330F 1

PURCHASED SERVICE
PROVIDER
1149 1 NM103 Purchased Service Provider AN 1 - 35 N/U
Name
REF OTHER PAYER 3 R 2330F

PURCHASED SERVICE
PROVIDER
IDENTIFICATION
Qualifier
1159 1 REF02 Other Payer Purchased Service AN 1 - 30 R
Provider Identifier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM1 OTHER PAYER 1 S 2330G 1

SERVICE FACILITY
LOCATION
1164 1 NM103 Service Facility Name AN 1 - 35 N/U
REF OTHER PAYER 3 R 2330G

SERVICE FACILITY
LOCATION
IDENTIFICATION
Qualifier
1174 1 REF02 Other Payer Service Facility AN 1 - 30 R
Location Identifier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM1 OTHER PAYER 1 S 2330H 1

SUPERVISING
PROVIDER
1179 1 NM103 Supervising Provider Last AN 1 - 35 N/U
Name
REF OTHER PAYER 3 R 2330H

SUPERVISING
PROVIDER
IDENTIFICATION
Qualifier
1189 1 REF02 Other Payer Supervising AN 1 - 30 R
Provider Identifier
1192 1 LX01 Assigned Number N0 1-6 R
SV1 PROFESSIONAL 1 R 2400

SERVICE
1194 1 SV101-1 Product or Service ID Qualifier ID 2-2 R

1200 SV101-7 Description AN 1 - 80 N/U
1201 1
1202 SV102 Line Item Charge Amount R 1 - 18 R
S9(7)V99
1203 1 SV103 Unit or Basis for Measurement ID 2-2 R
Code
1204 SV104 Service Unit Count "F2" = R 1 - 15 R
9(7)V999 "MJ" = 9(4) "UN" =
9(3)V9
1205 1 SV105 Place of Service Code AN 1-2 S
1206 SV106 Service Type Code ID 1-2 N/U

1207 SV107 COMPOSITE DIAGNOSIS S
CODE POINTER
1208 SV107-1 Diagnosis Code Pointer N0 1-2 R
1209 SV107-2 Diagnosis Code Pointer N0 1-2 S
1212 SV108 Monetary Amount R 1 - 18 N/U
1213 SV109 Emergency Indicator ID 1-1 S
1214 SV110 Multiple Procedure Code ID 1-2 N/U
1215 SV111 EPSDT Indicator ID 1-1 S
1216 SV112 Family Planning Indicator ID 1-1 S
1217 SV113 Review Code ID 1-2 N/U
1218 SV114 National or Local Assigned AN 1-2 N/U
Review Value
1219 SV115 Co-Pay Status Code ID 1-1 S
1220 SV116 Health Care Professional ID 1-1 N/U
Shortage Area Code
1221 SV117 Reference Identification AN 1 - 30 N/U
1222 SV118 Postal Code ID 3 - 15 N/U
1223 SV119 Monetary Amount R 1 - 18 N/U
1224 SV120 Level of Care Code ID 1-1 N/U
1225 SV121 Provider Agreement Code ID 1-1 N/U
SV5 DURABLE MEDICAL 1 S 2400

EQUIPMENT SERVICE
PROCEDURE
1227 SV501-1 Procedure Identifier ID 2-2 R
1229 SV501-3 Procedure Modifier AN 2-2 N/U
1233 SV501-7 Desription AN 1 - 80 N/U
1234 1
1235 SV502 Unit or Basis for Measurement ID 2-2 R
Code
1236 SV503 Length of Medical Necessity R 1 - 15 R
9(3)
1237 SV504 DME Rental Price S9(7)V99 R 1 - 18 S
1238 SV505 DME Purchase Price S9(7)V99 R 1 - 18 S
1239 SV506 Rental Unit Price Indicator ID 1-1 S

1240 SV507 Prognosis Code ID 1-1 N/U
PWK DMERC CMN 1 S 2400

INDICATOR

1245 1 PWK05 Identification Code Qualifier ID 1-2 N/U
1246 1 PWK06 Identification Code AN 2 - 80 N/U
1
1
1
1
1
1
1

TRANSPORT
INFORMATION
1250 CR101 Unit or Basis for Measurement ID 2-2 S
Code
1251 CR102 Patient Weight 9(3) R 1 - 10 S
1252 1 CR103 Ambulance Transport Code ID 1-1 R
1253 CR104 Ambulance Transport Reason ID 1-1 R
Code
Code
1255 CR106 Transport Distance 9(4) R 1 - 15 R
1258 CR109 Round Trip Purpose AN 1 - 80 S
Description
1259 CR110 Stretcher Purpose Description AN 1 - 80 S
CR2 SPINAL 5 S 2400

MANIPULATION
SERVICE
INFORMATION
1260 1 CR201 Treatment Series Number 9(3) N0 1-9 N/U
1261 1 CR202 Treatment Count 9(3) R 1 - 15 N/U

1264 1 CR205 Unit or Basis for Measurement ID 2-2 N/U

Code
1265 1 CR206 Treatment Period Count 9(3) R 1 - 15 N/U
1266 1 CR207 Monthly Treatment Count 9(2) R 1 - 15 N/U
1267 1 CR208 Patient Condition Code ID 1-1 R

1268 1 CR209 Complication Indicator ID 1-1 N/U
1269 1 CR210 Patient Condition Description AN 1 - 80 S
1270 1 CR211 Patient Condition Description AN 1 - 80 S
1271 1 CR212 X-ray Availability Indicator ID 1-1 S
CR3 DURABLE MEDICAL 1 S 2400

EQUIPMENT
CERTIFICATION
1272 CR301 Certification Type Code ID 1-1 R
Code
1274 CR303 Durable Medical Equipment R 1 - 15 R
Duration 9(2)
1275 CR304 Insulin Dependent Code ID 1-1 N/U
1276 CR305 Description AN 1 - 80 N/U
CR5 HOME OXYGEN 1 S 2400

THERAPY
INFORMATION
1277 1 CR501 Certification Type Code ID 1-1 R
1278 1 CR502 Treatment Period Count 9(2) R 1 - 15 R
1279 1 CR503 Oxygen Equipment Type Code ID 1-1 N/U
1281 1 CR505 Description AN 1 - 80 N/U

1282 1 CR506 Quantity R 1 - 15 N/U
1283 1 CR507 Quantity R 1 - 15 N/U
1284 1 CR508 Quantity R 1 - 15 N/U
1285 1 CR509 Description AN 1 - 80 N/U
1286 1 CR510 Arterial Blood Gas Quantity R 1 - 15 S
9(2)V9
1287 1 CR511 Oxygen Saturation Quantity R 1 - 15 S
9(2)V9
1288 1 CR512 Oxygen Test Condition Code ID 1-1 R
1289 1 CR513 Oxygen Test Findings Code ID 1-1 S

1292 1 CR516 Quantity R 1 - 15 N/U
1293 1 CR517 Oxygen Delivery System code ID 1-1 N/U

CERTIFICATION
1296 CRC02 Certification Condition Indicator ID 1-1 R
1297 1 CRC03 Condition Code ID 2-2 R
CRC HOSPICE EMPLOYEE 1 S 2400

INDICATOR
1303 CRC02 Hospice Employed Provider ID 1-1 R
Indicator
1304 CRC03 Condition Indicator ID 2-2 R
1305 1 CRC04 Condition Indicator ID 2-2 N/U
CRC DMERC CONDITION 2 S 2400

INDICATOR

1310 CRC02 Certification Condition Indicator ID 1-1 R
1311 1 CRC03 Condition Indicator ID 2-2 R

1312 1 CRC04 Condition Indicator ID 2-2 S
1
1

Qualifier
1318 DTP03 Service Date AN 1 - 35 R
DTP DATE -CERTIFICATION 1 S 2400

REVISION DATE

Qualifier
1321 DTP03 Certification Revision Date AN 1 - 35 R
DTP DATE -BEGIN 1 S 2400

THERAPY DATE
Qualifier
1324 DTP03 Begin Therapy Date AN 1 - 35 R

CERTIFICATION DATE

Qualifier
1327 DTP03 Last Certification Date AN 1 - 35 R
SEEN
Qualifier
1330 DTP03 Last Seen Date AN 1 - 35 R
DTP DATE -TEST 2 S 2400

Qualifier
1333 DTP03 Test Performed Date AN 1 - 35 R
DTP DATE -OXYGEN 3 S 2400

SATURATION/ARTERIA
L BLOOD GAS TEST
Qualifier
1336 1 DTP03 Oxygen Saturation Test Date AN 1 - 35 R
DTP DATE -SHIPPED 1 S 2400

Qualifier
1339 DTP03 Shipped Date AN 1 - 35 R

CURRENT
SYMPTOM/ILLNESS
Qualifier
1342 1 DTP03 Onset Date AN 1 - 35 R

Qualifier
1345 DTP03 Last X-Ray Date AN 1 - 35 R

MANIFESTATION
Qualifier
1348 1 DTP03 Acute Manifestation Date AN 1 - 35 R

TREATMENT
Qualifier
1351 DTP03 Initial Treatment Date AN 1 - 35 R
DTP DATE -SIMILAR 1 S 2400
ILLNESS/SYMPTOM
ONSET
Qualifier
1354 1 DTP03 Similar Illness or Symptom AN 1 - 35 R
Date
1
1
1
1
MEA TEST RESULTS 20 S 2400

1355 MEA01 Measurement Reference ID 2-2 R
Identification Code
1356 1 MEA02 Measurement Qualifier ID 1-3 R
1357 1 MEA03 Test Result 9(3) "GRA", "R1", R 1 - 20 R

"R2", "R4", & "ZO" = 9(2)V9
1358 MEA04 COMPOSITE UNIT OF N/U

MEASURE
1359 MEA05 Range Minimum R 1 - 20 N/U
1360 MEA06 Range Maximum R 1 - 20 N/U
1361 MEA07 Measurement Significance ID 2-2 N/U
Code
1362 MEA08 Measurement Attribute Code ID 2-2 N/U
1363 MEA09 Surface/Layer/Position Code ID 2-2 N/U
1364 MEA10 Measurement Method or ID 2-4 N/U

Device
1365 1
1366 1

INFORMATION
1367 CN101 Contract Type Code ID 2-2 R
1368 CN102 Contract Amount S9(7)V99 R 1 - 18 S
1369 CN103 Contract Percentage 9(2)V99 R 1-6 S
1370 1 CN104 Contract Code AN 1 - 30 S

9(2)V99
1372 CN106 Contract Version Identifier AN 1 - 30 S

REFERENCE NUMBER
Qualifier
1374 1 REF02 Repriced Line Item Reference AN 1 - 30 R
Number
1377 1
1378 1
1379 1
1380 1
1381 1
1382 1

LINE ITEM
REFERENCE NUMBER
Qualifier
1384 1 REF02 Adjusted Repriced Line Item AN 1 - 30 R
Reference Number
1387 1
1388 1
1389 1
1390 1
1391 1
1392 1
REF PRIOR 2 S 2400

AUTHORIZATION OR
REFERRAL NUMBER
Qualifier
1394 1 REF02 Prior Authorization or Referral AN 1 - 30 R
Number
1397 1
1398 1
1399 1
1400 1
1401 1
1402 1

NUMBER
Qualifier
1407 1
1408 1
1409 1
1410 1
1411 1
1412 1

CERTIFICATION
NUMBER
1413 REF01 Reference identification ID 2-3 R
Qualifier
1414 1 REF02 Mammography Certification AN 1 - 30 R
Number
1417 1
1418 1
1419 1
1420 1
1421 1
1422 1

LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
IDENTIFICATION
Qualifier
1424 1 REF02 Clinical Laboratory AN 1 - 30 R
Number
1427 1
1428 1
1429 1
1430 1
1431 1
1432 1
REF REFERRING CLINICAL 1 S 2400

LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
FACILITY
IDENTIFICATION

Qualifier
1434 1 REF02 Referring CLIA Number AN 1 - 30 R
1437 1
1438 1
1439 1
1440 1
1441 1
1442 1
REF IMMUNIZATION BATCH 1 S 2400

NUMBER
Qualifier
1444 1 REF02 Immunization Batch Number AN 1 - 30 R
1447 1
1448 1
1449 1
1450 1
1451 1
1452 1
1
1
1
1
1
1
REF AMBULATORY 4 S 2400

PATIENT GROUP
(APG)
Qualifier
1454 1 REF02 Ambulatory Patient Group AN 1 - 30 R
Number
REF OXYGEN FLOW RATE 1 S 2400

Qualifier
1458 1 REF02 Oxygen Flow Rate AN 1 - 30 R
REF UNIVERSAL PRODUCT 1 S 2400

NUMBER (UPN)

Qualifier
1462 1 REF02 Universal Product Number AN 1 - 30 R
AMT SALES TAX AMOUNT 1 S 2400

1466 AMT02 Sales Tax Amount S9(7)V99 R 1 - 18 R
AMT APPROVED AMOUNT 1 S 2400

1469 1 AMT02 Approved Amount S9(7)V99 R 1 - 18 R
AMT POSTAGE CLAIMED 1 S 2400

AMOUNT
1472 AMT02 Postage Claimed Amount R 1 - 18 R
S9(7)V99
1474 1 K301 Fixed Format Information AN 1 - 80 R
1475 1 K302 Record Format Code ID 1-2 N/U
1476 1 K303 COMPOSITE UNIT OF N/U
MEASURE
NTE LINE NOTE 1 S 2400

1477 1 NTE01 Note Reference Code ID 3-3 R
1478 NTE02 Line Note Text AN 1 - 80 R
PS1 PURCHASED SERVICE 1 S 2400

INFORMATION
1479 1 PS101 Purchased Service Provider AN 1 - 30 R

Identifier
1480 PS102 Purchased Service Charge R 1 - 18 R
Amount S9(7)V99
1481 PS103 State or Province Code ID 2-2 N/U
HSD HEALTH CARE 1 S 2400

SERVICES DELIVERY
1483 1 HSD02 Number of Visits 9(3) R 1 - 15 S
1485 1 HSD04 Frequency Count 9(2)V9 R 1-6 S
1487 1 HSD06 Duration of Visits, Number of N0 1-3 S
Units
1488 1 HSD07 Ship, Delivery or Calendar ID 1-2 S
Pattern Code
HCP LINE 1 S 2400

PRICING/REPRICING
INFORMATION

S9(7)V99
S9(7)V99
Identifier
Amount S9(5)V99
1495 1 HCP06 Repriced Approved Ambulatory AN 1 - 30 S
Patient Group Code
1496 HCP07 Repriced Approved Ambulatory R 1 - 18 S

S9(7)V99

1498 1 HCP09 Product or Service ID Qualifier ID 2-2 S
1499 HCP10 Procedure Code AN 1 - 48 S

1500 1 HCP11 Unit or Basis for Measurement ID 2-2 S
Code
1501 HCP12 Repriced Approved Service R 1 - 15 S
Unit Count "DA" = 9(3) "UN" =
9(3)V9
1505 LIN01 Assigned Identification AN 1 - 20 N/U

1506 LIN02 Product or Service ID Qualifier ID 2-2 R
1507 LIN03 National Drug Code AN 1 - 48 R

CTP DRUG PRICING 1 S 2410

1536 CTP01 Class of Trade Code ID 2-2 N/U
1537 CTP02 Price Identifier Code ID 3-3 N/U
1538 CTP03 Drug Unit Price S9(7)V99 R 1 - 17 R
1539 1 CTP04 National Drug Unit Count when R 1 - 15 R
CTP05 = "UN" 9(3)V9, CTP05
= "F2" 9(7)V999, CTP05 = "ML"
or "GR" 9(2)V99
1540 CTP05 COMPOSITE UNIT OF

MEASURE
1541 1 CTP05-1 Unit or Basis For Measurement ID 2-2 R
Code
Code
Code
Code
Code
1556 CTP06 Price Multiplier Qualifier ID 3-3 N/U
1557 CTP07 Multiplier R 1 - 10 N/U
1558 CTP08 Monetary Amount R 1 - 18 N/U
1559 CTP09 Basis of Unit Price Code ID 2-2 N/U
1560 CTP10 Condition Value AN 1 - 10 N/U
1561 CTP11 Multiple Price Quantity N0 1-2 N/U
REF PRESCRIPTION 1 S 2410

NUBER

Qualifier
1563 1 REF02 Prescription Number AN 1 - 30 R
1564 REF03 Desciption AN 1 - 80 N/U
1566 1
1567 1
1568 1
1569 1
1570 1
1571 1
NM1 RENDERING 1 S 2420A 1

PROVIDER NAME
1574 1 NM103 Rendering Provider Last or AN 1 - 35 R
Organization Name
1575 1 NM104 Rendering Provider First Name AN 1 - 25 S
1576 NM105 Rendering Provider Middle AN 1 - 25 S

Name
1578 NM107 Rendering Provider Name AN 1 - 10 S
Suffix
1580 NM109 Rendering Provider Identifier AN 2 - 80 R
1583 1
PRV RENDERING 1 S 2420A

PROVIDER SPECIALTY
INFORMATION

Qualifier
1586 PRV03 Provider Taxonomy Code AN 1 - 30 R
INFORMATION
REF RENDERING 5 S 2420A

PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
Identifier
1594 1
1595 1
1596 1
1597 1
1598 1
1599 1
NM1 PURCHASED SERVICE 1 S 2420B 1

PROVIDER NAME

Name
1608 NM109 Purchased Service Provider AN 2 - 80 S
Identifier
1611 1
REF PURCHASED SERVICE 5 S 2420B

PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
1613 1 REF02 Purchased Service Provider AN 1 - 30 R
1616 1
1617 1
1618 1
1619 1
1620 1
1621 1
NM1 SERVICE FACILITY 1 S 2420C 1

LOCATION
1624 1 NM103 Laboratory or Facility Name AN 1 - 35 S

Identifier
1633 1
N3 SERVICE FACILITY 1 R 2420C

LOCATION ADDRESS
Line
Line
LOCATION
CITY/STATE/ZIP
Name
Province Code
Zone or ZIP Code

1641 N406 Location Identifier ID 1 - 30 N/U
1642 1
REF SERVICE FACILITY 5 S 2420C

LOCATION
SECONDARY
IDENTIFICATION
Qualifier
1644 1 REF02 Service Facility Location AN 1 - 30 R
1647 1
1648 1
1649 1
1650 1
1651 1
1652 1
NM1 SUPERVISING 1 S 2420D 1

PROVIDER NAME
1655 1 NM103 Supervising Provider Last AN 1 - 35 R
Name
1656 1 NM104 Supervising Provider First AN 1 - 25 R
Name
1657 NM105 Supervising Provider Middle AN 1 - 25 S
Name
1659 NM107 Supervising Provider Name AN 1 - 10 S
Suffix
1661 NM109 Supervising Provider Identifier AN 2 - 80 S

1664 1
REF SUPERVISING 5 S 2420D
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
1666 1 REF02 Supervising Provider AN 1 - 30 R
1669 1
1670 1
1671 1
1672 1
1673 1
1674 1
NM1 ORDERING PROVIDER 1 S 2420E 1

NAME
1677 1 NM103 Ordering Provider Last Name AN 1 - 35 R
1678 1 NM104 Ordering Provider First Name AN 1 - 25 R
1679 NM105 Ordering Provider Middle Name AN 1 - 25 S

1681 NM107 Ordering Provider Name Suffix AN 1 - 10 S

1683 NM109 Ordering Provider Identifier AN 2 - 80 S

1686 1
N3 ORDERING PROVIDER 1 S 2420E

ADDRESS
1687 N301 Ordering Provider Address Line AN 1 - 55 R
1688 N302 Ordering Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
1689 N401 Ordering Provider City Name AN 2 - 30 R

1690 N402 Ordering Provider State Code ID 2-2 R
1691 N403 Ordering Provider Postal Zone ID 3 - 15 R

or ZIP Code

1695 1
REF ORDERING PROVIDER 5 S 2420E

SECONDARY
IDENTIFICATION

Qualifier
1697 1 REF02 Ordering Provider Secondary AN 1 - 30 R
Identifier
1700 1
1701 1
1702 1
1703 1
1704 1
1705 1
PER ORDERING PROVIDER 1 S 2420E

CONTACT
INFORMATION
1707 PER02 Ordering Provider Contact AN 1 - 60 R
Name
Qualifier
Qualifier
Qualifier
NM1 REFERRING 1 S 2420F 2

PROVIDER NAME
1717 1 NM103 Referring Provider Last Name AN 1 - 35 R
1718 1 NM104 Referring Provider First Name AN 1 - 25 R
1719 NM105 Referring Provider Middle AN 1 - 25 S

Name
1721 NM107 Referring Provider Name Suffix AN 1 - 10 S

1723 NM109 Referring Provider Identifier AN 2 - 80 S

1726 1
PRV REFERRING 1 S 2420F

PROVIDER SPECIALTY
INFORMATION

1728 1 PRV02 Reference Identification Code ID 2-3 R

1730 1 PRV04 State or Province Code ID 2-2 N/U
1731 1 PRV05 PROVIDER SPECIALTY N/U
INFORMATION
1732 1 PRV06 Provider Organization Code ID 3-3 N/U
REF REFERRING 5 S 2420F

PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
1734 1 REF02 Referring Provider Secondary AN 1 - 30 R
Identifier
1737 1
1738 1
1739 1
1740 1
1741 1
1742 1
NM1 OTHER PAYER PRIOR 1 S 2420G 4

AUTHORIZATION OR
REFERRAL NUMBER
1751 1 NM109 Other Payer Identification AN 2 - 80 R
Number
REF OTHER PAYER PRIOR 2 R 2420G
AUTHORIZATION OR
REFERRAL NUMBER
Qualifier
1755 1 REF02 Other Payer Prior Authorization AN 1 - 30 R
or Referral Number

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

INFORMATION
1758 SVD01 Other Payer Primary Identifier AN 2 - 80 R
1759 SVD02 Service Line Paid Amount R 1 - 18 R

S9(7)V99
1761 1 SVD03-1 Product or Service ID Qualifier ID 2-2 R
1762 SVD03-2 Procedure Code AN 1 - 48 R

1767 SVD03-7 Procedure Code Description AN 1 - 80 S
1768 1
1769 SVD04 Product or Service ID AN 1 - 48 N/U
1770 SVD05 Paid Service Unit Count R 1 - 15 R
9(7)V999
1771 SVD06 Bundled Line Number N0 1-6 S


1774 CAS03 Adjustment Amount S9(7)V99 R 1 - 18 R





DTP LINE ADJUDICATION 1 R 2430

DATE
Qualifier
1
1
LQ FORM IDENTIFICATION 1 S 2440 5

CODE
1794 LQ01 Code List Qualifier Code ID 1-3 R

1795 LQ02 Form Identifier AN 1 - 30 R
FRM SUPPORTING 99 S 2440

DOCUMENTATION
1796 FRM01 Question Number/Letter AN 1 - 20 R
1797 FRM02 Question Response ID 1-1 S
1798 1 FRM03 Question Response AN 1 - 30 S
1799 FRM04 Question Response DT 8-8 S
1800 FRM05 Question Response 9(3)V9 R 1-6 S
TRAILER
Number
GE FUNCTION GROUP 1 R ___ >1

TRAILER
Included

CONTROL TRAILER
Groups
1444
al Claim 5010 837P Professional Claim

CONTROL HEADER
Qualifier

ZZ
ZZ
U ISA11 Interchange Control Standards 1-1 R
ID
Number


HEADER
HC GS01 Functional Identifier Code ID 2-2 R

HEADER

Number
Reference

HIERARCHICAL
TRANSACTION
00, 18 BHT02 Transaction Set Purpose Code ID 2-2 R

Transaction ID
HHMM, HHMMSS, BHT05 Transaction Set Creation Time TM 4-8 R

HHMMSSD, HHMMSSDD
CH, RP BHT06 Claim or Encounter ID ID 2-2 R
87
004010X098A1,
004010X098DA1

NM103 Submitter Last or Organization AN 1 - 60 R
Name
NM104 Submitter First Name AN 1 - 35 S
NM105 Submitter Middle Name AN 1 - 25 S
NM109 Submitter Identifier AN 2 - 80 R
Name

CONTACT
INFORMATION
ED, EM, FX. TE PER03 Communication Number ID 2-2 R
Qualifier
Qualifier
Qualifier

NM103 Receiver Name AN 1 - 60 R
NM109 Receiver Primary Identifier AN 2 - 80 R
Name
HL BILLING PROVIDER 1 R 2000A >1

HIERARCHICAL LEVEL


PRV BILLING PROVIDER 1 S 2000A

SPECIALTY
INFORMATION
BI, PT PRV01 Provider Code ID 1-3 R

Qualifier
INFORMATION

INFORMATION
CUR03 Exchange Rate R 4 - 10 N/U
CUR06 Currency Market/Exchange ID 3-3 N/U
Code

NM103 Billing Provider Last or AN 1 - 60 R
Organizational Name
NM104 Billing Provider First Name AN 1 - 35 S
NM105 Billing Provider Middle Name AN 1 - 25 S
NM107 Billing Provider Name Suffix AN 1 - 10 S
NM109 Billing Provider Identifier AN 2 - 80 S
Name

ADDRESS
N301 Billing Provider Address Line AN 1 - 55 R
N302 Billing Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
N401 Billing Provider City Name AN 2 - 30 R

N402 Billing Provider State or ID 2-2 S
Province Code
N403 Billing Provider Postal Zone or ID 3 - 15 S
ZIP Code
REF BILLING PROVIDER 1 R 2010AA

TAX IDENTIFICATION
0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, REF01 Reference Identification ID 2-3 R
B3, BQ, EI, FH, G2, G5, LU, Qualifier
SY, U3, X5
Identifier
REF04-1 Reference Identifier Qualifier ID 2-3 N/U
REF04-2 Other Payer Primary Idenitifer AN 1 - 50 N/U

Qualifier
Qualifier
06, 8U, EM, IJ, LU, RB, ST, TT
REF BILLING PROVIDER 2 S 2010AA

UPIN/LICENSE
INFORMATION
Qualifier
Identifier

Qualifier
Qualifier

CONTACT
INFORMATION

Qualifier
Qualifier
Qualifier
NM1 PAY-TO ADDRESS 1 S 2010AB 1

NAME
NM103 Pay-to Provider Last or AN 1 - 60 N/U
Organization Name
NM104 Pay-to Provider First Name AN 1 - 35 N/U
NM105 Pay-to Provider Middle Name AN 1 - 25 N/U

NM107 Pay-to Provider Name Suffix AN 1 - 10 N/U
24, 34, XX NM108 Identification Code Qualifier ID 1-2 N/U
NM109 Pay-to Provider Identifier AN 2 - 80 N/U
Name

ADDRESS
N301 Pay-to Provider Address Line AN 1 - 55 R
N302 Pay-to Provider Address Line AN 1 - 55 S

CITY/STATE/ZIP CODE
N401 Pay-to Provider City Name AN 2 - 30 R

N402 Pay-to Provider State Code ID 2-2 S
N403 Pay-to Provider Postal Zone or ID 3 - 15 S
ZIP Code
N404 Pay-to Provider Country Code ID 2-3 S

0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J,

B3, BQ, EI, FH, G2, G5, LU,
SY, U3, X5
NM1 PAY TO PLAN NAME 1 S 2010AC 1

NM103 Pay to Plan Organizational AN 1 - 60 R
Name
NM108 Identification Code Qualifier ID 1-2 R
Name
N3 PAY-TO PLAN 1 R 2010AC

ADDRESS
N301 Pay-to Plan Address Line AN 1 - 55 R
N302 Pay-to Plan Address Line AN 1 - 55 S
N4 PAY-TO PLAN 1 R 2010AC
CITY/STATE/ZIP CODE
N401 Pay-to Plan City Name AN 2 - 30 R

N402 Pay-to Plan State Code ID 2-2 S
N403 Pay-to Plan Postal Zone or ZIP ID 3 - 15 S
Code
N404 Pay-to Plan Country Code ID 2-3 S
REF PAY-TO PLAN 1 S 2010AC

SECONDARY
IDENTIFICATION
Qualifier

Qualifier
Qualifier
REF PAY-TO PLAN TAX 1 R 2010AC

IDENTIFICATION
Qualifier

Qualifier
Qualifier

HIERARCHICAL LEVEL


INFORMATION
P, S, T SBR01 Payer Responsibility Sequence ID 1-1 R
Number Code
Number
SBR04 Insured Group Name AN 1 - 60 S
12, 13, 14, 15, 16, 41, 42, 43, SBR05 Insurance Type Code ID 1-3 S
47

Code
LM, MB, MC, OF, TV, VA, WC,
ZZ
PAT PATIENT 1 S 2000B

INFORMATION
PAT01 Individual Relationship Code ID 2-2 N/U
D8 PAT05 Date Time Period Format ID 2-3 S
Qualifier
CCYYMMDD PAT06 Insured Individual Death Date AN 1 - 35 S

Code
PAT08 Patient Weight 9(6)V99 R 1 - 10 S
Y PAT09 Pregnancy Indicator ID 1-1 S

NM109 Subscriber Primary Identifier AN 2 - 80 R
Name
ADDRESS
N301 Subscriber Address Line AN 1 - 55 R
N302 Subscriber Address Line AN 1 - 55 S
CITY/STATE/ZIP CODE
N401 Subscriber City Name AN 2 - 30 R

N402 Subscriber State Code ID 2-2 S
N403 Subscriber Postal Zone or ZIP ID 3 - 15 S
Code

DEMOGRAPHIC
INFORMATION
Qualifier
F, M, U DMG03 Subscriber Gender Code ID 1-1 R

SECONDARY
IDENTIFICATION
1W, 23, IG, SY REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Subscriber Supplemental AN 1 - 50 R
Identifier

Qualifier
Qualifier
REF PROPERTY AND 1 S 2010BA

CASUALTY CLAIM
NUMBER
Qualifier
Number

Qualifier
Qualifier
PER PROPERTY AND 1 S 2010BA

CASUALTY
SUBSCRIBER
CONTACT
INFORMATION
PER03 Communication Number ID 2-2 R

Qualifier
PER05 Communication Number ID 2-2 S
Qualifier
PER07 Communication Number ID 2-2 N/U
Qualifier
PER08 Communication Number AN 1-256 N/U
NM1 PAYER NAME 1 R 2010BB 1

Name
N3 PAYER ADDRESS 1 S 2010BB

N301 Payer Address Line AN 1 - 55 R
N302 Payer Address Line AN 1 - 55 S
N4 PAYER 1 R 2010BB
CITY/STATE/ZIP CODE
N401 Payer City Name AN 2 - 30 R

N402 Payer State Code ID 2-2 S
N403 Payer Postal Zone or ZIP Code ID 3 - 15 S
N404 Payer Country Code ID 2-3 S

REF PAYER SECONDARY 3 S 2010BB

IDENTIFICATION
2U, FY, NF, TJ REF01 Reference Identification ID 2-3 R
Qualifier

Qualifier
Qualifier
REF BILLING PROVIDER 2 S 2010BB

SECONDARY
IDENTIFICATION
Qualifier

Qualifier
Qualifier
QD
1, 2
AO
1,2
MI
AB, BB

HIERARCHICAL LEVEL


INFORMATION
01, 04, 05, 07, 09, 10, 15, 17, PAT01 Individual Relationship Code ID 2-2 R
19, 20, 21, 22, 23, 24, 29, 32,
33, 34, 36, 39, 40, 41, 43, 53,
G8

D8 PAT05 Date Time Period Format ID 2-3 S
Qualifier
CCYYMMDD PAT06 Patient Death Date AN 1 - 35 S
Code
PAT08 Patient Weight 9(6)V99 R 1 - 10 S
Y PAT09 Pregnancy Indicator ID 1-1 S

NM107 Patient Name Suffix AN 1 - 10 S
Name

N301 Patient Address Line AN 1 - 55 R
N302 Patient Address Line AN 1 - 55 S
CITY/STATE/ZIP CODE
N401 Patient City Name AN 2 - 30 R

N402 Patient State Code ID 2-2 S
N403 Patient Postal Zone or ZIP ID 3 - 15 S
Code
N404 Patient Country Code ID 2-3 S

DEMOGRAPHIC
INFORMATION
Qualifier
F, M, U DMG03 Patient Gender Code ID 1-1 R
1W, 23, IG, SY

CASUALTY CLAIM
NUMBER
Qualifier
Number

Qualifier
Qualifier
PER PROPERTY AND 1 S 2010CA

CASUALTY PATIENT
CONTACT
INFORMATION

Qualifier
Qualifier
Qualifier

CLM01 Patient Account Number AN 1 - 38 R
CLM02 Total Claim Charge Amount R 1 - 18 R
S9(7)V99
CLM03 Claim Filing Indicator Code ID 1-2 N/U
CLM04 Non-Institutional Claim Type ID 1-2 N/U
Code
11, 12, 21, 22, 23, 24, 25, 26, CLM05-1 Facility Type Code AN 1-2 R
31, 32, 33, 34, 41, 42, 51, 52,
53, 54, 55, 56, 50, 60, 61, 62,
65, 71, 72, 81, 99
CLM05-2 Facility Code Qualifier ID 1-2 R

Refer to Code Source 235 CLM05-3 Claim Frequency Code ID 1-1 R
N, Y CLM06 Provider or Supplier Signature ID 1-1 R
Indicator
A, B, C, P CLM07 Medicare Assignment Code ID 1-1 R
N, Y CLM08 Benefits Assignment ID 1-1 R
A, I, M, N, O, Y CLM09 Release of Information Code ID 1-1 R
B, C, M, P, S CLM10 Patient Signature Source Code ID 1-1 S
CLM11 RELATED CAUSES S

INFORMATION
AA, AP, EM, OA CLM11-1 Related Causes Code ID 2-3 R
AA, AP, EM, OA CLM11--2 Related Causes Code ID 2-3 S
AA, AP, EM, OA CLM11-3 Related Causes Code ID 2-3 N/U
CLM11-4 Auto Accident State or Province ID 2-2 S
Code
CLM11-5 Country Code ID 2-3 S
01, 02, 03, 05, 07, 08, 09 CLM12 Special Program Indicator ID 2-3 S
Code
Code
P CLM16 Participation Agreement ID 1-1 N/U
Code
CLM19 Claim Submission Reason ID 2-2 N/U
Code
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 CLM20 Delay Reason Code ID 1-2 S

CURRENT
ILLNESS/SYMPTOM
Qualifier
DTP03 Onset of Current Illness or AN 1 - 35 R
Injury Date

TREATMENT
Qualifier
CCYYMMDD DTP03 Initial Treatment Date AN 1 - 35 R

SEEN
Qualifier
CCYYMMDD DTP03 Last Seen Date AN 1 - 35 R
431
D8
CCYYMMDD

MANIFESTATION
Qualifier
CCYYMMDD DTP03 Acute Manifestation Date AN 1 - 35 R
438
D8
CCYYMMDD
DTP DATE -ACCIDENT 1 S 2300

D8, DT DTP02 Date Time Period Format ID 2-3 R
Qualifier
CCYYMMDD, DTP03 Accident Date AN 1 - 35 R
CCYYMMDDHHM M

MENSTRUAL PERIOD
Qualifier
CCYYMMDD DTP03 Last Menstrual Period Date AN 1 - 35 R

Qualifier
CCYYMMDD DTP03 Last X-Ray Date AN 1 - 35 R
DTP DATE -HEARING AND 1 S 2300
VISION PRESCRIPTION
DATE
Qualifier
CCYYMMDD DTP03 Prescription Date AN 1 - 35 R
DTP DATE -DISABILITY 1 S 2300

DATES
Qualifier
CCYYMMDD DTP03 Disability From Date AN 1 - 35 R
361
D8
CCYYMMDD
DTP DATE -LAST WORKED 1 S 2300

Qualifier
CCYYMMDD DTP03 Last Worked Date AN 1 - 35 R
DTP DATE -AUTHORIZED 1 S 2300

RETURN TO WORK
Qualifier
CCYYMMDD DTP03 Work Return Date AN 1 - 35 R

Qualifier
CCYYMMDD DTP03 Related Hospitalization AN 1 - 35 R
Admission Date

Qualifier
CCYYMMDD DTP03 Related Hospitalization AN 1 - 35 R
Discharge Date
DTP DATE -ASSUMED AND 2 S 2300

RELINQUISHED CARE
DATES
090, 091 DTP01 Date Time Qualifier ID 3-3 R
Qualifier
CCYYMMDD DTP03 Assumed or Relinquished Care AN 1 - 35 R
Date
DTP DATE -PROPERTY AND 1 S 2300

CASUALTY DATE OF
FIRST CONTACT

Qualifier
DTP DATE -REPRICER 1 S 2300

RECEIVED DATE
Qualifier
PWK CLAIM 10 S 2300

SUPPLEMENTAL
INFORMATION
77, AS, B2, B3, B4, CT, DA, PWK01 Attachment Report Type Code ID 2-2 R
DG, DS, EB, MT, NN, OB, OZ,
PN, PO, PZ, RB, RR, RT
AA, BM, EL, EM, FX PWK02 Attachment Transmission Code ID 1-2 R

PWK06 Attachment Control Number AN 2 - 80 S

INFORMATION
02, 03, 04, 05, 06, 09 CN101 Contract Type Code ID 2-2 R
CN102 Contract Amount S9(7)V99 R 1 - 18 S
CN103 Contract Percentage 9(2)V99 R 1-6 S

9(2)V99
AMT PATIENT AMOUNT 1 S 2300
PAID
AMT02 Patient Amount Paid S9(7)V99 R 1 - 18 R
NE

AUTHORIZATION
EXCEPTION CODE
4N REF01 Reference Identification ID 2-3 R
Qualifier
1, 2, 3, 4, 5, 6, 7 REF02 Service Authorization Exception AN 1 - 50 R
Code

Qualifier
Qualifier
REF MANDATORY 1 S 2300

MEDICARE (SECTION
4081) CROSSOVER
INDICATOR
Qualifier
Y,N REF02 Medicare Section 4081 AN 1 - 50 R
Indicator

Qualifier
Qualifier
CERTIFICATION
NUMBER
EW REF01 Mammography Certification ID 2-3 R
Number
REF02 Mammography Certification AN 1 - 50 R
Number

Qualifier
Qualifier

Qualifier
Number

Qualifier
Qualifier
REF PRIOR 1 S 2300

AUTHORIZATION
Qualifier
Number

Qualifier
Qualifier

CONTROL NUMBER

Qualifier
REF02 Claim Original Reference AN 1 - 50 R
Number

Qualifier
Qualifier

LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
NUMBER
X4 REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Clinical Laboratory AN 1 - 50 R
Number


Qualifier
Qualifier

NUMBER
9A REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Repriced Claim Reference AN 1 - 50 R
Number

Qualifier
Qualifier

CLAIM NUMBER
9C REF01 Reference Identification ID 2-3 R

Qualifier
REF02 Adjusted Repriced Claim AN 1 - 50 R
Reference Number

Qualifier
Qualifier

DEVICE EXEMPTION
NUMBER
LX REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Investigational Device AN 1 - 50 R
Exemption Number

Qualifier
Qualifier

FOR TRANSMISSION
INTERMEDIARIES
D9 REF01 Reference Identification ID 2-3 R

Qualifier

Qualifier
Qualifier
1S

NUMBER
EA REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Medical Record Number AN 1 - 50 R

Qualifier
Qualifier

PROJECT IDENTIFIER
P4 REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Demonstration Project Identifier AN 1 - 50 R


Qualifier
Qualifier
REF CARE PLAN 1 S 2300

OVERSIGHT
Qualifier
REF02 Care Plan Oversight Number AN 1 - 50 R

Qualifier
Qualifier

MEASURE

ADD, CER, DCP,DGN,PMT,T NTE01 Note Reference Code ID 3-3 R
PO

TRANSPORT
INFORMATION
LB CR101 Unit or Basis for Measurement ID 2-2 S
Code
CR102 Patient Weight 9(3) R 1 - 10 S
I, R, T, X CR103 Ambulance Transport Code ID 1- 1 N/U
A, B, C, D, E CR104 Ambulance Transport Reason ID 1- 1 R
Code
DH CR105 Unit or Basis for Measurement ID 2-2 R
Code
CR106 Transport Distance 9(4) R 1 - 15 R
CR107 Address Information AN 1 - 55 N/U
CR109 Round Trip Purpose AN 1 - 80 S
Description
CR110 Stretcher Purpose Description AN 1 - 80 S
CR2 SPINAL 1 S 2300

MANIPULATION
SERVICE
INFORMATION
CR201 Treatment Series Number 9(3) N0 1-9 N/U
CR202 Treatment Count 9(3) R 1 - 15 N/U

C1, C2, C3, C4, C5, C6, C7, CR203 Subluxation Level Code ID 2-3 N/U
CO, IL, L1, L2, L3, L4, L5, OC,
SA, T1, T10, T11, T12, T2, T3,
T4, T5, T6, T7, T8, T9
C1, C2, C3, C4, C5, C6, C7, CR204 Subluxation Level Code ID 2-3 N/U
CO, IL, L1, L2, L3, L4, L5, OC,
SA, T1, T10, T11, T12, T2, T3,
T4, T5, T6, T7, T8, T9
DA, MO, WK, YR CR205 Unit or Basis for Measurement ID 2-2 N/U
Code
CR206 Treatment Period Count 9(3) R 1 - 15 N/U
CR207 Monthly Treatment Count 9(2) R 1 - 15 N/U
A, C, D, E, F, G, M CR208 Patient Condition Code ID 1- 1 R

N, Y CR209 Complication Indicator ID 1- 1 N/U
CR210 Patient Condition Description AN 1 - 80 S
CR211 Patient Condition Description AN 1 - 80 S
N, Y CR212 Yes/No Condition or Response ID 1- 1 N/U
Code

CERTIFICATION
N, Y CRC02 Certification Condition Indicator ID 1- 1 R
01, 02, 03, 04, 05, 06, 07, 08, CRC03 Condition Code ID 2-3 R
09, 60
01, 02, 03, 04, 05, 06, 07, 08, CRC04 Condition Code ID 2-3 S
09, 60
09, 60
09, 60
09, 60
CRC PATIENT CONDITION 3 S 2300

INFORMATION: VISION
E1, E2, E3 CRC01 Code Category ID 2-2 R

L1, L2, L3, L4, L5 CRC03 Condition Code ID 2-3 R

L1, L2, L3, L4, L5 CRC04 Condition Code ID 2-3 S
CRC HOMEBOUND 1 S 2300

INDICATOR
Y CRC02 Certification Condition Indicator ID 1- 1 R
IH CRC03 Homebound Indicator ID 2-3 R


ZZ CRC01 Code Category ID 2-2 R
AV, NU, S2, ST CRC03 Condition Code ID 2-3 R

AV, NU, S2, ST CRC04 Condition Code ID 2-3 S
AV, NU, S2, ST CRC05 Condition Code ID 2-3 S
HI HEALTH CARE 1 R 2300

DIAGNOSIS CODE
INFORMATION
BK HI01-1 Diagnosis Type Code ID 1-3 R
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
HI ANESTHESIA 1 S 2300
RELATED
PROCEDURE
INFORMATION
HI01-1 Code List Qualifier ID 1-3 R
HI01-2 Anesthesia Related Surgical AN 1 - 30 R
Procedure
Qualifier
Code
INFORMATION
HI02-2 Anesthesia Related Surgical AN 1 - 30 R
Procedure
Qualifier
Code
INFORMATION
HI03-1 Code List Qualifier ID 1-3 N/U
HI03-2 Anesthesia Related Surgical AN 1 - 30 N/U
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
INFORMATION
Procedure
Qualifier
Code
HI CONDITION 2 S 2300
INFORMATION
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
INFORMATION
Qualifier
Code
HCP CLAIM 1 S 2300

PRICING/REPRICING
INFORMATION
09, 10 ,11, 12, 13, 14
S9(7)V99
S9(7)V99
Identifier
HCP05 Repricing Per Diem or Flat Rate R 1-9 S
Amount S9(5)V99
HCP06 Repriced Approved Ambulatory AN 1 - 50 S
Patient Group Code
HCP07 Repriced Approved Ambulatory R 1 - 18 S

S9(7)V99
HCP09 Product/Service ID Qualifier ID 2-2 N/U
HCP11 Unit or Basis for Measurement ID 2-2 N/U
Code
HCP12 Quantity 9(3)V9 R 1 - 15 N/U
AI, MS, OT, PT, SN, ST
VS
DA, MO, Q1, WK
7, 35
1-7, A-H, J-L, N, O, S, SA, SB,

SC, SD, SG, SL, SP, SX, SY,
SZ, W
D, E, F
NM1 REFERRING 1 S 2310A 2

PROVIDER NAME
DN, P3 NM101 Entity Identifier Code ID 2-3 R

Name
NM107 Referring Provider Name Suffix AN 1 - 10 S

NM109 Referring Provider Identifier AN 2 - 80 S
Name
RF
ZZ
REF REFERRING 3 S 2310A
PROVIDER
SECONDARY
IDENTIFICATION
0B, 1B, 1C, 1D, 1G, 1H, EI, G2, REF01 Reference Identification ID 2-3 R
LU, N5, SY, X5 Qualifier
Identifier

Qualifier
Qualifier
NM1 RENDERING 1 S 2310B 1

PROVIDER NAME
Organization Name
NM104 Rendering Provider First Name AN 1 - 35 S

Name
Suffix
Name
PRV RENDERING 1 S 2310B

PROVIDER SPECIALTY
INFORMATION
PE PRV01 Provider Code ID 1-3 R

Qualifier
INFORMATION
REF RENDERING 4 S 2310B
PROVIDER
SECONDARY
IDENTIFICATION
Identifier

Qualifier
Qualifier
QB
1,2
24, 34, XX
0B,1A,1B,1C,1D,1
G,1H,EI,G2,LU,N5 ,SY,U3,X5

LOCATION
77, FA, LI, TL NM101 Entity Identifier Code ID 2-3 R
NM103 Laboratory or Facility Name AN 1 - 60 R
NM109 Laboratory or Facility Primary AN 2 - 80 S
Identifier
Name

LOCATION ADDRESS
Line
Line

LOCATION
CITY/STATE/ZIP
Name
Province Code
Zone ZIP Code
N404 Laboratory/Facility Country ID 2-3 S
Code

LOCATION
SECONDARY
IDENTIFICATION
0B,1A,1B,1C,1D,1G,1 REF01 Reference Identification ID 2-3 R
Qualifier
H,G2,LU,N5,TJ,X4,
X5
REF02 Laboratory or Facility AN 1 - 50 R

Qualifier
Qualifier
PER SERVICE FACILITY 1 R 2310C
CONTACT
INFORMATION
Qualifier
Qualifier
Qualifier

PROVIDER NAME
DQ NM101 Entity Identifier Code ID 2-3 R
NM103 Supervising Provider Last AN 1 - 60 R
Name
NM104 Supervising Provider First AN 1 - 35 S
Name
NM105 Supervising Provider Middle AN 1 - 25 S
Name
NM107 Supervising Provider Name AN 1 - 10 S
Suffix

NM109 Supervising Provider Identifier AN 2 - 80 S

Name

PROVIDER
SECONDARY
IDENTIFIER
0B, 1B, 1C, 1D, 1G, 1H, REF01 Reference Identification
Qualifier
ID 2-3 R
EI, G2, LU, N5, SY, X5
REF02 Supervising Provider AN 1 - 50 R


Qualifier
Qualifier
NM1 AMBULANCE PICK UP 1 S 2310E 1

LOCATION
Name
Name
N3 AMBULANCE PICK UP 1 R 2310E

LOCATION ADDRESS
N301 Ambulance Pick Up Address AN 1 - 55 R

Line
N302 Ambulance Pick Up Address AN 1 - 55 S
Line
N4 AMBULANCE PICK UP 1 R 2310E

LOCATION
CITY/STATE/ZIP
N401 Ambulance Pick Up City Name AN 2 - 30 R
N402 Ambulance Pick Up State or ID 2-2 S

Province Code
N403 Ambulance Pick Up Postal ID 3 - 15 S
Zone ZIP Code
N404 Ambulance Pick Up Country ID 2-3 S
Code
NM1 AMBULANCE DROP 1 S 2310F 1

OFF LOCATION
NM103 Ambulance Drop Off Location AN 1 - 60 S

Name
N3 AMBULANCE DROP 1 R 2310F
OFF LOCATION
ADDRESS
N301 Ambulance Drop Off Address AN 1 - 55 R
Line
N302 Ambulance Drop Off Address AN 1 - 55 S
Line
N4 AMBULANCE DROP 1 R 2310F

OFF LOCATION
CITY/STATE/ZIP
N401 Ambulance Drop Off City Name AN 2 - 30 R
N402 Ambulance Drop Off State or ID 2-2 S

Province Code
N403 Ambulance Drop Off Postal ID 3 - 15 S
Zone ZIP Code
N404 Ambulance Drop Off Country ID 2-3 S
Code

INFORMATION
P, S, T SBR01 Payer Responsibility Sequence ID 1-1 R
Number Code
01, 04, 05, 07, 10, 15, SBR02 Individual Relationship Code ID 2-2 R
17, 18, 19, 20, 21, 22, 23,

24, 29, 32, 33, 36, 39,
40, 41, 43, 53, G8

Number
SBR04 Other Insured Group Name AN 1 - 60 S
AP, C1, CP, GP, SBR05 Insurance Type Code ID 1-3 S
HM, IP, LD, LT, MB,

MC, MI, MP, OT, PP,
SP

Code
09, 10, 11, 12, 13, 14, 15, SBR09 Claim Filing Indicator Code ID 1-2 S
16, AM, BL, CH, CI, DS, HM,

LI, LM, MB, MC, OF, TV, VA,
WC, ZZ

ADJUSTMENTS

CAS03 Adjustment Amount S9(7)V99 R 1 - 18 R
CAS04 Adjustment Quantity 9(7) R 1 - 15 S

CAS06 Adjustment Amount S9(7)V99 R 1 - 18 S





AMOUNT
D AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Payer Paid Amount S9(7)V99 R 1 - 18 R
AAE
B6
AMT COB TOTAL NON 1 S 2320

COVERED AMOUNT

AMT02 Non-Covered Amount S9(7)V99 R 1 - 18 R

LIABILITY
Amount S9(7)V99
F2
AU
D8
DY
F5
T2
D8
CCYYMMDD
F, M, U

COVERAGE
INFORMATION
OI01 Claim Filing Indicator Code ID 1-2 N/U
OI02 Claim Submission Reason ID 2-2 N/U
Code
N, Y OI03 Benefits Assignment ID 1=1 R
B, C, M, P, S OI04 Patient Signature Source Code ID 1=1 S
OI05 Provider Agreement Code ID 1=1 N/U

A, I, M, N, O, Y OI06 Release of Information Code ID 1=1 R

OUTPATIENT
ADJUDICATION
INFORMATION
MOA01 Reimbursement Rate 9(3)V99 R 1 - 10 S
MOA02 HCPCS Payable Amount R 1 - 18 S

S9(7)V99
MOA08 End Stage Renal Disease R 1 - 18 S
Payment Amount S9(7)V99
MOA09 Non-Payable Professional R 1 - 18 S
S9(7)V99

NAME
NM103 Other Insured Last Name AN 1 - 60 R
NM104 Other Insured First Name AN 1 - 35 S
NM105 Other Insured Middle Name AN 1 - 25 S
NM107 Other Insured Name Suffix AN 1 - 10 S
NM109 Other Insured Identifier AN 2 - 80 R
Name

ADDRESS
N301 Other Insured Address Line AN 1 - 55 R
N302 Other Insured Address Line AN 1 - 55 S
N4 OTHER SUBSCRIBER 1 R 2330A

CITY/STATE/ZIP CODE
N401 Other Insured City Name AN 2 - 30 R

N402 Other Insured State Code ID 2-2 S
N403 Other Insured Postal Zone or ID 3 - 15 S
ZIP Code

SECONDARY
IDENTIFICATION
1W, 23, IG, SY REF01 Reference Identification
Qualifier
ID 2-3 R
REF02 Other Insured Additional AN 1 - 50 R

Identifier

Qualifier
Qualifier

NM103 Other Payer Last or AN 1 - 60 R
Organization Name
NM109 Other Payer Primary Identifier AN 2 - 80 R

Name
ADDRESS
N301 Other Payer Address Line AN 1 - 55 R
N302 Other Payer Address Line AN 1 - 55 S
N4 OTHER PAYER 1 R 2330B

CITY/STATE/ZIP CODE
N401 Other Payer City Name AN 2 - 30 R

N402 Other Payer State Code ID 2-2 S
N403 Other Payer Postal Zone or ZIP ID 3 - 15 S
Code
N404 Other Payer Country Code ID 2-3 S
IC
ED, EM, FX, TE
ED, EM, EX, FX, TE
ED, EM, EX, FX, TE
DTP DATE -CLAIM CHECK 1 S 2330B

OR REMITTANCE
DATE
Qualifier

SECONDARY
IDENTIFICATION
2U, F8, FY, NF, TJ REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Other Payer Secondary AN 1 - 50 R
Identifier

Qualifier
Qualifier

AUTHORIZATION
NUMBER
9F, G1 REF01 Reference Identification
Qualifier
ID 2-3 R
REF02 Other Payer Prior Authorization AN 1 - 50 R

Number

Qualifier
Qualifier

REFERRAL NUMBER
Qualifier
REF02 Other Payer Referral Number AN 1 - 50 R


Qualifier
Qualifier

ADJUSTMENT
INDICATOR
T4 REF01 Reference Identification ID 2-3 R
Qualifier
Y REF02 Other Payer Claim Adjustment AN 1 - 50 R
Indicator

Qualifier
Qualifier

CONTROL NUMBER
Qualifier
REF02 Other Payer Claim Control AN 1 - 50 R
Number

Qualifier
Qualifier
QC
1
MI
1W, 23, IG, SY

REFERRING
PROVIDER
Name

Name
REF OTHER PAYER 3 R 2330C

REFERRING
PROVIDER
SECONDARY
IDENTIFIER
1B, 1C, 1D, EI, G2, REF01 Reference Identification

Qualifier
ID 2-3 R
LU, N5
REF02 Other Payer Referring Provider AN 1 - 50 R


Qualifier
Qualifier

RENDERING
PROVIDER
Name

Name
RENDERING
PROVIDER
SECONDARY
IDENTIFIER
1B, 1C, 1D, EI, G2, LU, REF01 Reference Identification

Qualifier
ID 2-3 R
N5
REF02 Other Payer Rendering AN 1 - 50 R


Qualifier
Qualifier

SERVICE FACILITY
LOCATION
Name

Name

SERVICE FACILITY
LOCATION
SECONDARY
IDENTIFIER
Qualifier
REF02 Other Payer Service Facility AN 1 - 50 R


Qualifier
Qualifier
QB
1, 2
1A, 1B, 1C, 1D, EI, G2, LU, N5
NM1 OTHER PAYER 1 S 2330F 1

SUPERVISING
PROVIDER
Name

Name
REF OTHER PAYER 3 R 2330F
SUPERVISING
PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
REF02 Other Payer Supervising AN 1 - 50 R


Qualifier
Qualifier
77, FA, LI, TL

2
1A, 1B, 1C, 1D,G2, LU, N5
NM1 OTHER PAYER 1 S 2330G 1

BILLING PROVIDER
Name

Name
REF OTHER PAYER 2 R 2330G

BILLING PROVIDER
SECONDARY
IDENTIFICATION
Qualifier
REF02 Other Payer Billing Provider AN 1 - 50 R
Secondary Identification

Qualifier
Qualifier
DQ
1
1B, 1C, 1D,EI, G2, N5

SV1 PROFESSIONAL 1 R 2400

SERVICE
HC, IV, ZZ SV101-1 Product or Service ID Qualifier ID 2-2 R

SV101-7 Description AN 1 - 80 S
SV101-8 Product/Service ID AN N/U
SV102 Line Item Charge Amount R 1 - 18 R
S9(7)V99
F2,MJ,UN SV103 Unit or Basis for Measurement

Code
ID 2-2 R
SV104 Service Unit Count "MJ" = 9(4) R 1 - 15 R

"UN" = 9(3)V9
11, 12, 21, 22, 23, 24, 25, 26, SV105 Place of Service Code AN 1-2 S
31, 32, 33, 34, 41, 42, 50, 51,
52, 53, 54, 55, 56, 60, 61, 62,
65, 71, 72, 81, 99
SV106 Service Type Code ID 1-2 N/U

SV107 COMPOSITE DIAGNOSIS R
CODE POINTER
SV107-1 Diagnosis Code Pointer N0 1-2 R
SV107-2 Diagnosis Code Pointer N0 1-2 S
SV108 Monetary Amount R 1 - 18 N/U
Y SV109 Emergency Indicator ID 1-1 S
SV110 Multiple Procedure Code ID 1-2 N/U
Y SV111 EPSDT Indicator ID 1-1 S
Y SV112 Family Planning Indicator ID 1-1 S
SV113 Review Code ID 1-2 N/U
SV114 National or Local Assigned AN 1-2 N/U
Review Value
0 SV115 Co-Pay Status Code ID 1-1 S
SV116 Health Care Professional ID 1-1 N/U
Shortage Area Code
SV117 Reference Identification AN 1 - 30 N/U
SV118 Postal Code ID 3 - 15 N/U
SV119 Monetary Amount R 1 - 18 N/U
SV120 Level of Care Code ID 1-1 N/U
SV121 Provider Agreement Code ID 1-1 N/U
SV5 DURABLE MEDICAL 1 S 2400

EQUIPMENT SERVICE
PROCEDURE
HC SV501-1 Procedure Identifier ID 2-2 R
SV501-3 Procedure Modifier AN 2-2 N/U
SV501-7 Desription AN 1 - 80 N/U
SV501-8 Product/Service ID AN 1 - 48 N/U
DA SV502 Unit or Basis for Measurement ID 2-2 R
Code
SV503 Length of Medical Necessity R 1 - 15 R
9(3)
SV504 DME Rental Price S9(7)V99 R 1 - 18 R
SV505 DME Purchase Price S9(7)V99 R 1 - 18 R
1, 4, 6 SV506 Rental Unit Price Indicator ID 1-1 R

SV507 Prognosis Code ID 1-1 N/U

INFORMATION
CT PWK01 Attachment Report Type Code ID 2-2 R
AB, AD, AF, AG, NS PWK02 Attachment Transmission Code ID 1-2 R

PWK05 Identification Code Qualifier ID 1-2 S
PWK06 Identification Code AN 2 - 80 S
PWK DURABLE MEDICAL 1 S 2400

EQUIPMENT
CERTIFICATE OF
MEDICAL NECESSITY
INDICATOR
PWK01 Attachment Report Type Code ID 2-2 R
PWK02 Attachment Transmission Code ID 1-2 R

PWK05 Identification Code Qualifier ID 1-2 N/U
PWK06 Identification Code AN 2 - 80 N/U

TRANSPORT
INFORMATION
LB CR101 Unit or Basis for Measurement ID 2-2 S
Code
CR102 Patient Weight 9(3) R 1 - 10 S
I, R, T, X CR103 Ambulance Transport Code ID 1-1 N/U
A, B, C, D, E CR104 Ambulance Transport Reason ID 1-1 R
Code
DH CR105 Unit or Basis for Measurement ID 2-2 R
Code
CR106 Transport Distance 9(4) R 1 - 15 R
CR109 Round Trip Purpose AN 1 - 80 S
Description
CR110 Stretcher Purpose Description AN 1 - 80 S
C1, C2, C3, C4, C5, C6, C7,

CO, IL, L1, L2, L3, L4, L5, OC,
SA, T1, T10, T11, T12, T2, T3,
T4, T5, T6, T7, T8, T9
C1, C2, C3, C4, C5, C6, C7,

CO, IL, L1, L2, L3, L4, L5, OC,
SA, T1, T10, T11, T12, T2, T3,
T4, T5, T6, T7, T8, T9
DA, MO, WK, YR
A, C, D, E, F, G, M
N, Y
N, Y
CR3 DURABLE MEDICAL 1 S 2400

EQUIPMENT
CERTIFICATION
I,R,S CR301 Certification Type Code ID 1-1 R
MO CR302 Unit or Basis for Measurement ID 2-2 R
Code
CR303 Durable Medical Equipment R 1 - 15 R
Duration 9(2)
CR304 Insulin Dependent Code ID 1-1 N/U
CR305 Description AN 1 - 80 N/U
I,R,S
E,R,S
1
2
3

CERTIFICATION
N, Y CRC02 Certification Condition Indicator ID 1-1 R
01, 02, 03, 04, 05, 06, 07, 08, CRC03 Condition Code ID 2-3 R
09, 60
09, 60
09, 60
09, 60
09, 60
CRC HOSPICE EMPLOYEE 1 S 2400

INDICATOR
N, Y CRC02 Hospice Employed Provider ID 1-1 R
Indicator
65 CRC03 Condition Indicator ID 2-3 R
CRC CONDITION 1 S 2400

INDICATOR DURABLE
MEDICAL EQUIPMENT
09,11 CRC01 Code Category ID 2-2 R

N, Y CRC02 Certification Condition Indicator ID 1-1 R
37,38,AL,P1, ZV CRC03 Condition Indicator ID 2-3 R

37,38,AL,P1, ZV CRC04 Condition Indicator ID 2-3 S
37,38,AL,P1, ZV CRC05 Condition Indicator ID 2-3 N/U
DTP DATE -PRESCRIPTION 1 S 2400

DATE
Qualifier
DTP03 Prescription Date AN 1 - 35 R

Qualifier
CYYMMDD, CCYYMMDDCCY DTP03 Service Date AN 1 - 35 R
YMMDD
DTP DATE -CERTIFICATION 1 S 2400

REVISION/RECERTIFIC
ATION DATE

Qualifier
CCYYMMDD DTP03 Certification Revision AN 1 - 35 R
Recertification Date
DTP DATE -BEGIN 1 S 2400

THERAPY DATE
Qualifier
CCYYMMDD DTP03 Begin Therapy Date AN 1 - 35 R

CERTIFICATION DATE

Qualifier
CCYYMMDD DTP03 Last Certification Date AN 1 - 35 R
SEEN
Qualifier
CCYYMMDD DTP03 Last Seen Date AN 1 - 35 R
DTP DATE -TEST 2 S 2400

738, 739 DTP01 Date Time Qualifier ID 3-3 R
Qualifier
CCYYMMDD DTP03 Test Performed Date AN 1 - 35 R
119, 480, 481

D8
CCYYMMDD
DTP DATE -SHIPPED 1 S 2400

Qualifier
CCYYMMDD DTP03 Shipped Date AN 1 - 35 R
431
D8
CCYYMMDD

Qualifier
CCYYMMDD DTP03 Last X-Ray Date AN 1 - 35 R
453
D8
CCYYMMDD

TREATMENT
Qualifier
CCYYMMDD DTP03 Initial Treatment Date AN 1 - 35 R
438
D8
CCYYMMDD
QTY AMBULANCE PATIENT 1 S 2400

COUNT
QTY02 Ambulance Patient Count 9(2) R 1 - 15 R
QTY03 COMPOSITE UNIT OF N/U

MEASURE
QTY04 Fee-Form Message AN 1 - 30 N/U
QTY OBSTETRIC 1 S 2400

ANESTHESIA
ADDITIONAL UNITS
QTY02 Obstetric Additional Units 9(2) R 1 - 15 R
QTY03 COMPOSITE UNIT OF N/U

MEASURE
QTY04 Fee-Form Message AN 1 - 30 N/U
MEA TEST RESULTS 5 S 2400

OG, TR MEA01 Measurement Reference ID 2-2 R
Identification Code
GRA, HT, R1, R2, R3, R4, ZO MEA02 Measurement Qualifier ID 1-3 R
MEA03 Test Result "HT" 9(2), "R1", R 1 - 20 R

"R2", "R3", "R4" = 9(2)V9
MEA04 COMPOSITE UNIT OF N/U

MEASURE
MEA05 Range Minimum R 1 - 20 N/U
MEA06 Range Maximum R 1 - 20 N/U
MEA07 Measurement Significance ID 2-2 N/U
Code
MEA08 Measurement Attribute Code ID 2-2 N/U
MEA09 Surface/Layer/Position Code ID 2-2 N/U
MEA10 Measurement Method or ID 2-4 N/U

Device
MEA11 Code List Qualifier Code ID 1-3 N/U
MEA12 Industry Code AN 1 - 30 N/U

INFORMATION
01, 02, 03, 04, 05, 06, 09 CN101 Contract Type Code ID 2-2 R
CN102 Contract Amount S9(7)V99 R 1 - 18 S
CN103 Contract Percentage 9(2)V99 R 1-6 S

9(2)V99

REFERENCE NUMBER
9B REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Repriced Line Item Reference AN 1 - 50 R
Number

Qualifier
Qualifier

LINE ITEM
REFERENCE NUMBER
9D REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Adjusted Repriced Line Item AN 1 - 50 R
Reference Number

Qualifier
Qualifier
REF PRIOR 5 S 2400

AUTHORIZATION

Qualifier
Number
REF04 REFERENCE IDENTIFIER

Qualifier
Qualifier

NUMBER
6R REF01 Reference Identification ID 2-3 R
Qualifier

Qualifier
Qualifier

CERTIFICATION
NUMBER
EW REF01 Reference identification ID 2-3 R
Qualifier
REF02 Mammography Certification AN 1 - 50 R
Number

Qualifier
Qualifier

LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
IDENTIFICATION
X4 REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Clinical Laboratory AN 1 - 50 R
Number

Qualifier
Qualifier
REF REFERRING CLINICAL 1 S 2400

LABORATORY
IMPROVEMENT
AMENDMENT (CLIA)
FACILITY
IDENTIFICATION

Qualifier
REF02 Referring CLIA Number AN 1 - 50 R

Qualifier
Qualifier
REF IMMUNIZATION BATCH 1 S 2400

NUMBER
BT REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Immunization Batch Number AN 1 - 50 R

Qualifier
Qualifier

Qualifier
REF02 Referral Number AN 1 - 50 R
REF04 REFERENCE IDENTIFIER

Qualifier
Qualifier
1S
TP
OZ, VP
AMT SALES TAX AMOUNT 1 S 2400

T AMT01 Amount Qualifier Code ID 1-3 R
AMT02 Sales Tax Amount S9(7)V99 R 1 - 18 R
AAE
AMT POSTAGE CLAIMED 1 S 2400

AMOUNT
AMT02 Sales Tax Amount S9(7)V99 R 1 - 18 R

MEASURE
NTE LINE NOTE 1 S 2400

ADD, DCP, PMT, TPO NTE01 Note Reference Code ID 3-3 R
NTE02 Line Note Text AN 1 - 80 R
NTE THIRD PARTY 1 S 2400

ORGANIZATION NOTE
NTE01 Third Party Organization Notes ID 3-3 R
NTE02 Line Note Text AN 1 - 80 R
PS1 PURCHASED SERVICE 1 S 2400

INFORMATION
PS101 Purchased Service Provider AN 1 - 50 R

Identifier
PS102 Purchased Service Charge R 1 - 18 R
Amount S9(7)V99
PS103 State or Province Code ID 2-2 N/U
VS
DA, MO, Q1, WK
7, 34, 35
1, 2, 3, 4, 5, 6, 7, A, B, C, D, E,
F, G, H, J, K, L, N, O, SA, SB,
SC, SD, SG, SL, SP, SX, SY,
SZ, W
D, E, F
HCP LINE 1 S 2400

PRICING/REPRICING
INFORMATION
08, 09, 10, 11, 12, 13, 14

S9(7)V99
S9(7)V99
Identifier
HCP05 Repricing Per Diem or Flat Rate R 1-9 S
Amount S9(5)V99
HCP06 Repriced Approved Ambulatory AN 1 - 50 S
Patient Group Code
HCP07 Repriced Approved Ambulatory R 1 - 18 S

S9(7)V99

HC, IV, ZZ HCP09 Product or Service ID Qualifier ID 2-2 S
HCP10 Procedure Code AN 1 - 48 S

DA, UN HCP11 Unit or Basis for Measurement ID 2-2 S
Code
HCP12 Repriced Approved Service R 1 - 15 S
Unit Count "MJ" = 9(4) "UN" =
9(3)V9
LIN01 Assigned Identification AN 1 - 20 N/U

N4 LIN02 Product or Service ID Qualifier ID 2-2 R
LIN03 National Drug Code AN 1 - 48 R

CTP DRUG PRICING 1 R 2410

CTP01 Class of Trade Code ID 2-2 N/U
CTP02 Price Identifier Code ID 3-3 N/U
CTP03 Unit Price R 1 - 17 N/U
CTP04 National Drug Unit Count when R 1 - 15 R
CTP05-1 = "UN" 9(3)V9, "F2"
9(7)V999, "ML" or "GR"
9(2)V99, ME 9(5)V999
CTP05 COMPOSITE UNIT OF R

MEASURE
F2, GR, ML, UN CTP05-1 Unit or Basis For Measurement ID 2-2 R
Code
CTP05-4 Unit or Basis For Measurement ID 2-2 N/U
Code
Code
Code
Code
CTP06 Price Multiplier Qualifier ID 3-3 N/U
CTP07 Multiplier R 1 - 10 N/U
CTP08 Monetary Amount R 1 - 18 N/U
CTP09 Basis of Unit Price Code ID 2-2 N/U
CTP10 Condition Value AN 1 - 10 N/U
CTP11 Multiple Price Quantity N0 1-2 N/U
REF PRESCRIPTION OR 1 S 2410

COMPOUND DRUG
ASSOCIATION
NUMBER
XZ REF01 Reference Identification ID 2-3 R
Qualifier
REF02 Prescription Number AN 1 - 50 R
REF03 Desciption AN 1 - 80 N/U

Qualifier
Qualifier
NM1 RENDERING 1 S 2420A 1

PROVIDER NAME
1,2 NM102 Entity Type Qualifier ID 1-1 R
Organization Name
NM104 Rendering Provider First Name AN 1 - 35 S

Name
Suffix
Name
PRV RENDERING 1 S 2420A

PROVIDER SPECIALTY
INFORMATION
PE PRV01 Provider Code ID 1-3 R

Qualifier
INFORMATION
REF RENDERING 20 S 2420A

PROVIDER
SECONDARY
IDENTIFICATION
Identifier

Qualifier
Qualifier
NM1 PURCHASED SERVICE 1 S 2420B 1

PROVIDER NAME
QB NM101 Entity Identifier Code ID 2-3 R

Name

Name
REF PURCHASED SERVICE 20 S 2420B

PROVIDER
SECONDARY
IDENTIFICATION
G2, LU, N5, SY, U3, X5 Qualifier
REF02 Purchased Service Provider AN 1 - 50 R

Qualifier
Qualifier

LOCATION NAME
77, FA, LI, TL NM101 Entity Identifier Code ID 2-3 R
NM103 Name Last or Organization AN 1 - 60 R
Name

Name

LOCATION ADDRESS
Line
Line
LOCATION
CITY/STATE/ZIP
Name
Province Code
Zone ZIP Code
N404 Laboratory or Facility Country ID 2-3 S
Code

LOCATION
SECONDARY
IDENTIFICATION
0B, 1A, 1B, 1C, 1D, 1G,1H, G2, REF01 Reference Identification ID 2-3 R
LU, N5, TJ, X4, X5 Qualifier
REF02 Service Facility Location AN 1 - 50 R

Qualifier
Qualifier

PROVIDER NAME
DQ NM101 Entity Identifier Code ID 2-3 R
NM103 Supervising Provider Last AN 1 - 60 R
Name



Name
PROVIDER
SECONDARY
IDENTIFICATION
REF02 Supervising Provider AN 1 - 50 R

Qualifier
Qualifier
NM1 ORDERING PROVIDER 1 S 2420E 1

NAME
DK NM101 Entity Identifier Code ID 2-3 R
NM103 Ordering Provider Last Name AN 1 - 60 R
NM104 Ordering Provider First Name AN 1 - 35 S
NM105 Ordering Provider Middle Name AN 1 - 25 S

or Initial
NM107 Ordering Provider Name Suffix AN 1 - 10 S


Name

ADDRESS
N301 Ordering Provider Address Line AN 1 - 55 R
N302 Ordering Provider Address Line AN 1 - 55 S
N4 ORDERING PROVIDER 1 R 2420E

CITY/STATE/ZIP CODE
N401 Ordering Provider City Name AN 2 - 30 R

N402 Ordering Provider State or ID 2-2 S
Province Code
N403 Ordering Provider Postal Zone ID 3 - 15 S
ZIP Code
N404 Ordering Provider Country ID 2-3 S
Code
REF ORDERING PROVIDER 20 S 2420E

SECONDARY
IDENTIFICATION
REF02 Ordering Provider Secondary AN 1 - 50 R
Identifier

Qualifier
Qualifier
PER ORDERING PROVIDER 1 S 2420E

CONTACT
INFORMATION
1C PER01 Contact Function Code ID 2-2 R
PER02 Ordering Provider Contact AN 1 - 60 S
Name
Qualifier
Qualifier
Qualifier
NM1 REFERRING 1 S 2420F 2

PROVIDER NAME

Name or Initial
NM107 Referring Provider Name Suffix AN 1 - 10 S


Name
RF
ZZ
REF REFERRING 20 S 2420F

PROVIDER
SECONDARY
IDENTIFICATION
Identifier

Qualifier
Qualifier
PR
2
PI, XV
9F, G1
NM1 AMBULANCE PICK UP 1 S 2420G 1

LOCATION
Name
Name
N3 AMBULANCE PICK UP 1 R 2420G

LOCATION ADDRESS
N301 Ambulance Pick Up Address AN 1 - 55 R

Line
N302 Ambulance Pick Up Address AN 1 - 55 S
Line
N4 AMBULANCE PICK UP 1 R 2420G

LOCATION
CITY/STATE/ZIP
N401 Ambulance Pick Up City Name AN 2 - 30 R
N402 Ambulance Pick Up State or ID 2-2 S

Province Code
N403 Ambulance Pick Up Postal ID 3 - 15 S
Zone ZIP Code
N404 Ambulance Pick Up Country ID 2-3 S
Code
NM1 AMBULANCE DROP 1 S 2420H 1

OFF LOCATION
NM103 Ambulance Drop Off Location AN 1 - 60 S
Name
N3 AMBULANCE DROP 1 R 2420H

OFF LOCATION
ADDRESS
N301 Ambulance Drop Off Address AN 1 - 55 R
Line
N302 Ambulance Drop Off Address AN 1 - 55 S
Line
N4 AMBULANCE DROP 1 R 2420H

OFF LOCATION
CITY/STATE/ZIP
N401 Ambulance Drop Off City Name AN 2 - 30 R
N402 Ambulance Drop Off State or ID 2-2 S

Province Code
N403 Ambulance Drop Off Postal ID 3 - 15 S
Zone ZIP Code
N404 Ambulance Drop Off Country ID 2-3 S
Code

INFORMATION
SVD01 Other Payer Primary Identifier AN 2 - 80 R
SVD02 Service Line Paid Amount R 1 - 18 R

S9(7)V99
HC, IV, ZZ SVD03-1 Product or Service ID Qualifier ID 2-2 R
SVD03-2 Procedure Code AN 1 - 48 R

SVD03-7 Procedure Code Description AN 1 - 80 S
SVD03-8 Product/Service ID AN 1 - 48 N/U
SVD04 Product or Service ID AN 1 - 48 N/U
SVD05 Paid Service Unit Count R 1 - 15 R
9(7)V999
SVD06 Bundled or Unbundled Line N0 1-6 S
Number


CAS03 Adjustment Amount S9(7)V99 R 1 - 18 R





DTP LINE CHECK OR 1 R 2430

REMITTANCE DATE
Qualifier

LIABILITY
Amount S9(7)V99
LQ FORM IDENTIFICATION 1 S 2440 >1

CODE
AS, UT LQ01 Code List Qualifier Code ID 1-3 R

LQ02 Form Identifier AN 1 - 30 R
FRM SUPPORTING 99 S 2440

DOCUMENTATION
FRM01 Question Number/Letter AN 1 - 20 R
N, W, Y FRM02 Question Response ID 1-1 S
FRM03 Question Response AN 1 - 50 S
CCYYMMDD FRM04 Question Response DT 8-8 S
FRM05 Question Response 9(3)V9 R 1-6 S
TRAILER
Number

TRAILER
Included

CONTROL TRAILER
Groups
al Claim
Values
00, 03
00, 01
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
YYMMDD
HHMM
501
0, 1
P, T
CCYYMMDD
HHMM
X
005010X222
837
19
00, 18
CCYYMMDD
HHMM, HHMMSS,
HHMMSSD, HHMMSSDD
31, CH, RP
41
1, 2
46
IC
EM, FX. TE
EM, EX, FX, TE
EM, EX, FX, TE
40
2
46
20
1
BI
PXC
85
85
1, 2
XX
EI, SY
0B, 1G
IC
EM, FX, TE
EM, EX, FX, TE
EM, EX, FX, TE
87
1, 2
PE
2
PI, XV
2U, FY, NF
EI
22
0, 1
A, B, C, D, E, F, G, H, P, S, T,
U
18
12, 13, 14, 15, 16, 41, 42, 43,

47
11, 12, 13, 14, 15, 16, 17, AM,

BL, CH, CI, DS, FI, HM, LM,
MA, MB, MC, OF, TV, VA, WC,
ZZ
D8
CCYYMMDD
IL
1, 2
II, MI
D8
CCYYMMDD
F, M, U
SY
Y4
IC
TE
EX
PR
2
PI, XV
2U, EI, FY, NF
G2, LU
23
0
01, 19, 20, 21, 39, 40, 53, G8
D8
CCYYMMDD
1
QC
1
D8
CCYYMMDD
F, M, U
Y4
IC
TE
EX
B
N, Y
A, B, C
N, W, Y
I, Y
P
AA, EM, OA
AA, EM, OA
02, 03, 05, 09
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
15
431
D8
CCYYMMDD
454
D8
CCYYMMDD
304
D8
CCYYMMDD
453
D8
CCYYMMDD
439
D8,
CCYYMMDD
484
D8
CCYYMMDD
455
D8
CCYYMMDD
471
D8
CCYYMMDD
314, 360, 361

D8, RD8
CCYYMMDD
297
D8
CCYYMMDD
296
D8
CCYYMMDD
435
D8
CCYYMMDD
96
D8
CCYYMMDD
090, 091
D8
CCYYMMDD
444
D8
CCYYMMDD
50
D8
CCYYMMDD
03, 04, 05, 06, 07, 08, 09, 10,

11, 13, 15, 21, A3, A4, AM,
AS, B2, B3, B4, BR, BS, BT,
CB, CK, CT, D2, DA, DB, DG,
DJ, DS, EB, HC, HR, I5, IR,
LA, M1, MT, NN, OB, OC, OD,
OE, OX, OZ, P4, P5, PE, PN,
PO, PQ, PY, PZ, RB, RR, RT,
RX, SG, V5, XP
AC
01, 02, 03, 04, 05, 06, 09

F5
4N
1, 2, 3, 4, 5, 6, 7
F5
Y,N
EW
9F
G1
F8
X4
9A
9C
LX
D9
EA
P4
1J
ADD, CER, DCP, DGN, TPO
LB
A, B, C, D, E
DH
A, C, D, E, F, G, M
7
N, Y
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
E1, E2, E3
N, Y
L1, L2, L3, L4, L5

L1, L2, L3, L4, L5
L1, L2, L3, L4, L5
L1, L2, L3, L4, L5
L1, L2, L3, L4, L5
75
Y
IH
ZZ
N, Y
AV, NU, S2, ST

AV, NU, S2, ST
AV, NU, S2, ST
ABK, BK
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ABF, BF
BP
BO
BG
BG
BG
BG
BG
BG
BG
BG
BG
BG
BG
BG
00, 01, 02, 03, 04, 05, 07, 08,

09, 10 ,11, 12, 13, 14
T1, T2, T3, T4, T5, T6

1, 2, 3, 4, 5
1, 2, 3, 4, 5, 6
DN, P3
1
XX
0B, 1G, G2
82
1, 2
XX
PE
PXC
0B, 1G, G2, LU
77
2
XX
0B, G2, LU
IC
TE
EX
DQ
1
XX
0B, 1G, G2, LU

PW
2
45
2
A, B, C, D, E, F, G,
H, P, S, T, U
01, 18, 19, 20, 21, 39, 40, 53,
G8
12, 13, 14, 15, 16,

41, 42, 43, 47
11, 12, 13, 14, 15, 16, 17, AM,

BL, CH, CI, DS, FI ,HM, LM,
MA, MB, MC, OF, TV, VA,
WC, ZZ
CO, CR, OA, PI, PR
A8
EAF
N, W, Y
I, Y
IL
1, 2
II, MI
SY
PR
2
PI, XV
573
D8
CCYYMMDD
2U, EI, FY, NF

G1
9F
T4
Y
F8
DN, P3
1
0B, 1G, G2
82
1, 2
0B, 1G, G2, LU
77
2
0B, G2, LU
DQ
1
0B, 1G, G2, LU
85
1, 2
G2, LU
ER, HC, IV, WK
MJ, UN
refer to CMS documentation
Y
Y
HC
DA
1, 4, 6
03, 04, 05, 06, 07,

08, 09, 10, 11, 13,
15, 21, A3, A4, AM,
AS, B2, B3, B4,
BR, BS, BT, CB,
CK, CT, D2, DA, DB,
DG, DJ, DS, EB,
HC, HR, I5, IR, LA,
M1, MT, NN, OB,
OC, OD, OE, OX,
OZ, P4, P5, PE, PN,
PO, PQ, PY, PZ,
RB, RR, RT, RX,
SG, V5, XP
AC
CT
AB, AD, AF, AG, NS

LB
A, B, C, D, E
DH
I,R,S
MO
7
N, Y
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
01, 04, 05, 06, 07, 08, 09, 12
70
N, Y
65
9
N, Y
38, ZV
38, ZV
471
D8
CCYYMMDD
472
D8, RD8
CYYMMDD, CCYYMMDDCCY
YMMDD
607
D8
CCYYMMDD
463
D8
CCYYMMDD
461
D8
CCYYMMDD
304
D8
CCYYMMDD
738, 739
D8
CCYYMMDD
11
D8
CCYYMMDD
455
D8
CCYYMMDD
454
D8
CCYYMMDD
PT
FL
OG, TR
HT, R1, R2, R3, R4
01, 02, 03, 04, 05, 06, 09

9B
9D
G1
2U
6R
EW
X4
F4
BT
9F
2U
F4
ADD, DCP
TPO
00, 01, 02, 03, 04, 05, 06, 07,

08, 09, 10, 11, 12, 13, 14
ER, HC, IV, WK
MJ, UN
T1, T2, T3, T4, T5, T6

1, 2, 3, 4, 5
1, 2, 3, 4, 5, 6
N4
F2, GR, ME, ML, UN
VY, XZ
82
1,2
XX
PE
PXC
OB, 1G, G2, LU
2U
QB
1, 2
XX
OB, 1G, G2
2U
77
2
XX
G2, LU
2U
DQ
1
XX
OB, 1G, G2, LU
2U
DK
1
XX
OB, 1G, G2
2U
1C
EM, FX, TE
EM, EX, FX, TE
EM, EX, FX, TE
DN, P3
1
XX
OB, 1G, G2
2U
PW
2
45
2
ER, HC, IV, WK
CO, CR, OA, PI, PR
573
D8
CCYYMMDD
EAF
AS, UT
N, W, Y
CCYYMMDD
Batch Header Record
NCPDP Data Dictionary Batch 1.1 Batch 1.2

Name Field Number NCPDP Definition of Field Format Format
Segment Identification 111-AM Identifies the segment in the request X(02) SAME
record.
Transmission Type 880-K6 Defines the Type of transmission X(01) SAME
being sent.
*Part of External Code List

under D.0
880-K1 Identification number assigned to the X(24) SAME
sender of the data by the processor of
the data.
806-5C Number assigned by processor. 9(07) SAME
Matches Trailer record.
Creation Date 880-K2 Date the file was created. 9(08) SAME
Creation Time 880-K3 Time the file was created. 9(04) SAME
File Type 702-MC Identifies that the data to be applied is X(01) SAME
a test or production file.

under D.0
102-A2 Code identifying the release syntax X(02) SAME
and corresponding Data Dictionary.
Receiver ID 880-K7 Identification number assigned to the X(24) SAME

receiver of the data by the processor
of the data.
Transmission Header Segment
NCPDP Data Dictionary Version 5.1 Version D.0

BIN Number 101-A1 Card Issuer or Bank ID used for 9(06) SAME
network routing.
Version/Release Number 102-A2 Code identifying the release syntax X(02) SAME
and corresponding Data Dictionary.

under D.0
Transaction Code 103-A3 Identifies type of transaction X(02) SAME

under D.0
Processor Control Number 104-A4 Number assigned by processor. X(10) SAME
Transaction Count 109-A9 Number of transactions in the X(01) SAME

transmission.

under D.0
Service Provider ID 202-B2 Code qualifying the Service Provider X(02) SAME
Qualifier ID

under D.0
Service Provider ID 201-B1 ID assigned to pharmacy or provider. X(15) SAME
Date of Service 401-D1 Identifies date the prescription was 9(08) SAME
filled or professional service rendered
or subsequent payer began coverage
Software Vendor/ 110-AK ID assigned by the switch or processor X(10) SAME
Certification ID to identify the software source.
Transmission Patient Segment

record.

under D.0
Patient ID Qualifier 331-CX Code qualifying the Patient ID X(02) SAME

under D.0
Patient ID 332-CY ID assigned to the patient. X(20) SAME

Date of Birth 304-C4 Date of birth of patient. 9(08) SAME
Patient Gender Code 305-C5 Code indicating the gender of the 9(01) SAME
patient.

under D.0
Patient First Name 310-CA Patient's first name. X(12) SAME
Patient Last Name 311-CB Patient's last name. X(15) SAME
Patient Street Address 322-CM Free form text for address information. X(30) SAME
Patient City Address 323-CN Free form text for city name. X(20) SAME
Patient State/ 324-CO Standard state/province code as X(02) SAME
defined by appropriate government
Province Address
agency.

under D.0
Patient ZIP/ 325-CP Code defining international postal X(15) SAME

zone excluding punctuation and blanks
Postal Zone
(zip code for US).
Patient Phone Number 326-CQ Patient's 10-digit phone number 9(10) SAME
Patient Location 307-C7 Code identifying the location of the 9(02) SAME
patient when receiving pharmacy
services
307-C7 Code identifying the location of the 9(02) SAME
patient when receiving pharmacy
*Field name changed to
services
Place of Service as of
version B.0
**Part of External Code List

under D.0
Employer ID 333-CZ ID assigned to the employer. X(15) SAME

Smoker/ 334-1C Code indicating whether the patient is X(01) Not Used in
a smoker or not. Billing Trans.
Non-Smoker Code

under D.0
Pregnancy Indicator 335-2C Code indicating whether the patient is X(01) SAME
pregnant or not.

under D.0
Patient E-mail Address 350-HN The E-Mail address of the patient N/A X(80)
(member).
Patient Residence 384-4X Code identifying the patient’s place of N/A 9(02)
residence.

under D.0
Transaction Pharmacy Segment
*This segment is not currently edited beyond the Implementation Guide level in VMS and is not used to populate any

record.
Provider ID Qualifier 465-EY Code qualifying the Provider ID X(02) SAME

under D.0
Provider ID 444-E9 ID assigned to the person responsible X(15) SAME
for the dispensing of the prescription.
Transaction Prescriber Segment

record.
Prescriber ID Qualifier 466-EZ Code qualifying the Prescriber ID X(02) SAME

under D.0
Prescriber ID 411-DB ID assigned to the prescriber. X(15) SAME

Prescriber Location Code 467-1E Location address code assigned to the X(03) Deleted from
prescriber as identified in the National Telecom. Std.
Provider System (NPS).
Prescriber Last Name 427-DR Individual last name. X(15) SAME
Prescriber Phone Number 498-PM Prescribers 10-digit phone number 9(10) SAME
Primary Care Provider ID 468-2E Code qualifying the Primary Care X(02) SAME
Qualifier Provider ID

under D.0
Primary Care Provider ID 421-DL Assigned to the primary care provider. X(15) SAME
Primary Care Provider 469-H5 Location address code assigned to the X(03) Deleted from
Location Code provider as identified in the National Telecom. Std.
Provider System (NPS).
Primary Care Provider Last 470-4E Providers last name. X(15) SAME
Name
Prescriber First Name 364-2J Individual first name N/A X(12)
*This replaces the

Ordering Physician First
Name that is currently
defined as a subset of the
Prior Authorization
Supporting Documentation
(498-PP) on the Prior
Authorization segment,
defined for use by Medicare
under 5.1
Prescriber Street Address 365-2K Free Form text for prescriber address N/A X(30)
information.
*This replaces the

Ordering Physician
Address that is currently
defined as a subset of the
Prior Authorization
Supporting Documentation
(498-PP) on the Prior
Authorization segment,
defined for use by Medicare
under 5.1
Prescriber City Address 366-2M Free form text for prescriber city name. N/A X(20)
*This replaces the

Ordering Physician City
that is currently defined as
a subset of the Prior
Authorization Supporting
Documentation (498-PP)
on the Prior Authorization
segment, defined for use by
Medicare under 5.1
Prescriber State/Province 367-2N Standard state/province code as N/A X(02)

Address defined by appropriate government
agency.
367-2N Standard state/province code as N/A X(02)
agency.
*This replaces the

Ordering Physician State
that is currently defined as
Medicare under 5.1
Prescriber Zip/Postal Zone 368-2P Code defining international postal N/A X(15)
(zip code for US).
*This replaces the

Ordering Physician Zip that
is currently defined as a
subset of the Prior
Medicare under 5.1
Transmission Insurance Segment

record.
Cardholder ID 302-C2 Insurance ID assigned to the X(20) SAME
cardholder.
Cardholder First Name 312-CC Individual first name. X(12) SAME
Cardholder Last Name 313-CD Individual last name. X(15) SAME
Home Plan 314-CE Blue Cross/Blue Shield plan ID X(03) SAME
Plan ID 524-FO Assigned by the processor to identify X(08) SAME
coverage criteria used to adjudicate a
claim.
Eligibility Clarification Code 309-C9 Code indicating that the pharmacy is 9(01) SAME
clarifying eligibility based on receiving
a denial.

under D.0
Facility ID 336-8C ID assigned to the patients clinic/host X(10)
party.
No
longer
used in
this
segment
*Moved to new
Facility
Segment in D.0
Group ID 301-C1 ID assigned to the cardholders or X(15) SAME

employers group.
*This
functionally will
be addressed by
the new
Medicaid
Indicator (360-
2B) in the
Insurance
Segment under
D.0
Person Code 303-C3 Code assigned to a specific person X(03) SAME

within a family.
Patient Relationship Code 306-C6 Code identifying relationship of patient 9(01) SAME
to cardholder.

under D.0
Other Payer BIN Number 990-MG Card Issuer or Bank ID used for N/A Not Used in
network routing. Billing Trans.
Other Payer Processor 991-MH A number that uniquely identifies the N/A Not Used in
Control Number secondary, tertiary, etc. payer to the Billing Trans.
processor.
Other Payer Cardholder ID 356-NU Cardholder ID for this member N/A Not Used in
Billing Trans.
that is associated with the
Payer noted.
Other Payer Group ID 992-MJ ID assigned to the cardholder group or N/A Not Used in
employer group by the secondary, Billing Trans.
tertiary, etc. payer.
Medigap ID 359-2A Patient’s ID assigned by the N/A X(20)
359-2A N/A X(20)
Medigap Insurer
*This field will

address
functionality
that is currently
addressed by
the Alternate ID
(330-CW) in the
Claim Segment
under 5.1
Medicaid Indicator 360-2B Two character State Postal Code N/A X(02)
indicating the state where Medicaid
coverage exists.
*This field will

address
functionality
that is currently
addressed by
the Group ID
(301-C1) in the
Insurance
Segment under
5.1

under D.0
361-2D Code indicating whether the provider N/A X(01)
accepts assignment.

under D.0
997-G2 Indicates that the patient resides in a N/A X(01)
facility that qualifies for the CMS Part
D benefit.
under D.0
115-N5 A unique member identification N/A X(20)
number assigned by the Medicaid
Agency.
Medicaid Agency Number 116-N6 Number assigned by processor to
identify the individual Medicaid Agency
N/A
Not used
or representative. in Billing
Trans.
Transaction Other COB Segment

record.
Coordination of Benefits/ 337-4C Count of other payment occurrences. 9(02) SAME
Other Payments Count
Other Payer Coverage 338-5C Code identifying the type of Other X(02) SAME
Type Payer ID.

under D.0
Other Payer ID Qualifier 339-6C Code qualifying the Other Payer ID. X(02) SAME

under D.0
Other Payer ID 340-7C ID assigned to the payer. X(10) SAME
Other Payer Date 443-E8 Payment or denial date of the claim 9(08) SAME
submitted to the other payer.
Internal Control Number 993-A7 Number assigned by the processor to N/A X(30)
identify an adjudicated claim when
supplied in payer-to-payer
*This field will coordination of benefits only.
address
functionality
that is currently
addressed by
the Alternate ID
(330-CW) in the
Claim Segment
under 5.1
Other Payer Amount Paid 341-HB Count of the Other Payer Amount Paid 9(02) SAME
Count occurrences.
Other Payer Amount Paid 342-HC Code qualifying the Other Payer X(02) SAME
Qualifier Amount Paid.

under D.0
Other Payer Amount Paid 431-DV Amount of any payment known by the s9(6)v99 SAME
pharmacy from other sources
(including coupons).
Other Payer Reject Count 471-5E Count of the Other Payer Reject Code 9(02) SAME
occurrences.
Other Payer Reject Code 472-6E The error encountered by the previous X(03) SAME
Other Payer.
Other Payer-Patient 353-NR The patient’s cost share from a N/A s9(8)v99
Responsibility Amount previous payer.
Count
Other Payer-Patient 351-NP Code qualifying the “Other Payer- N/A X(02)
Responsibility Amount Patient Responsibility Amount (352-
Qualifier NQ)”.
Other Payer-Patient 352-NQ The patient’s cost share from a N/A s9(8)v99
Responsibility Amount previous payer
Benefit Stage Count 392-MU Count of ‘Benefit Stage Amount’ (394- N/A 9(02)
MW) occurrences.
Benefit Stage Qualifier 393-MV Code qualifying the ’Benefit Stage N/A X(02)
Amount’ (394-MW).
Benefit Stage Amount 394-MW The amount of claim allocated to the N/A s9(6)v99
Medicare stage identified by the
‘Benefit Stage Qualifier’ (393-MV).
Transaction Workers Comp Segment


record.
Date of Injury 434-DY Date on which the injury occurred. 9(08) SAME
Employer Name 315-CF Complete name of employer. X(30) SAME
Employer Street Address 316-CG Free-form text for address information. X(30) SAME
Employer City Address 317-CH Free-form text for city name. X(20) SAME
Employer State/Province 318-CI Standard state/province code as X(02) SAME
agency.
318-CI Standard state/province code as X(02) SAME
agency.

under D.0
Employer ZIP/Postal Code 319-CJ Code defining international postal X(15) SAME
(zip code for US).
Employer Phone Number 320-CK Ten-digit phone number of employer. 9(10) SAME
Employer Contact Name 321-CL Employer primary contact. X(30) SAME

Carrier ID 327-CR Carrier code assigned in Worker's X(10) SAME
Compensation program
Claim/Reference ID 435-DZ Identifies the claim number assigned X(30) SAME
by the Worker's Compensation
program.
Billing Entity Type Indicator 117-TR A code that identifies the entity N/A 9(02)
submitting the billing transaction.

under D.0
118-TS Code qualifying the ‘Pay To ID’ N/A X(02)

(119-TT).
under D.0
119-TT Identifying number of the entity to N/A X(15)
receive payment for claim.
120-TU Name of the entity to receive payment N/A X(20)
for claim.
Pay To Street Address 121-TV Street address of the entity to receive N/A X(30)
payment for claim.
Pay To City Address 122-TW City of the entity to receive payment N/A X(20)
for claim.
Pay To State/Province 123-TX Standard state/province code as N/A X(02)
agency.
Pay To Zip/Postal Zone 124-TY Code defining international postal N/A X(15)
(zip code for US).
Generic Equivalent Product 125-TZ Code qualifying the ‘Generic N/A X(02)
ID Qualifier Equivalent Product ID’ (126-UA).
under D.0
Generic Equivalent Product 126-UA Identifies the generic equivalent of the N/A X(19)
ID brand product dispensed.
Transaction Claim Segment
NCPDP Data Dictionary Field Number NCPDP Definition of Field Version 5.1 Version D.0
Name Format Format
record.
Prescription/Service 455-EM Indicates the type of billing submitted. X(01) SAME
Reference Number
Qualifier

under D.0
402-D2 Reference number assigned by the 9(07) 9(12)
provider for the dispensed
drug/product and/or service provided.
436-E1 Code qualifying the Product/Service ID X(02) SAME

under D.0
Product/Service ID 407-D7 ID of the product dispensed or service X(19) SAME
provided.
Associated Prescription/ 456-EN Related Prescription/Service 9(07) 9(12)

Service Reference Number Reference Number to which the
service is associated.
Associated Prescription/ 457-EP Date of the Associated 9(08) SAME
Service Date Prescription/Service Reference
Number.
Procedure Modifier Code 458-SE Count of the Procedure Modifier Code 9(02) SAME
Count
Procedure Modifier Code 459-ER Identifies special circumstances X(02) SAME

related to the performance of the
service.
Quantity Dispensed 442-E7 Quantity dispensed expressed in 9(7)v999 SAME
metric decimal units.
Fill Number 403-D3 The code indicating whether the 9(02) SAME
prescription is an original or a refill.

under D.0
405-D5 Estimated number of days that the 9(03) SAME
prescription will last.
406-D6 Code indicating whether or not the 9(01) SAME
prescription is a compound.

under D.0
408-D8 Code indicating whether or not the X(01) SAME

prescriber's instructions regarding
generic substitution were followed.

under D.0
Date Prescription Written 414-DE Date prescription was written. 9(08) SAME
Number of Refills 415-DF Number of refills authorized by the 9(02) SAME

Authorized prescriber.
Prescription Origin Code 419-DJ Code indicating the origin of the 9(01) SAME
prescription.

under D.0
Submission Clarification 354-NX Count of the ‘Submission Clarification N/A 9(02)

Code Count Code’ (420-DK) occurrences.
Submission Clarification 420-DK Code indicating that the pharmacist is 9(02) SAME
Code clarifying the submission.
*New value 11
addresses by
the functionality
that was
addressed by
the Certificate
on File Indicator
that is currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
**New value 12
will be utilized if
VMS’ NCPDP
processing is
expanded to
include Durable
Medical
Equipment.
***Part of External Code

List under D.0
Quantity Prescribed 460-ET Amount expressed in metric decimal 9(7)v999 Not Used in
units. Billing Trans.
Other Coverage Code 308-C8 Code indicating whether or not the 9(02) SAME
patient has other insurance coverage.

under D.0
Unit Dose Indicator 429-DT Code indicating the type of unit dose 9(01) SAME
dispensing.
*Field name
changed to
Special
Packaging
Indicator as of
version C.4

under D.0
under D.0
Originally Prescribed 453-EJ Code qualifying the value in Originally X(02) SAME
Product/Service ID Qualifier Prescribed Product/Service Code.

under D.0
445-EA Code of the initially prescribed product X(19) SAME
or service.
446-EB Product initially prescribed amount 9(7)v999 SAME
expressed in metric decimal units.
Alternate ID 330-CW Person identifier to be used for X(20) Not Used in

controlled product reporting. ID may Billing Trans.
be that of person picking up the
*The current prescription.
inbound
functionally will
be addressed by
the new
Medigap ID
(359-2A) in the
Insurance
Segment under
D.0
**The current
outbound
functionally will
be addressed by
the new Internal
Control Number
(993-A7) in the
COB/Other
Payments
Segment under
D.0
Scheduled Prescription ID 454-EK The serial number of the prescription X(12) Not Used in
Number blank/form. Billing Trans.
Unit of Measure 600-28 NCPDP standard product billing codes X(02) SAME

under D.0
418-DI Coding indicating the type of service 9(02) SAME
the provider rendered.

under D.0
Prior Authorization Type 461-EU Code clarifying the Prior Authorization 9(02) SAME
Code Number

under D.0
Prior Authorization Number 462-EV Number submitted by the provider to 9(11) SAME
Submitted identify the prior authorization.
Intermediary Authorization 463-EW Value indicating that authorization 9(02) SAME
Type ID occurred for intermediary processing.

under D.0
464-EX Value indicating intermediary X(11) SAME

authorization occurred.
Dispensing Status 343-HD Code indicating the quantity is a partial X(01) SAME
fill or the completion of a partial fill.

under D.0
Quantity Intended To Be 344-HF Metric decimal quantity of medication 9(7)v999 SAME

Dispensed that would be dispensed on original
filling if inventory were available.
Days Supply Intended To 345-HG Days supply for metric decimal 9(03) SAME
Be Dispensed quantity that would be dispensed on
original fill if inventory were available.
Delay Reason Code 357-NV Code to specify the reason that N/A 9(02)
submission of the transactions has
been delayed.

under D.0
Transaction Reference 880-K5 A reference number assigned by the N/A Not Used in
Number provider to each of the data records in Billing Trans.
the batch or real-time transactions.
The purpose of this number is to
facilitate the process of matching the
transaction response to the
transaction. The transaction reference
number assigned should be returned
in the response.
Patient assignment 391-MT Code to indicate a patient’s choice on N/A X(01)

Indicator (Direct Member assignment of benefits.
Reimbursement Indicator)

under D.0
995-E2 This is an override to the “default” N/A X(11)
route referenced for the product. For a
multi-ingredient compound, it is the
route of the complete compound
mixture.
*This replaces
Compound
Route of
Administration
(452-EH) on the
Compound
Segment
Compound Type 996-G1 Clarifies the type of compound N/A X(02)

under D.0
Medicaid Subrogation 114-N4 Claim number assigned by the N/A Not Used in
Internal Control Billing Trans.
Medicaid Agency.
Number/Transaction
Pharmacy Service Type 147-U7 The type of service being performed N/A 9(02)
by a pharmacy when different
contractual terms exist between a
payer and the pharmacy, or when
*Part of External Code List benefits are based upon the type of
under D.0 service performed.
by a pharmacy when different
contractual terms exist between a
payer and the pharmacy, or when
*Part of External Code List benefits are based upon the type of
under D.0 service performed.
Transaction DUR-PPS Segment


record.
DUR/PPS Code Counter 473-7E Counter number for each DUR/PPS 9(02) SAME
set/logical grouping.
Reason For Service Code 439-E4 Code identifying the type of utilization X(02) SAME
conflict detected or the reason for the
pharmacist's professional service.

under D.0
440-E5 Code identifying pharmacist X(02) SAME
intervention when a conflict code has
been identified or service has been
*Part of External Code List rendered.
under D.0
441-E6 Action taken by pharmacist in X(02) SAME
response to a conflict or the result of a
pharmacist's professional service.
under D.0
474-8E Code indicating the level of effort as 9(02) SAME
determined by the complexity of
decision making or resources utilized
*Part of External Code List by a pharmacist to perform a
under D.0 professional service.
DUR Co-agent ID Qualifier 476-H6 Code qualifying the value in DUR Co- X(02) SAME
agent ID.

under D.0
DUR Co-agent ID 458-SE Identifies the co-existing agent X(19) SAME
contributing to the DUR event.
Transaction Coupon Segment

record.
Coupon Type 485-KE Code indicating the type of coupon X(02) SAME
being used.

under D.0
486-ME Unique serial number assigned to the X(15) SAME
prescription coupons.
487-NE Value of the coupon. s9(6)v99 SAME
Transaction Compound Segment

record.
Compound Dosage Form 450-EF Dosage form of the complete X(02) SAME
Description Code compound mixture.

under D.0
Compound Dispensing Unit 451-EG NCPDP standard product billing 9(01) SAME
Form Indicator codes.

under D.0
452-EH Code for the route of administration of 9(02) N/A
the complete compound mixture.
*This is
replaced by
Route of
Administration
(995-E2) on the
Claim Segment
Compound Ingredient 447-EC Count of compound product IDs in the 9(02) SAME
Component Count compound mixture.
Compound Product ID 488-RE Code qualifying the type of product X(02) SAME
Qualifier dispensed.

under D.0
489-TE Product identification of an ingredient X(19) SAME
used in the compound.
448-ED Amount expressed in metric decimal 9(7)v999 SAME

units of the compound included in the
compound mixture.
Compound Ingredient Drug 449-EE Ingredient cost of the metric decimal s9(6)v99 SAME
Cost quantity of the product included in the
compound mixture indicated in
Compound Ingredient Quantity.
Compound Ingredient Basis 490-UE Code indicating the method by which X(02) SAME
of Cost Determination the cost of an ingredient used in a
compound was calculated.

under D.0
Compound Ingredient 362-2G Code indicating the number of N/A 9(2)
Modifier Code Count
Compound Ingredient Modifier
*This replaces Code (363-2H).
the Ingredient
Number that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Compound Ingredient 363-2H Identifies special circumstances N/A X(02)

Modifier Code related to the dispensing/payment of
the product as identified in the
Compound Product ID (498-
363-2H N/A X(02)
*This replaces TE).
the Ingredient
Modifier that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Transaction Pricing Segment

record.
Ingredient Cost Submitted 409-D9 Submitted product component cost of s9(6)v99 SAME
the dispensed prescription. Included in
the Gross Amount Due.
Dispensing Fee Submitted 412-DC Dispensing fee submitted by s9(6)v99 SAME

pharmacy. Included in Gross Amount
Due.
Professional Service Fee 477-BE Amount submitted by the provider for s9(6)v99 Not Used in
Submitted professional services rendered. Billing Trans.
Included in Gross Amount Due.
Patient Paid Amount 433-DX Amount the pharmacy received from s9(6)v99 SAME
Submitted the patient for the prescription
dispensed.
Incentive Amount 438-E3 Amount represents the contractually s9(6)v99 SAME
Submitted agreed upon incentive fee paid for
specific services rendered. Included in
Gross Amount Due.
Incentive Amount 438-E3 Amount represents the contractually s9(6)v99 SAME
Submitted agreed upon incentive fee paid for
specific services rendered. Included in
Gross Amount Due.
Other Amount Claimed 478-H7 Count of Other Amount Claimed 9(02) SAME
Submitted Count Submitted occurrences.
Other Amount Claimed 479-H8 Code identifying the additional X(02) SAME
Submitted Qualifier incurred cost claimed in Other Amount
Claimed Submitted.

under D.0
Other Amount Claimed 480-H9 Amount representing the additional s9(6)v99 SAME
Submitted incurred costs for a dispensed
prescription or service. Included in
Gross Amount Due.
Flat Sales Tax Amount 481-HA Flat sales tax amount submitted for s9(6)v99 SAME
Submitted prescription. Included in Gross Amount
Due
Percentage Sales Tax 482-GE Percentage sales tax submitted. s9(6)v99 SAME
Amount Submitted Included in Gross Amount Due.
Percentage Sales Tax Rate 483-HE Percentage sales tax rate used to s9(3)v9(4) SAME
Submitted calculate Percentage Sales Tax
Amount Submitted.
Percentage Sales Tax 484-JE Code indicating the percentage sales X(02) SAME
Basis Submitted tax paid basis.
Usual and Customary 426-DQ Amount charged cash customers for s9(6)v99 SAME
Charge the prescription exclusive of sales tax
or other amounts claimed.
Gross Amount Due 430-DU Total price claimed from all sources. s9(6)v99 SAME
Basis of Cost 423-DN Code indicating the method by which X(02) SAME
Determination Ingredient Cost Submitted was
calculated.

under D.0
Medicaid Paid Amount 113-N3 N/A Not Used in
Billing Trans.
Transaction Prior Authorization Segment
*This segment is no longer valid for use in the Billing Transaction

Segment Identification 111-AM Identifies the segment in the request X(02) N/A
record.
Request Type 498-PA Code identifying type of prior X(01) N/A
authorization request.
*This
functionality is
addressed by
the Request
Status (373-2U)
in the new
Additional
Documentation
Segment under
D.0

under D.0
498-PB The beginning date of need. 9(08) N/A
*This
functionality is
addressed by
the Request
Period Begin
Date (374-2V) in
the new
Additional
Documentation
Segment under
D.0
Request Period Date-End 498-PC Ending date for a prior authorization 9(08) N/A
request.
498-PC Ending date for a prior authorization 9(08) N/A
request.
*This
functionality is
addressed by
the Request
Period Begin
Date (374-2V)
and Length of
Need (370-2R) in
the new
Additional
Documentation
Segment under
D.0
Basis of Request 498-PD Code describing the reason for prior X(02) N/A
authorization request.
*This
functionality is
addressed by
the addition of
the new
Additional
Documentation,
Facility, and
Narrative
Segments under
D.0

under D.0
498-PE First name of the patient’s authorized X(12) N/A
representative.
498-PE First name of the patient’s authorized X(12) N/A
representative.
*This
functionality is
addressed by
the Facility
Name (385-3Q)
in the new
Facility
Segment under
D.0
Authorized Representative 498-PF Last name of the patient’s authorized X(15) N/A
Last Name representative.
*This
functionality is
addressed by
the Facility
Name (385-3Q)
in the new
Facility
Segment under
D.0
Authorized Representative 498-PG Free-form text for address information. X(30) N/A
Street Address
*This
functionality is
addressed by
the Facility
Street Address
(385-3U) in the
new Facility
Segment under
D.0
Authorized Representative 498-PH Free-form text for city name. X(20) N/A
City Address
498-PH Free-form text for city name. X(20) N/A
*This
functionality is
addressed by
the Facility City
Address (385-
5J) in the new
Facility
Segment under
D.0
Authorized Representative 498-PJ Standard state/province code as X(02) N/A

State/Province Address defined by appropriate government
agency.
*This
functionality is
addressed by
the Facility
State/Province
Address (387-
3V) in the new
Facility
Segment under
D.0
Authorized Representative 498-PK Code defining international postal X(15) N/A

ZIP/Postal Zone zone excluding punctuation and blanks
(zip code for US).
*This
functionality is
addressed by
the Facility
Zip/Postal Zone
(389-6D) in the
new Facility
Segment under
D.0
Prior Authorization 498-PY Unique number identifying the prior 9(11) N/A
Number-Assigned authorization assigned by the
processor.
Authorization Number 503-F3 Number assigned by the processor to X(20) N/A
identify an authorized transaction.
Prior Authorization 498-PP This space is being used to store CMN X(500) N/A
Supporting Documentation information, Narrative information,
Facility information, and Compound
Ingredient Modifiers that are not
available elsewhere in the NCPDP
format. Details on the fields are listed
below.
Authorization Information N/A Indicates that the Supporting X(03) N/A

Qualifier Documentation that follows is
Medicare required CMN information.
*This * This field represents

functionality is a subset of the Prior
addressed by Authorization
the addition of Supporting
the new Documentation (498-
Additional PP), defined for use by
Documentation, Medicare under 5.1
Facility, and
Narrative
Segments under
D.0
Form Identifier N/A CMN form being submitted. X(06) N/A

the Additional Supporting
Documentation Documentation (498-
Type ID (369-2Q) PP), defined for use by
in the new Medicare under 5.1
Additional
Documentation
Segment under
D.0
Ordering Physician First N/A First name of the Prescriber. Note that X(12) N/A
Name the last name is already stored on the
Prescriber segment.

the new Supporting
Prescriber First Documentation (498-
Name (364-2J) PP), defined for use by
in the Prescriber Medicare under 5.1
Segment under
D.0
Ordering Physician N/A Address of the prescribing physician. X(30) N/A

Address

the new Supporting
Prescriber Documentation (498-
Street Address PP), defined for use by
(365-2K) in the Medicare under 5.1
Prescriber
Segment under
D.0
Ordering Physician City N/A City of the prescribing physician. X(20) N/A
*This functionality is * This field represents a subset of the

addressed by the new Prior Authorization Supporting
Prescriber City Address Documentation (498-PP), defined for
(366-2M) in the Prescriber use by Medicare under 5.1
Segment under D.0
Ordering Physician State N/A Standard state/province code as X(02) N/A

agency.
the new Supporting
State/Province PP), defined for use by
Address (367- Medicare under 5.1
2N) in the
Prescriber
Segment under
D.0
Ordering Physician ZIP N/A Code defining international postal X(15) N/A
(zip code for US).

the new Supporting
Zip/Postal Zone PP), defined for use by
(368-2P) in the Medicare under 5.1
Prescriber
Segment under
D.0
Certificate on File Indicator N/A This indicates whether or not the X(01) N/A
supplier has a paper copy of the CMN
on file and available for review.
N/A X(01) N/A

the new value Supporting
11 – Documentation (498-
Certification on PP), defined for use by
File for the Medicare under 5.1
Submission
Clarification
Code (420-DK)
in the Claim
Segment under
D.0
Signature Date N/A For form 8.02, this is the date that the X(08) N/A
supplier signed the form.

the Supporting
Prescriber/Supp Documentation (498-
lier Date Signed PP), defined for use by
(372-2T) in the Medicare under 5.1
new Additional
Documentation
Segment under
D.0
Question 01A (CMN Form N/A The HCPCS code of the drug X(11) N/A
08.02) prescribed.
N/A X(11) N/A

the Question Supporting
Alphanumeric Documentation (498-
Response (383- PP), defined for use by
4K) in the new Medicare under 5.1
Additional
Documentation
Segment under
D.0
Question 01B (CMN Form N/A Dosage in milligrams of the drug 9(04) N/A
08.02) prescribed in Question 01A.

Numeric Documentation (498-
4J) in the new Medicare under 5.1
Additional
Documentation
Segment under
D.0
Question 01C (CMN Form N/A The frequency of administration of the 9(02) N/A
08.02) drug prescribed in Question 01A.
Expressed as times per day.
*This functionality is * This field represents a subset of the

addressed by the Question Prior Authorization Supporting
Numeric Response (382- Documentation (498-PP), defined for
4J) in the new Additional use by Medicare under 5.1
Documentation Segment
under D.0
08.02) prescribed. Required if more than 1
drug has been prescribed.
N/A X(11) N/A

Additional
Documentation
Segment under
D.0
08.02) prescribed in Question 02A. Required
if Question 02A has been answered.
* This field represents

Authorization
Supporting
Documentation (498-
PP), defined for use by
Medicare under 5.1
*This
functionality is
addressed by
the Question
Numeric
Response (382-
4J) in the new
Additional
Documentation
Segment under
D.0
Expressed as times per day. Required

Additional
Documentation
Segment under
D.0
08.02) prescribed. Required if more than 2
drugs have been prescribed.
N/A X(11) N/A

Additional
Documentation
Segment under
D.0
08.02) prescribed in Question 03A. Required

Additional
Documentation
Segment under
D.0
Expressed as times per day. Required
Additional
Documentation
Segment under
D.0
Question 04 (CMN Form N/A Indicates whether or not the patient X(01) N/A
08.02) has had an organ transplant that was
covered by Medicare.

Authorization
Supporting
Documentation (498-
Medicare under 5.1
*This
functionality is
addressed by
the Question
Alphanumeric
Response (383-
4K) in the new
Additional
Documentation
Segment under
D.0
Question 05A (CMN Form N/A Indicates which organ(s) have been X(01) N/A
08.02) transplanted. The most recent one(s)
should be listed.

Additional
Documentation
Segment under
D.0
Question 05B (CMN Form N/A Indicates which organ(s) have been X(01) N/A
should be listed.

Additional
Documentation
Segment under
D.0
Question 05C (CMN Form N/A Indicates which organ(s) have been X(01) N/A
should be listed.
N/A X(01) N/A

Additional
Documentation
Segment under
D.0
Question 11 (CMN Form N/A The date the patient was discharged X(08) N/A
08.02) from the hospital following this
transplant surgery.

Date Response Documentation (498-
(380-4G) in the PP), defined for use by
new Additional Medicare under 5.1
Documentation
Segment under
D.0
Question 12 (CMN Form N/A Indicates whether or not there was a X(01) N/A
08.02) prior transplant of the same organ.
N/A X(01) N/A

Additional
Documentation
Segment under
D.0
Narrative Information N/A Free form text area X(80) N/A

When the T12 Authorization
Information Qualifier is CNA, CNF,
FAN, NAR, MNA, MNF, MAN, or MAR,
move the T12 Narrative Information to
the NOTE field on the VANS H152 and
VANS VCL1 screens.
*This
functionality is
addressed by
the Narrative
Message (390-
BM) in the new
Narrative
Segment under
D.0

Authorization
Supporting
Documentation (498-
Medicare under 5.1
Facility Name N/A
* This field represents X(27) N/A

Authorization
Supporting
Documentation (498-
Medicare under 5.1
*This
functionality is
addressed by
the Facility
Name (385-3Q)
in the new
Facility
Segment under
D.0
Facility Address N/A


Authorization
Supporting
Documentation (498-
Medicare under 5.1
*This
functionality is
addressed by
the Facility
Street Address
(386-3U) in the
new Facility
Segment under
D.0
Facility City N/A


Authorization
Supporting
Documentation (498-
Medicare under 5.1
*This
functionality is
addressed by
the Facility City
Address (386-
5J) in the new
Facility
Segment under
D.0
Facility State N/A Standard state/province code as X(02) N/A

agency.
the Facility Supporting
State/Province Documentation (498-
Address (387- PP), defined for use by
3V) in the new Medicare under 5.1
Facility
Segment under
D.0
Facility ZIP N/A Code defining international postal X(15) N/A

(zip code for US).

the Facility Supporting
Zip/Postal Zone Documentation (498-
(389-6D) in the PP), defined for use by
new Facility Medicare under 5.1
Segment under
D.0
Ingredient Number N/A

* This field represents 9(02) N/A

Authorization
Supporting
Documentation (498-
Medicare under 5.1
*This
functionality is
addressed by
the Compound
Ingredient
Modifier Code
Count (362-2G)
in the
Compound
Segment under
D.0
Ingredient Modifier N/A


Authorization
Supporting
Documentation (498-
Medicare under 5.1
* This
functionality is
addressed by
the Compound
Ingredient
Modifier Code
(363-2H) under
D.0
Transaction Clinical Segment

record.
Diagnosis Code Count 491-VE Count of diagnosis occurrences. 9(02) SAME
Diagnosis Code Qualifier 492-WE Code qualifying the Diagnosis Code. X(02) SAME

under D.0
Diagnosis Code 424-DO Code identifying the diagnosis of the X(15) SAME
patient.
Clinical Information Counter 493-XE Counter number of clinical information 9(02) SAME
measurement sets/logical groupings.
Measurement Date 494-ZE Date clinical information was collected 9(08) SAME
or measured.
Measurement Time 495-H1 Time clinical information was collected 9(04) SAME
or measured.
Measurement Dimension 496-H2 Code indicating the clinical domain of X(02) SAME
the observed value in Measurement
Value.

under D.0
Measurement Unit 497-H3 Code indicating the metric or English X(02) SAME
units used with the clinical information.

under D.0
497-H3 Code indicating the metric or English X(02) SAME
units used with the clinical information.

under D.0
Measurement Value 499-H4 Actual value of clinical information. X(15) SAME
Transaction Additional Documentation Segment

*This is a new optional segment
**This segment will support CMN processing, similar to the 2440 FRM segment in the 837 format. However, the only current CMN fo
of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by CMS, per CR4241. Unless th

Segment Identification 111-AM Identifies the segment in the request N/A X(02)
record.
Additional Documentation 369-2Q Unique identifier for the data being N/A X(03)
Type ID submitted.
*This replaces
the Form
Identifier that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
**Part of
External Code
List under D.0
Request Period Begin Date 375-2V The beginning date of need. N/A 9(08)
*This replaces
the functionality
of the Request
Period Date -
Begin (498-PB)
on the Prior
Authorization
segment, as it is
used by
Medicare under
5.1
Request Period 375-2W The effective date of the revision or re- N/A 9(08)
Recert/Revised Date certification provided by the certifying
physician.
*This replaces
the functionality
of the Request
Period Date –
End (498-PC)
on the Prior
Authorization
segment, as it is
used by
Medicare under
5.1
Request Status 373-2U Code identifying type of request. N/A X(01)

373-2U Code identifying type of request. N/A X(01)
*This replaces
the functionality
of the Request
Type (498-PA)
on the Prior
Authorization
segment, as it is
used by
Medicare under
5.1

under D.0
371-2S Code qualifying the length of need. N/A 9(02)

under D.0
Length of Need 370-2R Length of time the physician expects N/A 9(03)
the patient to require use of the
ordered item.
Prescriber/Supplier Date 372-2T The date the form was completed and N/A 9(08)
Signed signed by the ordering physician.
372-2T The date the form was completed and N/A 9(08)
signed by the ordering physician.
*This replaces
the Signature
Date that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Supporting Documentation 376-2X Free text message N/A X(65)
Question Number/Letter 377-2Z Count of Question Number/Letter N/A 9(02)

Count occurrences.
Question Number/Letter 378-4B Identifies the question number/letter N/A X(03)
that the question response applies to
(part of the question information).
Question Percent 379-4D Percent response to a question (part N/A 9(3)v99

Response of the question information).
Question Date Response 380-4G Date response to a question (part of N/A 9(08)
the question information).
Question Dollar Amount 381-4H Dollar Amount response to a question N/A s9(9)v99
Response (part of the question information).
Question Numeric 382-4J Numeric response to a question (part N/A 9(11)

Response of the question information).
Question Alphanumeric 383-4K Alphanumeric response to a question N/A X(30)
Response (part of the question information).
Transaction Facility Segment

Segment Identification 111-AM Identifies the segment in the request N/A (X02)
record.
Facility ID 336-8C ID assigned to the patient’s clinic/host N/A X(10)
party.
Facility Name 385-3Q Name identifying the location of the N/A X(30)
service rendered.
*This replaces
the Facility
Name that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Facility Street Address 386-3U Free form text for Facility address N/A X(30)
information.
386-3U Free form text for Facility address N/A X(30)
information.
*This replaces
the Facility
Address that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Facility City Address 388-5J Free form text for facility city N/A X(20)
Name.
388-5J N/A X(20)
*This replaces
the Facility City
that is currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Facility State/Province 387-3V Standard state/province code as N/A X(02)

agency.
387-3V Standard state/province code as N/A X(02)
agency.
*This replaces
the Facility
State that is
currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Facility Zip/Postal Zone 389-6D Code defining international postal N/A X(15)
(zip code for US).
389-6D Code defining international postal N/A X(15)
(zip code for US).
*This replaces
the Facility Zip
that is currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Transaction Narrative Segment

**This segment will support the submission of narrative information per DME Form 11.02 – Section C Continuation Form. Howev
supported in VMS processing of NCPDP claims is DIF Form 08.02 for Immunosuppressives and that form is no longer required by C

Segment Identification 111-AM Identifies the segment in the request N/A (X02)
record.
Narrative Message 390-BM Free form text. N/A X(200)
390-BM Free form text. N/A X(200)
*This replaces
the Narrative
Information that
is currently
defined as a
subset of the
Prior
Authorization
Supporting
Documentation
(498-PP) on the
Prior
Authorization
segment,
defined for use
by Medicare
under 5.1
Batch Trailer Segment
NCPDP Data Dictionary Batch 1.1 Batch 1.2

record.
Batch Number 806-5C Number assigned by processor. 9(07) SAME
Matches header.
Record Count 751 Record count within batch file. 9(10) SAME
Message 504-F4 Free form message. X(35) SAME
rd
VMS Claim/CMN field

that is currently
populated from this
Valid values per the Standard information
00 = File Control (header) N/A
T = Transaction N/A
R = Response
E = Error
To be defined by processor/switch. Submitter ID
Matches Trailer N/A
Format = CCYYMMDD Submitter Creation Date
Format = HHMM N/A

P = production N/A
T = test
11=Version 1.1 N/A
12=Version 1.2
To be defined by processor/switch. N/A
egment
VMS Claim/CMN field

that is currently
populated from this
N/A N/A
01=Version 1.0
02=Version 2.0 N/A

03=Version 3.0 *Currently, VMS only
processes Version 5.1
31=Version 3.1
32=Version 3.2
3A=Standard Claim/Reversal
3B=Workers Compensation
3C=Medicaid Claim/Reversal
33=Version 3.3
34=Version 3.4
35=Version 3.5
40=Version 4.0
41=Version 4.1
42=Version 4.2
50=Version 5.0
51=Version 5.1
52=Version 5.2
53=Version 5.3
54=Version 5.4
55=Version 5.5
56=Version 5.6
60=Version 6.0
70=Version 7.0
71=Version 7.1
80=Version 8.0
81=Version 8.1
82=Version 8.2
83=Version 8.3
90=Version 9.0
A0=Version A.0
A1=Version A.1
B0=Version B.0
C0=Version C.0
C1=Version C.1
C2=Version C.2
C3=Version C.3
C4=Version C.4
D0=Version D.0
B1=Billing N/A
B2=Reversal *Currently, VMS only
processes the Billing (B1)
transaction
B3=Rebill
C1=Controlled Substance Reporting
Reversal
Rebill
*D1=Determination of
Benefits
E1=Eligibility Verification
N1=Information Reporting
N2=Information Reporting Reversal
N3=Information Reporting Rebill
P1=P.A. Request & Billing
P2=P.A. Reversal
P3=P.A. Inquiry
P4=P.A. Request Only
*S1=Service Billing
*S2=Service Reversal
*S3=Service Rebill
*New value under D.0

N/A Patient Account Number
Blank=Not Specified Claim Line Count

1=One Occurrence
2=Two Occurrences
3=Three Occurrences
4=Four Occurrences
Blank=Not Specified N/A
01=National Provider Identifier (NPI)

02=Blue Cross
*Value 01 (NPI)
should be only
valid value for
Medicare once
NPI is fully
implemented
03=Blue Shield
04=Medicare
05=Medicaid
06=UPIN
07=NCPDP Provider ID
08=State License
09=Champus
10=Health Industry Number (HIN)
11=Federal Tax ID
12=Drug Enforcement Administration
(DEA)
13=State Issued
14=Plan Specific
*15=HCID (HC IDea)

99=Other

N/A Supplier/Rendering
Provider
Format=CCYYMMDD From/To Dates of Service
N/A N/A
egment
VMS Claim/CMN field

that is currently
populated from this
01=Patient
02=Pharmacy Provider
03=Prescriber
04=Insurance
05=Coordination of Benefits/Other
Payments
06=Worker’s Compensation
07=Claim
08=DUR/PPS
09=Coupon
10=Compound
11=Pricing
12=Prior Authorization
13=Clinical
*14=Additional
Documentation
*15=Facility
*16=Narrative
20=Response Message
21=Response Status
22=Response Claim
23=Response Pricing
24=Response DUR/PPS
25=Response Insurance
26=Response Prior Authorization
*27=Response Insurance
Additional Information
Segment
*28=Response
Coordination of
Benefits/Other Payers

01=Social Security Number
02=Driver’s License Number
03=U.S. Military ID
*04=SSN-based ID
assigned by plan
*05= Non-SSN-based ID
assigned by plan
*06=Medicaid ID
99=Other

N/A Beneficiary HICN
Format=CCYYMMDD Beneficiary Birth Date
0=Not Specified Beneficiary Sex

1=Male
2=Female
N/A Beneficiary First Name

N/A Beneficiary Last Name
N/A Beneficiary Address
N/A Beneficiary City

Standard United States and Beneficiary State
Canadian province two-letter postal Beneficiary Pricing State
service abbreviations should be used.
N/A Beneficiary Zip Code
Format=AAAEEENNNN N/A
5.1 Values Place of Service

Place of Service
0=Not specified
1=Home
2=Inter-Care
3=Nursing Home
4=Long Term/Extended Care
5=Rest Home
6=Boarding Home
7=Skilled Care Facility
8=Sub-Acute Care Facility
9=Acute Care Facility
10=Outpatient
11=Hospice
*As of version B.0, this

field uses the standard
CMS Place of Service
values
N/A N/A
1=Non-Smoker
2=Smoker

1=Not pregnant
2=Pregnant
N/A N/A
0=Not Specified N/A
1=Home
2=Skilled Nursing Facility
3=Nursing Facility
4=Assisted Living Facility
5=Custodial Care Facility
6=Group Home
7=Inpatient Psychiatric
Facility
8=Psychiatric Facility –
Partial Hospitalization
9=Intermediate Care
Facility/Mentally Retarded
10=Residential Substance
Abuse Treatment Facility
11=Hospice
12=Psychiatric Residential
Treatment Facility
13=Comprehensive
Inpatient Rehabilitation
Facility
14=Homeless Shelter
15=Correctional Institution
egment
VMS and is not used to populate any VMS claim or CMN fields.
VMS Claim/CMN field

that is currently
populated from this
See Listing in the Transmission Patient N/A
Segment
(DEA) *Value 05 (NPI)

should be only
valid value for
Medicare once
NPI is fully
implemented
02=State License
03=Social Security Number (SSN)
04=Name
07=State Issued
99=Other
N/A N/A
egment
VMS Claim/CMN field

that is currently
populated from this
Segment
02=Blue Cross
*Value 01(NPI)
should be only
valid value for
Medicare once
NPI is fully
implemented
03=Blue Shield
04=Medicare
05=Medicaid
06=UPIN
07=NCPDP Provider ID
08=State License
09=Champus
11=Federal Tax ID
(DEA)
13=State Issued
14=Plan Specific
*15=HC IDea
99=Other

N/A Referring Provider Number
N/A N/A
N/A Referring Physician Last

Name
N/A CMN Referring Physician
Phone

02=Blue Cross
*Value 01(NPI)
should be only
valid value for
Medicare once
NPI is fully
implemented
03=Blue Shield
04=Medicare
05=Medicaid
06=UPIN
**07=NCPDP Provider ID
08=State License
09=Champus
11=Federal Tax ID
(DEA)
13=State Issued
14=Plan Specific
*15= HC IDea
99=Other
**Not valid for D.0

N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
Standard United States and N/A
Canadian province two-letter postal

N/A
N/A N/A
Segment
VMS Claim/CMN field

that is currently
populated from this
Segment
N/A Beneficiary HICN
N/A N/A
N/A N/A
N/A N/A
N/A N/A
0=Not Specified N/A
1=No Override
2=Override
3=Full Time Student

4=Disabled Dependent
5=Dependent Parent
6=Significant Other
N/A Facility Number
N/A Other Carrier Name and

Address Key - Used to
identify claim-based
Medicaid crossover claims
N/A N/A
0=Not Specified N/A
1=Cardholder
2=Spouse
3=Child
4=Other
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A

Y=Assigned N/A
N=Non-assigned *Currently, VMS processes all
NCPDP claims as Assigned
claims, based on CMS’
Mandatory Assignment Policy
for Drugs and Biologicals
Y=Yes N/A
N=No
N/A N/A
N/A N/A
egment
VMS Claim/CMN field

that is currently
populated from this
Segment
Maximum count of 9 N/A
Blank=Not Specified Other Primary Insurance

Indicator
01=Primary
02=Secondary
03=Tertiary
*04=Quaternary
*05=Quinary
*06=Senary
*07=Septenary
*08=Octonary
*09=Nonary
**98=Coupon
**99=Composite
**Not valid for D.0

01=National Payer ID
03=Bank Information Number (BIN)
04=National Association of Insurance
Commissioners (NAIC)
*05=Medicare Carrier
Number
**09=Coupon
99=Other

**Not valid for D.0
N/A N/A
N/A N/A
N/A N/A
01=Delivery
02=Shipping
03=Postage
04=Administrative
05=Incentive
06=Cognitive Service
07=Drug Benefit
**08=Sum of All
Reimbursement
**98=Coupon
**99=Other
**Not valid for D.0
N/A MSP Primary Paid Amt.
MSP OTA Amount
MSP Primary Allowed Amt.

See current NCPDP Reject Code list N/A
00=Blank Not Specified N/A

01=Amount Applied to Periodic
Deductible (517-FH).
02=Amount Attributed to Product
Selection/Brand Drug (134-UK).
03=Amount Attributed to Sales Tax (523-
FN).
04=Amount Exceeding Periodic Benefit
Maximum (520-FK).
05=
Amount of Copay (518-FI).
06=Patient Pay Amount (505-F5).
07=Amount of Coinsurance (572-4U).
08=Amount Attributed to Product

Selection/Non-Preferred Formulary
Selection (135-UM).
09=Amount Attributed to Health Plan
Assistance Amount (129-UD).
N/A N/A
01=Deductible N/A
02=Initial Benefit
03=Coverage Gap (donut hole)
04=Catastrophic Coverage
N/A N/A
p Segment
VMS Claim/CMN field

that is populated from
Valid values per the Standard this information
Segment
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A

N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
00=Provider Submitted-Pay to Provider N/A
01=Provider Submitted-Pay to Another

Party
02=Agent Submitted-Pay to Agent
03=Agent Submitted-Pay to Another Party
00=Not Specified N/A

01=NPI
11= Federal Tax ID
N/A N/A
N/A N/A
N/A N/A
N/A N/A

N/A N/A
See Listing for the Product/Service ID N/A

Qualifier (436-E1) in the Claim Segment
N/A N/A
ment
Valid values per the Standard VMS Claim/CMN field
that is currently
populated from this
information

Segment
1=Rx Billing
2=Service Billing
N/A Line Control Number
00=Not Specified N/A

01=UPC
02=HRI *Currently, only value 3 (NDC)
is accepted in VMS
03=NDC
04=UPN (5.1)/HIBCC (D.0)
**05=DOD
06= DUR/PPS
07=CPT4
08=CPT5
09=HCPCS
10=PPAC
11=NAPPI
12=EAN (5.1)/GTIN (D.0)
**13=DIN
*15=GCN
*28= FDB Med Name ID
*29= FDB Routed Name

ID
*30= FDB Rtd. Dos. Form
Med ID
*31= FDBMedID
*32=GCN_SEQ_NO
*33= HICL_SEQ_NO
*34=UPN
99=Other

**Not valid for D.0
N/A Procedure Code (The
submitted NDC is
crosswalked to a HCPCS
code for processing).
N/A N/A
Format=CCYYMMDD N/A
Maximum count is 10 *VMS is currently limited to 4

modifiers per Procedure Code
CMS code set of HCPCS modifiers Procedure Code Modifier
N/A Metric Decimal Quantity,

which is converted to
Number Of Services for
processing
0=Original dispensing N/A

1-99=Refill number
N/A N/A
0=Not Specified N/A

1= Not a Compound
2=Compound *Determines whether
Compound Segment is
processed or not
0=No Product Selection Indicated N/A

1=Substitution Not Allowed by Prescriber
2=Substitution Allowed-Patient
Requested Product Dispensed
3=Substitution Allowed-Pharmacist
Selected Product Dispensed
4=Substitution Allowed-Generic Drug Not
in Stock
5=Substitution Allowed-Brand Drug
Dispensed as a Generic
6=Override
7=Substitution Not Allowed-Brand Drug
Mandated by Law
8=Substitution Allowed-Generic Drug Not
Available in Marketplace
9= Other (5.1)/Substitution Allowed By
Prescriber but Plan Requests Brand -
Patient's Plan Requested Brand
Product To Be Dispensed (D.0)

Format=CCYYMMDD N/A
0=Original dispensing N/A

1-99=Refill number
0=Not Known N/A
1=Written
2=Telephone
3=Electronic
4=Facsimile
Maximum Count is 3. N/A
0=Not Specified N/A
1=No Override
2=Other Override
3=Vacation Supply
4=Lost Prescription
5=Therapy Change
6=Starter Dose
7=Medically Necessary
8=Process Compound For Approved
Ingredients
9=Encounters
*10=Meets Plan
Limitations
*11=Certification on File
*12=DME Replacement
Indicator
*13=Payer-Recognized
Emergency/Disaster
Assistance Request
*14=Long Term Care

Leave of Absence
*15=Long Term Care
Replacement Medication
*16=Long Term Care

Emergency box (kit) or
automated dispensing
machine
*17=Long Term Care
Emergency supply
remainder
*18=Long Term Care
Patient Admit/Readmit
Indicator
*19=Split Billing
99=Other
N/A N/A
0=Not Specified by patient N/A

1=No other coverage.
2=Other coverage exists-payment
collected.
3=Other Coverage Billed – claim not
covered.
4=Other coverage exists-payment not
collected.
**5=Managed care plan

denial
**6=Other coverage
denied-not a
participating provider
**7=Other coverage
exists-not in effect at
time of service
8=Claim is billing for patient financial
responsibility only.
**Not valid for D.0

0=Not Specified N/A
1=Not Unit Dose.
2=Manufacturer Unit Dose.
3=Pharmacy Unit Dose.
*4=Custom Packaging.
*5=Multi-drug
compliance packaging.

N/A N/A
N/A N/A
N/A Medigap ID (Inbound)
Claim Control Number

(Outbound)
N/A N/A
EA=Each. N/A
GM=Grams.
ML=Milliliters.
0=Not Specified N/A
1=Patient consultation
2=Home delivery
3=Emergency
4=24 hour service
5=Patient consultation regarding generic
product selection
6=In-Home Service
0=Not Specified N/A
1=Prior Authorization.
2=Medical Certification.
3=EPSDT (Early Periodic Screening
Diagnosis Treatment.
4=Exemption from Copay and/or.
5=Exemption from RX.
6=Family Planning Indicator.
7=AFDC (5.1)/ TANF (D.0).
8=Payer Defined Exemption.
*9=Emergency
Preparedness
N/A N/A
0=Not Specified N/A
1=Intermediary Authorization.
99=Other Override
N/A N/A
**Blank=Not Specified. N/A
P= Partial Fill.
C=Completion of Partial Fill.
**Not valid for D.0

N/A N/A
N/A N/A
1=Proof of eligibility unknown or N/A

unavailable
2=Litigation
3=Authorization delays
4=Delay in certifying provider
5=Delay in supplying billing forms
6=Delay in delivery of custom-made
appliances
7=Third party processing delay
8=Delay in eligibility determination
9=Original claims rejected or denied due
to a reason unrelated
to the billing limitation rules
10=Administration delay in the prior
approval process
11=Other
12=Received late with no exceptions
13=Substantial damage by fire, etc to
provider records
14=Theft, sabotage/other willful acts by
employee
N/A N/A
Y=Patient assigns benefits N/A
N=Patient does not assign benefits
Systematized Nomenclature of Medicine N/A

Clinical Terms® (SNOMED CT)
SNOMED CT® terminology which is
available from the College of American
Pathologists, Northfield, Illinois

http://www.snomed.org/
01=Anti-infective N/A
02=Ionotropic
03=Chemotherapy
04=Pain management
05=TPN/PPN (Hepatic, Renal, Pediatric)
06=Hydration
07=Ophthalmic
99=Other
N/A N/A
1=Community/Retail Pharmacy Services N/A
2=Compounding Pharmacy Services

3=Home Infusion Therapy Provider
Services
4=Institutional Pharmacy Services
5=Long Term Care Pharmacy Services
6=Mail Order Pharmacy Services

7=Managed Care Organization Pharmacy
Services
8=Specialty Care Pharmacy Services
99=Other
egment
VMS Claim/CMN field

that is currently
populated from this
Segment
Maximum count of 9. N/A
See NCPDP External Code List. N/A
See NCPDP External Code List N/A
See NCPDP External Code List N/A
0=Not Specified N/A

11=Level 1 (Lowest)
12=Level 2
13=Level 3
14=Level 4
15=Level 5 (Highest)
N/A N/A
gment
VMS Claim/CMN field

that is currently
populated from this
Segment
01=Price Discount N/A
02=Free Product
99=Other
N/A N/A
N/A N/A
Segment
VMS Claim/CMN field

that is currently
populated from this
Segment
01=Capsule
02=Ointment
03=Cream
04=Suppository
05=Powder
06=Emulsion
07=Liquid
10=Tablet
11=Solution
12=Suspension
13=Lotion
14=Shampoo
15=Elixir
16=Syrup
17=Lozenge
18=Enema
1=Each. N/A
2=Grams.
3=Milliliters.
0=Not Specified N/A
1=Buccal
2=Dental
3=Inhalation
4=Injection
5=Intraperitoneal
6=Irrigation
7=Mouth/Throat
8=Mucous Membrane
9=Nasal
10=Ophthalmic
11=Oral
12=Other/Miscellaneous
13=Otic
14=Perfusion
15=Rectal
16=Sublingual
17=Topical
18=Transdermal
19=Translingual
20=Urethral
21=Vaginal
22=Enteral
Maximum count remains at 25. Claim Line Count, when
processing a Compound
See Listing for the Product/Service ID

N/A Procedure Code, when

N/A Metric Decimal Quantity,

when processing a
Compound
N/A Submitted Charge, when

00=Default N/A
01=AWP (Average Wholesale Price).

02=Local Wholesaler.
03=Direct.
04=EAC (Estimated Acquisition Cost.
05=Acquisition.
06=MAC (Maximum Allowable Cost).
07=Usual & Customary.
*08=340B
/Disproportionate Share
Pricing/Public Health
Service.
09 Other.
*10=ASP (Average Sales

Price).
*11=AMP (Average
Manufacturer Price).
*12=WAC (Wholesale
Acquisition Cost).

Maximum count is 10. N/A
CMS code set of HCPCS modifiers N/A

CMS code set of HCPCS modifiers N/A
gment
VMS Claim/CMN field

that is currently
populated from this
Segment
N/A N/A
N/A N/A
*Used to generate HCPCS

codes for dispensing fees
N/A N/A
N/A Beneficiary Paid Amount
N/A N/A
N/A
*Used to generate HCPCS

codes for incentive fees
01=Delivery Cost N/A
02=Shipping Cost
03=Postage Cost
04=Administrative Cost
99=Other
N/A N/A
N/A N/A
N/A N/A
N/A N/A
**01=Gross Amount Due
02=Ingredient Cost.
03=Ingredient Cost + Dispensing Fee.
**Not valid for D.0

N/A N/A
N/A Submitted Charge
See Listing for the Compound Ingredient N/A

Basis of Cost Determination (490-UE) in
the Compound Segment
N/A N/A
on Segment
n the Billing Transaction
VMS Claim/CMN field

that is currently
populated from this
Segment
1=Initial. CMN Type (Initial,
Recertification, or
2=Reauthorization.
Revision)
3=Deferred
Format = CCYYMMDD CMN Initial Date
Format = CCYYMMDD CMN Recert/Revise Date

Format = CCYYMMDD CMN Recert/Revise Date
ME=Medical N/A
PR=Plan Requirement
PL=Increase Plan Limitation
N/A Rep Payee First Name

N/A Rep Payee First Name
N/A Rep Payee Last Name
N/A Rep Payee Address
N/A Rep Payee City

N/A Rep Payee City
Standard United States and Rep Payee State

N/A Rep Payee Zip Code
N/A N/A
N/A N/A
N/A See descriptions of the

specific fields, following
this one, that are defined
subsets of this field for
uses.
N/A N/A
N/A CMN Form

N/A Referring Physician First
Name

Address

City
Standard United States and CMN Referring Physician

State

State

Zip Code
N/A CMN Certificate On File

Indicator
N/A CMN Certificate On File
Indicator
Format = CCYYMMDD CMN Signature Date
N/A Response to Question 01A

on CMN Form 08.02
on CMN Form 08.02
N/A Response to Question 01B

on CMN Form 08.02
N/A Response to Question 01C

on CMN Form 08.02

on CMN Form 08.02
on CMN Form 08.02

on CMN Form 08.02
on CMN Form 08.02

on CMN Form 08.02
on CMN Form 08.02

on CMN Form 08.02

on CMN Form 08.02
N/A Response to Question 04
on CMN Form 08.02
on CMN Form 08.02

on CMN Form 08.02

on CMN Form 08.02
on CMN Form 08.02

on CMN Form 08.02

on CMN Form 08.02
on CMN Form 08.02
N/A CMN narrative information

per DME Form 11.02 –
Section C Continuation
Form
N/A CMN Facility Name
N/A CMN Facility Address

N/A CMN Facility City
Standard United States and CMN Facility State

N/A CMN Facility Zip
Occurs 25 times N/A

Occurs 25 times HCPCS Modifier, when
gment
VMS Claim/CMN field

that is currently
populated from this
Segment
Maximum count remains at 5 N/A
00=Not Specified *Currently, only value 01
(ICD9) is accepted in VMS
01=ICD9
02=ICD-10-CM
03=National Criteria Care Institute (NCCI)
04=SNOMED
05=Common Dental Terminology (CDT)
06=Medi-Span Product Line Diagnosis

Code
07= DSM IV
*08=First DataBank
Disease Code (FDBDX)
*09=First DataBank FML

Disease Identifier (FDB
DxID)
99=Other

N/A Claim Header/Line
Diagnosis
CMN Diagnosis
Maximum count remains at 5 N/A
Format=CCYYMMDD N/A
Format: HHMM N/A
01=Blood Pressure (BP)

02=Blood Glucose
03=Temperature
04=Serum Creatinine (SCr)
05=Glycosylated Hemoglobin
06=Sodium (Na+)
07=Potassium (K+)
08=Calcium (Ca++)
09=SGOT
10=SGPT
11=Alkaline Phosphatase
12=Theophylline
13=Digoxin
14=Weight
15=Body Surface Area (BSA)
16=Height
17=Creatinine Clearance (CrCl)
*18=Cholesterol
*19=Low Density
Lipoprotein
*20=High Density
Lipoprotein
*21=Triglycerides (TG)
*22=Bone Mineral
Density
*23=Prothrombin Time
(PT)
*24=Hemoglobin (Hb;
Hgb)
*25=Hematocrit (Hct)
*26=White Blood Cell
Count
*27=Red Blood Cell
Count (RBC)
*28=Heart Rate
*29=Absolute Neutrophil
Count
*30=APTT
*31=CD4 Count
*32=Partial
Thromboplastin Time
*33=T-Cell Count
*34=INR
99=Other

01=Inches (In)
02=Centimeters (cm)
03=Pounds (lb)
N/A
04=Kilograms (kg)
05=Celsius (C)
06=Fahrenheit (F)
07=Meters squared (m2)
08=Milligrams per deciliter (mg/dl)
09=Units per milliliter (U/ml)
10=Millimeters of mercury (mmHg)
11=Centimeters squared (cm2)
12=Milliliters per minute (ml/min)
13=Percent (%)
14=Milliequivalents per milliliter
15 =International units per liter
16=Micrograms per milliliter
17=Nanograms per milliliter
18=Milligrams per milliliter
*19=Ratio
*20=SI Units
*21=Millimoles (mmol/l
*22=Seconds
*23=Grams per deciliter
(g/dl)
*24=Cells per cubic
millimeter
*25=1,000,000 cells per
cubic millimeter (million
cells/cu mm)
*26=Standard deviation
*27=Beats per minute

N/A CMN Beneficiary Height
CMN Beneficiary Weight
tation Segment
egment
at. However, the only current CMN form that is supported in VMS processing
uired by CMS, per CR4241. Unless the universe of DME items allowed to be
VMS Claim/CMN field
that is currently
populated from this
Segment
001=Medicare 01.02A Hospital Beds N/A
002=Medicare 01.02B Support Surfaces

003=Medicare 02.03A Motorized Wheel Chair
004=Medicare 02.03B Manual Wheelchair

005=Medicare 03.02 Continuous Positive
Airway Pressure (CPAP)
006=Medicare 04.03B Lymphedema Pumps
007=Medicare 04.03C Osteogenesis Stimulator
008=Medicare 06.02B Transcutaneous

Electrical Nerve
Stimulator TENS)
009=Medicare 07.02A Seat Lift Mechanisms
010=Medicare 07.02B Power Operated

Vehicles (POV)
011=Medicare 08.02 Immunosuppressive
Drugs
012=Medicare 09.02 Infusion Pump
013=Medicare 10.02A Parenteral Nutrition
014=Medicare 10.02B Enteral Nutrition
015=Medicare 484.2 Oxygen
Format = CCYYMMDD N/A
0=Not Specified. N/A

1=Initial.
N/A
2=Revision.
3=Recertification.
0=Not Specified N/A

1=Hours
2=Days
3=Weeks
4=Months
5=Years
6=Lifetime
N/A N/A

N/A N/A
Values to be determined by Trading N/A

Partner Agreement
N/A N/A
N/A N/A
N/A N/A
N/A N/A
gment
egment
VMS Claim/CMN field
that is currently
populated from this
Segment
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A

N/A
N/A N/A
N/A N/A
egment
egment
Section C Continuation Form. However, the only current CMN form that is
d that form is no longer required by CMS, per CR4241. Unless the universe of
VMS Claim/CMN field
that is currently
populated from this
Segment
N/A N/A
N/A N/A
ent
VMS Claim/CMN field

that is currently
populated from this
99 = File Control (trailer) N/A
Matches Header N/A
N/A N/A
N/A N/A

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4010A1 270 Member Eligibility Inquiry

Element Description ID Min. Usage Loop Loop Values

3 ISA03 Security Information ID 2-2 R 00, 01

9 ISA09 Interchange Date DT 6-6 R YYMMDD

10 ISA10 Interchange Time TM 4-4 R HHMM

11 ISA11 Interchange Control ID 1-1 R U

16 ISA16 Component Element 1-1 R

22 GS06 Group Control Number N0 1-9 R

23 GS07 Responsible Agency ID 1-2 R X

31 BHT04 Date DT 8-8 R CCYYMMDD

32 BHT05 Time TM 4-8 R

33 1 BHT06 Transaction Type Code ID 2-2 S RT, RU

HL INFORMATION 1 R 2000A >1

35 HL02 Hierarchical Parent ID AN 1 - 12 N/U

37 HL04 Hierarchical Child Code ID 1-1 R 1

NM1 INFORMATION 1 R 2100A 1

39 NM102 Entity Type Qualifier ID 1-1 R 1, 2

40 1 NM103 Name Last or AN 1 - 35 S

43 NM106 Name Prefix AN 1 - 10 N/U

44 NM107 Name Suffix AN 1 - 10 S

47 NM110 Entity Relationship Code ID 2-2 N/U

48 NM111 Entity Identifier Code ID 2-3 N/U

HL INFORMATION 1 R 2000B >1

51 HL02 Hierarchical Parent ID AN 1 - 12 R

53 HL04 Hierarchical Child Code ID 1-1 R 1

NM1 INFORMATION 1 R 2100B 1

56 1 NM103 Name Last or AN 1 - 35 S

58 NM105 Name Middle AN 1 - 25 S

59 NM106 Name Prefix AN 1 - 10 N/U

60 NM107 Name Suffix AN 1 - 10 S

63 NM110 Entity Relationship Code ID 2-2 N/U

64 NM111 Entity Identifier Code ID 2-3 N/U

69 REF04 REFERENCE N/U

71 N302 Address Information AN 1 - 55 S

72 N401 City Name AN 2 - 30 R

73 N402 State or Province Code ID 2-2 R

74 N403 Postal Code ID 3 - 15 R

75 N404 Country Code ID 2-3 S

76 N405 Location Qualifier ID 1-2 N/U

77 N406 Location Qualifier AN 1 - 30 N/U

PER INFORMATION 3 S 2100B

81 1 PER03 Communication Number ID 2-2 S ED, EM, FX, TE

83 1 PER05 Communication Number ID 2-2 S ED, EM, EX, FX, TE

87 1 PER09 Contact Inquiry AN 1 - 20 N/U

PRV INFORMATION 1 S 2100B

89 1 PRV02 Reference Identification ID 2-3 R ZZ

91 PRV04 State or Province Code ID 2-2 N/U

92 PRV05 PROVIDER SPECIALTY N/U

93 PRV06 Provider Organization ID 3-3 N/U

HL SUBSCRIBER LEVEL 1 R 2000C >1

94 HL01 Hierarchical ID Number AN 1 - 12 R

95 HL02 Hierarchical Parent ID AN 1 - 12 R

97 HL04 Hierarchical Child Code ID 1-1 R 0, 1

TRN SUBSCRIBER TRACE 2 S 2000C

99 1 TRN02 Reference Identification AN 1 - 30 R

100 TRN03 Originating Company AN 10 - 10 R

NM1 SUBSCRIBER NAME 1 R 2100C 1

102 NM101 Entity Identifier Code ID 2-3 R IL

103 NM102 Entity Type Qualifier ID 1-1 R 1

106 NM105 Name Middle AN 1 - 25 S

107 NM106 Name Prefix AN 1 - 10 N/U

108 NM107 Name Suffix AN 1 - 10 S

109 1 NM108 Identification Code ID 1-2 S MI, ZZ

111 NM110 Entity Relationship Code ID 2-2 N/U