Ansi Loop Logic-2010

Rendering Provider Name or ID Information
Payer 'XXXXX'
PayerID Payers that require Rendering Provider Name , ID or Address information
87815 Acordia National

65093 Advocate Health Partners
52149 Alliance PPO Inc. (Maryland)
36369 American Imaging Management, Inc.
81400 American Medical Security, Inc.
27514 Amerigroup
27515
27516
27517
27518
27519
22248 Amerihealth Mercy Health Plan

34196 Apex
59274 AvMed
87265 Benesight
62183 Better Health Plans, Inc.
23738 Blue Cross / Blue Shield of Louisiana
47198 Blue Cross of California
36609 Boilermaker
74230 Boon Chapman Administrators
74230 Boon Chapman Administrators
38245 Cape Health Plan
14182 CareCore National
14184 CareCore National Health Net
14179 CareCore Aetna Radiology Claims
14185 CareCore National LLC Health Net New Jersey
43172 Care Partners
25139 Carelink
10010 CareWorks
93040 Cascade East Health Plan
62308 CIGNA
90010 Community Health Plan
06105 ConnectiCare, Inc.
35180 Core Source of North Carolina
25141 Coventry Health Care
25143 Coventry Health Care
25129 Coventry Health Care (Carolinas)
25127 Coventry Health Care (GA)
25137 Coventry Health Care (DE Medicaid)
25130 Coventry Health Care (DE)
25132 Coventry Health Care (IA)
25133 Coventry Health Care (Kansas City)
25134 Coventry Health Care (Wichita)
25135 Coventry Health Care (LA)
25136 Coventry Health Care (NE)
25144 Coventry - Kansas City Medicare (Advantra)
81039 EBMS Employee Benefit Management Services, Inc.
94318 East Bay Medical Network
73288 Employers Health Insurance (EHI)
39026 Employers Insurance of Wausau (aka Wausau)
1
Payer 'XXXXX'
59298 Employer Mutual

59276 Florida First (1st)
59321 Florida Hospital Healthcare Systems
39065 Fortis Insurance Company
70408 Fortis Benefits
60550 Gateway Health Plan
25531 GHI HMO
13551 Group Health , Inc. New York (GHI)
31147 HTP
25126 Health America Inc./Health Assurance/Advantra
55247 Health Insurance Plan of Greater New York (HIP)
38216 Health Plus of Michigan
80141 Healthfirst, Inc. (NY)
95567 HealthNet of California
38309 Health Net of Arizona
06108 Health Net of the Northeast, Inc.
80142 Health Partners, PA
90001 Healthlink PPO.
59140 HealthPlan Services (Tampa Only)
48153 HealthSCOPE Benefits, Inc. (Repricing AR)
13335 Healthsource Hudson
02039 Healthsource New Hampshire (Medicare)
71074 Healthsource, AR
35167 Healthsource, IN
61127 Healthsource, KY
31141 Healthsource, OH
00046 Hill Physicians Medical Group
22326 Horizon Mercy
61101 Humana
61125 Humana Military -Tricare: Regions 3 and 4
95378 John Deere Health Care/Heritage National Healthplan
68036 John Muir/Mt. Diablo Health Network
23284 Keystone Mercy Health Plan
52148 MAMSI Life and Health Insurance Co. (MLH)
41154 Mayo Management Services Inc.
38264 Mcare
36364 McKesson
58204 MedAdmin
94265 Medica
36193 Memphis Managed Care
38336 Molina Washington
13174 Montefiore Contract Management Organization
95444 MPLAN Inc/Health Care Group, LLC
70491 Mutual Group (The) (US)
14180 NYMI-Oxford
36398 North American Medical Managment
56190 OptiCare Eye Health Network
52152 Optimum Choice of the Carolinas, Inc. (OCCI)
06111 Oxford Health Plans
95964 Pacificare of Arizona
56152 Partners National Health Plans of North Carolina
61129 Passport Health Plan
65018 PCA Health Plan of Florida
2
Payer 'XXXXX'
62155 PHP TennCare

16111 POMCO Plus
35173 Preferred Health Network (PHN)
60110 Preferred Health Systems Insurance Company
63088 Prime Health
61271 Principle Financial Group
35174 Qual Choice of Arkansas
35172 Qual Choice of North Carolina
35171 Qual Choice of Virginia
23285 Select Health of South Carolina
00014 Selectcare
54154 Sentara Health Management
25128 Southern Health Services, Inc.
95202 SummaCare Health Plan
77303 Sutter Medical Foundation
39188 Superior Health Plan-Texas
25175 Three Rivers Health Plans, Inc.
57106 Tricare Palmetto (CHAMPUS)
04298 Tufts Associated Health
23281 UPMC Health Plan
22264 Vytra Healthcare
62153 Xantus Healthplan of Tennessee
3
PayerID Payers that require RT D0-20 Provider ID
23738 Blue Cross Blue Shield of Louisana
02039 Healthsource of NH
04298 Tufts
16105 Univera
23281 UPMC Health
25169 Gateway Health
27514 Amerigroup
27515
27516
27517
27518
27519
33002 Universal Care-TN

35171 Qual Choice of VA
35174 Qual Choice of AR
35173 Preferred Health Network
38224 Health Alliance of Michigan
57106 Tricare (CHAMPUS)
59321 Florida Hospital
61125 Humana Military
63092 Oath
65358 BCBS of CT
00700
72127 Ochsner Health
86047 Americhoice
86001
86048
86002
86049
86003
90060 First Guard Health

91051 Group Health Cooperative
95570 Health Net CA Encounters
95958 Pacificare
95973
95975
95969
95977
Call for Payer ID Pacificare of CO.
Final IB 4010 to PCDS Code Table
X12N PCDS Description

Code Code
ISA ISA14 Acknowledgment Request
0 N No Acknowledgment Requested
1 Y Interchange Acknowledgment Requested
ISA ISA15 Usage Indicator
P PROD Production
T TEST Test
Header BHT02 Transcation Set Purpose Code
00 0 Original
18 8 Reissue
Header BHT06 Claim/Encounter Identifier
CH 100 Chargable
RP 102 Reporting
2000B SBR01 Payer Responsibility Sequence Number Code
P 01 Primary
S 02 Secondary
T 03 Teritary
2000B SBR02 Relationship Code
18 01 Self
2000B SBR05 Insurance Type Code
12 12 Medicare Secondary, Working Aged Beneficiary/Spouse with EGHP
13 13 Medicare Secondary ESRD Beneficiary in 12 Month Period with EGHP
14 14 Medicare Secondary, No Fault Insurance, Including Auto is Primary
15 15 Medicare Secondary, Workers Comp
16 16 Medicare Secondary, PHS and Other Federal Agencies
41 41 Medicare Secondary, Black Lung
42 42 Medicare Secondary, Veterans Administration
43 43 Medicare Secondary, Disabled Beneficiary Under Age 65 With LGHP
47 47 Medicare Secondary, Other Liability Insurance is Primary
5 09/27/2022
2000B SBR09 Claim Filing Indicator Code

09 A Self Pay
10 K Central Certification
11 Z Other/Other Non Federal Programs
12 X Preferred Provider Organization (PPO)
13 Q Point of Service
14 R Exclusive Provider Organization (EPO)
15 S Indemnity Insurance
16 2 Health Maintenance Organization-Medicare Risk
AM 3 Automobile Medical
BL G Blue Shield
BL P Blue Cross Provider Number
CH H Champus
CI F Commercial Insurance Co.
DS 5 Disability
HM Y HMO
LI W Liability
LM 1 Liability Medical
MB C Medicare
MC D Medicaid
OF E Other Federal Program
TV T Title V
VA V Veteran's Administration Plan
WC B Workers Compensation
ZZ 4 Mutually Defined
2010BA DMG03 Patient Gender Code
F F Female
M M Male
U U Unknown
2010BA REF01 Subscriber Secondary ID Qualifier
SY SY Social Security Number
IG IG Insurance Policy Number
1W 1W Member Identification Number
23 23 Client Number
6 09/27/2022
2010BB REF01 Payer Secondary ID Qualifier

2U 2U Payer Identification Number
NF NF National Association of Insurance Commissioners (NAIC) Code
TJ TJ Federal Taxpayer's Identification Number
F8 F8 Original Reference Number (non-destination payer only)
2000C PAT01 Patient Relation to Insured
01 02 Spouse
04 19 Grandfather or Grandmother
05 13 Grandson or Granddaughter
07 14 Nephew or Niece
09 24 Adopted Child
10 06 Foster Child
15 07 Ward
17 05 Stepson or Stepdaughter
19 03 Child
20 08 Employee
21 09 Unknown
22 10 Handicapped Dependent
23 16 Sponsored Dependent
24 17 Dependent of a Minor Dependent
29 22 Significant Other
32 18 Father or Mother
34 25 Other Adult
36 21 Emancipated Minor
39 11 Organ Donor
40 12 Cadaver Donor
41 15 Injured Plaintiff
43 04 Child where insured has no financial responsibility
53 20 Life Partner
G8 99 Other Relationship
2000C PAT04 Student Status Code
F F Full-time Student
N N Not a Student
P P Part-time Student
7 09/27/2022
2000C PAT09 Pregnancy Indicator

Y Y Patient is Pregnant
2010CA DMG03 Patient Gender Code
F F Female
M M Male
U U Unknown
2010CA REF01 Patient Secondary ID Qualifier
23 23 Client Number
2300 CLM05-1 Place of Service Code
03 03 School
04 04 Homeless Shelter
05 05 Indian Health Service Free-Standing Facility
06 06 Indian Health Service Provider-Based Facility
07 07 Tribal 638 Free-Standing Facility
08 08 Tribal 638 Provider-Based Facility
11 11 Office
12 12 Home
13 13 Assisted Living Facility
14 14 Group Home
15 15 Mobile Unit
20 20 Urgent Care Facility
21 21 Inpatient Hospital
22 22 Outpatient Hospital
23 23 Emergency Room - Hospital
24 24 Ambulatory Surgical Center
25 25 Birthing Center
26 26 Military Treatment Facility
31 31 Skilled Nursing Facility
32 32 Nursing Facility
33 33 Custodial Care Facility
34 34 Hospice
41 41 Ambulance - Land
8 09/27/2022
42 42 Ambulance - Air or Water

49 49 Independent Clinic
50 50 Federal Qualified Health Center
51 51 Psychiatric Facility - Inpatient
52 52 Psychiatric Facility - Partial Hospitalization
53 53 Community Mental Health Center
54 54 Intermediate Care Facility/Mentally Retarded
55 55 Residential Substance Abuse Treatment Facility
56 56 Psychiatric Residential Treatment Center
57 57 Non-Residential Substance Abuse Treatment Facility
60 60 Mass Immunization Center
61 61 Comprehensive Inpatient Rehabilitation Facility
62 62 Comprehensive Outpatient Rehabilitation Facility
65 65 End-Stage Renal Disease Treatment Facility
71 71 Public Health Clinic
72 72 Rural Health Clinic
81 81 Independent Laboratory
99 99 Other Place of Service
2300 CLM05-3 Claim Frequency Code
* * Source:
National Uniform Billing Data Element Specifications Type of Bill Position 3
Available From:
National Uniform Billing Committee
American Hospital Association
840 Lake Shore Drive
Chicago, IL 60694
2300 CLM06 Provider Signature Indicator

N N No
Y Y Yes
2300 CLM07 Provider Accepts Assignment Indicator
A A Assigned
B B Assignment Accepted on Clinical lab Services Only
C N Not Assigned
P P Patient Refuses to Assign Benefits
2300 CLM08 Benefits Assigment Certification Indicator
9 09/27/2022
Y A Yes, benefits are assigned

N N No, benefits are not assigned
2300 CLM09 Release of Information
A A Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review
Organization.
I I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal
Statutes.
M R The Provider has Limited or Restricted Ability to Release Data Related to a Claim.
N N No, Provider is Not Allowed to Release Data
O O On file at Payer or at Plan Sponsor
Y Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim.
2300 CLM10 Patient Signature Source Code
B B Authorization Form - Block 12 & 13
C Y Signed HCFA 1500 on file
M M Authorization Form - Block 13
P N Provider Signed
S S Authorization Form - Block 12
2300 CLM11-1 Accident Code
CLM11-2
CLM11-3
AA A Auto Accident Related

AP P Another Party Responsible
OA N Other Accident (not as a result of an auto or another party responsible)
2300 CLM11-1 Employment Related Flag
CLM11-2
CLM11-3
EM Y Employment Related (E0-17)

2300 CLM12 Special Program Code
01 01 Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program
(CHAP)
02 02 Physically Handicapped Children's Program
03 03 Special Federal Funding/Planning
05 05 Disability
07 07 Induced Abortion - Danger to Life
08 08 Induced Abortion - Rape or Incest
09 09 Second Opinion or Surgery
10 09/27/2022
2300 CLM20 Delay Reason Code

1 1 Proof of Eligibility Unknown or Unavailable
2 2 Litigation
3 3 Authorization Delays
4 4 Delay in Certifying Provider
5 5 Delay in Supplying Billing Forms
6 6 Delay in Delivery of Custom-made Appliances
7 7 Third Party Processing Delay
8 8 Delay in Eligibility Determination
9 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10 10 Administration Delay in the Prior Approval Process
11 11 Other
2300 PWK01 Attachment Report Type Code
77 77 Support Data for Verification REFERRAL: Use this code to indicate a completed referral form
AS AS Admission Summary
B2 B2 Prescription
B3 B3 Physician Order
B4 B4 Referral Form
CT CT Certification
DA DA Dental Models
DG DG Diagnostic Report
DS DS Discharge Summary
EB EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer)
MT MT Models
NN NN Nursing Notes
OB OB Operative Note
OZ OZ Support Data for Claim
PN PN Physical Therapy Notes
PO PO Prosthetics or Orthotic Certification
PZ PZ Physical Therapy Certification
RB RB Radiology Films
RR RR Radiology Report
RT RT Report of Tests and Analysis Report
11 09/27/2022
2300 PWK02 Attachment Transmission Type Code

AA AA Available on Request at Provider Site
BM BM By Mail
EL EL Electronically Only
EM EM E-Mail
FX FX By Fax
2300 CN101 Contract Type Code
02 02 Per Diem
03 03 Variable Per Diem
04 04 Flat
05 05 Capitated
06 06 Percent
09 09 Other
2300 REF02 Service Authorization Exception Code
1 1 Immediate/Urgent Care
2 2 Services rendered in a retroactive period
3 3 Emergency Care
4 4 Client as temporary Medicaid
5 5 Request from County for second opinion to recipient can work
6 6 Request for override pending
7 7 Special handling
2300 REF02 Assign for 4081 Claims
Y Y 4081
N N Regular Crossover
2300 NTE01 Claim Note Qualifier
ADD ADD Additional Information
CER CER Certification Narrative
DCP DCP Goals, Rehabilitation Potential, or Discharge Plans
DGN DGN Diagnosis Description
PMT PMT Payment
TPO TPO Third Party Organization Notes
2300 CR103 Transport Code
I I Initial Trip
R R Return Trip
12 09/27/2022
T T Transfer Trip
X X Round Trip
2300 CR104 Transport Reason Code
A A Patient was transported to nearest facility for care of symptoms, complaints, or both
B B Patient was transported for the benefit of a preferred physician
C C Patient was transported for the nearness of family members
D D Patient was transported for the care of a specialist or for availability of specialized equipment
E E Patient Transferred to Rehabilitation Facility
2300 CR208 Nature of Condition Code
A A Acute Condition
C C Chronic Condition
D D Non-acute Condition
E E Non-life Threatening
F F Routine
G G Symptomatic
M M Acute Manifestation of a Chronic Condition
2300 CRC01 Ambulance Certification Category
07 07 Ambulance Certification
2300 CRC02 Ambulance Certification Condition Indicator
N N No
Y Y Yes
2300 CRC03-07 Ambulance Condition Code
01 01 Patient was admitted to a hospital
02 02 Patient was bed confined before the ambulance service
03 03 Patient was bed confined after the ambulance service
04 04 Patient was moved by stretcher
05 05 Patient was unconscious or in shock
06 06 Patient was transported in an emergency situation
07 07 Patient had to be physically restrained
08 08 Patient had visible hemorrhaging
09 09 Ambulance service was medically necessary
60 60 Transportation Was to the Nearest Facility
2300 CRC01 Vision Certification Category
E1 E1 Spectacle Lenses
E2 E2 Contact Lenses
13 09/27/2022
E3 E3 Spectacle Frames
14 09/27/2022
2300 CRC02 Vision Certification Condition Indicator

N N No
Y Y Yes
2300 CRC03-07 Vision Condition Code
L1 L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
L2 L2 Replacement Due to Loss or Theft
L3 L3 Replacement Due to Breakage or Damage
L4 L4 Replacement Due to Patient Preference
L5 L5 Replacement Due to Medical Reasons
2300 CRC01 EPSDT Referral Certification Category
ZZ ZZ Mutually Defined
2300 CRC02 Certification Condition Applies Indicator
N N No
Y Y Yes
2300 CRC03-05 EPSDT Condition Code
AV AV Available- Not Used
NU NU Not Used
S2 S2 Under Treatment
ST ST New Services Requested
2300 HI01-1 Diagnosis Code Qualifier
BK BF ICD-9 Diagnosis Codes
2300 HCP01 Pricing Methodology
00 00 Zero Pricing (Not Covered Under Contract)
01 01 Priced as Billed at 100%
02 02 Priced at the Standard Fee Schedule
03 03 Priced at a Contractual Percentage
04 04 Bundled Pricing
05 05 Peer Review Pricing
07 07 Flat Rate Pricing
08 08 Combination Pricing
09 09 Maternity Pricing
10 10 Other Pricing
11 11 Lower of Cost
12 12 Ratio of Cost
13 13 Cost Reimbursed
15 09/27/2022
14 14 Adjustment Pricing
2300 HCP13 Rejection Reason Code
T1 1 Cannot Identify Provider as TPO (Third Party Organization) Participant
T2 2 Cannot Identify Payer as TPO (Third Party Organization) Participant
T3 3 Cannot Identify Insured as TPO (Third Party Organization) Participant
T4 4 Payer Name or Identifier Missing
T5 5 Certification Information Missing
T6 6 Claim Does Not Contain Enough Information for Repricing
2300 HCP14 Policy Compliance Code
1 01 Procedure Followed (Compliance)
2 02 Not Followed - Call Not Made (Non-Compliance Call Not Made)
3 03 Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4 04 Not Followed Other (Non-Compliance Other)
5 05 Emergency Admit To Non-Network Hospital
2300 HCP15 Exception Code
1 01 Non-Network Professional Provider in Network Hospital
2 02 Emergency Care
3 03 Services or Specialist not in Network
4 04 Out -of- Service Area
5 05 State Mandates
6 06 Other
2305 CR701 Home Health Discipline Type Code
AI AI Home Health Aide
MS MS Medical Social Worker
OT OT Occupational Therapy
PT PT Physical Therapy
SN SN Skilled Nursing
ST ST Speech Therapy
2305 HSD03 Home Health Modulus UBM Code
DA DA Days
MO MO Month(s)
Q1 Q1 Quarter (Time) Q1
WK WK Week
2305 HSD05 Home Health Time Period Qualifier
7 7 Day
16 09/27/2022
35 35 Week
17 09/27/2022
2305 HSD07 Home Health Calendar Pattern Code

1 1 1st Week of Month
2 2 2nd Week of Month
3 3 3rd Week of Month
4 4 4th Week of Month
6 6 1st & 3rd Weeks of Month
7 7 2nd & 4th Weeks of Month
A A Monday through Friday
B B Monday through Saturday
C C Monday through Sunday
D D Monday
E E Tuesday
F F Wednesday
G G Thursday
H H Friday
J J Saturday
K K Sunday
L L Monday through Thursday
N N As Directed
O O Daily Monday through Friday
S S Once Anytime Monday through Friday
SA SA Sunday, Monday, Thursday, Friday, Saturday
SB SB Tuesday through Saturday
SC SC Sunday, Wednesday, Thursday, Friday, Saturday
SD SD Monday, Wednesday, Thursday, Friday, Saturday
SG SG Tuesday through Friday
SL SL Monday, Tuesday and Thursday
SP SP Monday, Tuesday and Friday
SX SX Wednesday and Thursday
SY SY Monday, Wednesday and Thursday
SZ SZ Tuesday, Thursday and Friday
W W Whenever Necessary
18 09/27/2022
2305 HSD08 Home Health Delivery Time Pattern Code

D D A.M.
E E P.M.
F F As Directed
2310A NM101 Provider Name Qualifiers
DN DN Referring Provider
P3 P3 Primary Care Physician
2310A NM102 Entity Type Qualifier
1 L Person
2 O Non Person Entity
2310A-B PRV03 Provider Taxonomy Code
* * Source:
BCBS Association and ASC X12N TG2 WG15
Available From:
Washington Publishing Company
http://www.wpc-edi.com
2310B NM101 Provider Name Qualifiers

82 82 Rendering Provider
2310B NM102 Entity Type Qualifier
1 L Person
2310C NM101 Provider Name Qualifiers
QB QB Purchase Service Provider
2310C NM102 Entity Type Qualifier
1 L Person
2310D NM101 Provider Name Qualifiers
77 77 Service Location
FA FA Facility
LI LI Independent Laboratory
TL TL Testing Laboratory
2310D NM102 Entity Type Qualifier
19 09/27/2022
2310E NM101 Provider Name Qualifiers

DQ DQ Supervising Physician
2310E NM102 Entity Type Qualifier
1 L Person
2320 SBR01 Sequence Number
P 01 Primary Payer
S 02 Secondary Payer
T 03 Tertiary Payer
T 04 Fourth Payer
T 05 Fifth Payer
2320 SBR02 Patient Relation to Insured
01 02 Spouse
04 19 Grandfather or Grandmother
05 13 Grandson or Granddaughter
07 14 Nephew or Niece
10 06 Foster Child
15 07 Ward
17 05 Stepson or Stepdaughter
18 01 Self
19 03 Child
20 08 Employee
21 09 Unknown
22 10 Handicapped Dependent
23 16 Sponsored Dependent
24 17 Dependent of a Minor Dependent
29 22 Significant Other
36 21 Emancipated Minor
39 11 Organ Donor
40 12 Cadaver Donor
41 15 Injured Plaintiff
43 04 Child where insured has no financial responsibility
53 20 Life Partner
G8 99 Other Relationship
20 09/27/2022
2320 SBR05 Insurance Type Code

AP AP Auto Insurance Policy
C1 C1 Commercial
CP CP Medicare Conditionally Primary
GP GP Group Policy
HM HM HMO
IP IP Individual Policy
LD LD Long Term Policy
LT LT Litigation
MB MB Medicare Part B
MC MC Medicaid
MI MG Medigap Part B
MP MP Medicare Primary
OT OT Other
PP PP Personal Payment (Cash - No Insurance)
SP SP Supplemental Policy
2320 SBR09 Claim Filing Indicator Code
09 A Self Pay
10 K Central Certification
11 Z Other/Other Non Federal Programs
12 X Preferred Provider Organization
13 Q Point of Service
14 R Exclusive Provider Organization (EPO)
15 S Indemnity Insurance
16 2 Health Maintenance Organization-Medicare Risk
AM 3 Automobile Medical
BL G Blue Shield
BL P Blue Cross Provider Number
CH H Champus
CI F Commercial Insurance Co.
DS 5 Disability
HM Y HMO
LI W Liability
LM 1 Liability Medical
MB C Medicare
21 09/27/2022
MC D Medicaid
OF E Other Federal Program
TV T Title V
VA V Veteran's Administration Plan
WC B Workers Compensation
ZZ 4 Mutually Defined
2320 CAS01 CAS Group Code
CO CO Contractual Obligations
CR CR Correction and Reversals
OA OA Other Adjustments
PI PI Payer Initiated Reductions
PR PR Patient Responsibility
2320 CAS02 CAS Code
* * Source:
National Health Care Claim Payment/Advice Committee Bulletins
Available from:
www.wpc-edi.com
2320 DMG03 Other Subscriber Gender Code

F F Female
M M Male
U U Unknown
2320 OI03 Benefits Assigment Certification Indicator
Y Y Yes, benefits are assigned
N N No, benefits are not assigned
2320 OI04 Patient Signature Source Code
B B Authorization Form - Block 12 & 13
C Y Signed HCFA 1500 on file
M M Authorization Form - Block 13
P N Provider Signed
S S Authorization Form - Block 12
22 09/27/2022
2320 OI06 Release of Information Code

A A Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review
Organization.
I I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal
M R Statutes.
The Provider has Limited or Restricted Ability to Release Data Related to a Claim.
N N No, Provider is Not Allowed to Release Data
O O On file at Payer or at Plan Sponsor
Y Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim.
2320 MOA03-07 Claim Payment Remark Code
* * Washington Publishing Company
or
Health Care Financing Administration (HCFA)
http://www.hcfa.gov/medicare/edi/edi.htm
2330A REF01 Other Subscriber Secondary ID Qualifier

23 23 Client Number
2330B REF01 Other Payer Secondary ID Qualifier
2U 2U Payer Identification Number
F8 F8 Original Reference Number (non-destination payer only)
NF NF National Association of Insurance Commissioners (NAIC) Code
TJ TJ Federal Taxpayer's Identification Number
2330C REF01 Other Patient Secondary ID Qualifier
23 23 Client Number
2330D REF01 Other Payer Referring Provider ID Qualifier
1B 1B Blue Shield Provider Number
1C 1C Medicare Provider Number
1D 1D Medicaid Provider Number
EI EI Employer's Identification Number
G2 G2 Provider Commercial Number
23 09/27/2022
LU LU Location Number
N5 N5 Provider Plan Network Identification Number
2330E REF01 Other Payer Rendering Provider ID Qualifier
2330F REF01 Other Payer Purchased Service Provider ID Qualifier
1A 1A Blue Cross Provider Number
2330G REF01 Other Payer Service Facility Provider ID Qualifier
1A 1A Blue Cross Provider Number
2330H REF01 Other Payer Supervising Provider ID Qualifier
24 09/27/2022
2400 SV101-1 Procedure Code Qualifier

HC HC HCPCS - Health Care Financing Administration Common Procedural Coding System Codes
IV IV HIEC - Home Infusion EDI Coalition Product/Service Code
ZZ ZZ Mutually Defined - Worker Compensation Claims Only
2400 SV103 Units of Service Qualifier
F2 F2 International Units
MJ MJ Minutes
UN UN Unit
2400 SV105 Place of Service Code
* * See CMS Web Site for Current Values
http://www.cms.hhs.gov/states/poshome.asp
2400 SV106 Type of Service Code

0 0 Blood Charges
1 1 Medical Care
2 2 Surgery
3 3 Consultation
4 4 Diagnostic Radiology
5 5 Diagnostic Laboratory
6 6 Radiation Therapy
7 7 Anesthesia
8 8 Surgical Assistance
9 9 Other Medical Service
A A Use DME
B B Ambulance
C C Chiropractic Services
D D DME Purchase
F F Ambulatory Surgery Center
G G Psychiatry
I I Interpretation
25 09/27/2022
L L Renal Supplies in the Home

M M Alternate Method Dialysis Payment
N N CRD Equipment
P P Pre-Admission Testing
R R DME Rental
V V Pneumonia Vaccine
Y Y Second Opinion on Elective Surgery
Z Z Third Opinion on Elective Surgery
2400 SV107-1-4 Diagnosis Code Pointer's
1-8 1-8 Points to appropriate Diagnosis code(s) for the service line
2400 SV506 Rental Unit Price Indicator
1 W Weekly
4 M Monthly
6 D Daily
2400 PWK02 Attachment Transmission Code
AB AB Previously Submitted to Payer
AD AD Certification Included in this Claim
AF AF Narrative Segment Included in this Claim
AG AG No Documentation is Required
NS NS Not Specified
2400 CR103 Transport Code
I I Initial Trip
R R Return Trip
T T Transfer Trip
X X Round Trip
2400 CR104 Transport Reason Code
A A Patient was transported to nearest facility for care of symptoms, complaints, or both
B B Patient was transported for the benefit of a preferred physician
C C Patient was transported for the nearness of family members
D D Patient was transported for the care of a specialist or for availability of specialized equipment
E E Patient Transferred to Rehabilitation Facility
26 09/27/2022
2400 CR208 Nature of Condition Code

A A Acute Condition
C C Chronic Condition
D D Non-acute Condition
E E Non-life Threatening
F F Routine
G G Symptomatic
M M Acute Manifestation of a Chronic Condition
2400 CR212 X-Ray Availibility Indicator
N N No
Y Y Yes
2400 CR301 DMERC Certificate of Medical Necessity
I I Initial
R R Renewal
S S Revised
2400 CR501 Home Oxygen Certification Type Code
I I Initial
R R Renewal
S S Revised
2400 CR512 Oxygen Test Condition Code
E E Exercising
R R At rest on room air
S S Sleeping
2400 CRC01 Ambulance Condition Code Category
07 07 Ambulance Certification
2400 CRC02 Ambulance Certification Condition Indicator
N N No
Y Y Yes
27 09/27/2022
2400 CRC03-7 Ambulance Condition Code

01 01 Patient was admitted to a hospital
02 02 Patient was bed confined before the ambulance service
03 03 Patient was bed confined after the ambulance service
04 04 Patient was moved by stretcher
05 05 Patient was unconscious or in shock
06 06 Patient was transported in an emergency situation
07 07 Patient had to be physically restrained
08 08 Patient had visible hemorrhaging
09 09 Ambulance service was medically necessary
60 60 Transportation Was to the Nearest Facility
2400 CRC01 DMERC Condition Code Category
09 09 Durable Medical Equipment Certification
11 11 Oxygen Therapy Certification
2400 CRC02 DMERC Certification Condition Indicator
N N No
Y Y Yes
2400 CRC03-7 DMERC Condition Code
37 37 Oxygen delivery equipment is stationary
38 38 Certification signed by the physician is on file at the supplier's office
AL AL Ambulation Limitations
P1 P1 Patient was Discharged from the First Facility
ZV ZV Replacement Item
2400 MEA01 Measurement ID Code
TR TR Test Results
OG OG Original Starting Dosage
2400 MEA02 Measurement ID Qualifier
GRA GRA Gas Test Rate
HT HT Height
R1 R1 Hemoglobin
R2 R2 Hematocrit
R3 R3 Epoetin Starting Dosage
R4 R4 Creatin
ZO ZO Oxygen
28 09/27/2022
2400 CN101 Contract Type Code

01 01 Diagnosis Related Group (DRG)
02 02 Per Diem
03 03 Variable Per Diem
04 04 Flat
05 05 Capitated
06 06 Percent
09 09 Other
2400 NTE01 Service Line Extra Narrative Data Qualifier
ADD ADD Additional Information
DCP DCP Goals, Rehabilitation Potential, or Discharge Plans
PMT PMT Payment
TPO TPO Third Party Organization Notes
2400 HSD03 Home Health Unit or Basis of Measurement
DA DA Days
MO MO Month(s)
Q1 Q1 Quarter (Time)
WK WK Week
2400 HSD05 Home Health Time Period Qualifier
7 7 Day
35 35 Week
34 34 Month
2400 HSD07 Home Health Ship/Delivery Calendar Pattern Code
1 1 1st Week of Month
2 2 2nd Week of Month
3 3 3rd Week of Month
6 6 1st & 3rd Weeks of Month
7 7 2nd & 4th Weeks of Month
A A Monday through Friday
B B Monday through Saturday
C C Monday through Sunday
D D Monday
E E Tuesday
29 09/27/2022
F F Wednesday
G G Thursday
H H Friday
J J Saturday
K K Sunday
L L Monday through Thursday
N N As Directed
O O Daily Monday through Friday
SA SA Sunday, Monday, Thursday, Friday, Saturday
SB SB Tuesday through Saturday
SC SC Sunday, Wednesday, Thursday, Friday, Saturday
SD SD Monday, Wednesday, Thursday, Friday, Saturday
SG SG Tuesday through Friday
SL SL Monday, Tuesday and Thursday
SP SP Monday, Tuesday and Friday
SX SX Wednesday and Thursday
SY SY Monday, Wednesday and Thursday
SZ SZ Tuesday, Thursday and Friday
W W Whenever Necessary
2400 HSD08 Home Health Ship/Delivery Time Pattern Code
D D A.M.
E E P.M.
F F As Directed
2400 HCP01 Pricing Methodology
00 00 Zero Pricing (Not Covered Under Contract)
01 01 Priced as Billed at 100%
02 02 Priced at the Standard Fee Schedule
03 03 Priced at Contractual Percentage
04 04 Bundled Pricing
05 05 Peer Review Pricing
06 06 Per Diem Pricing
07 07 Flat Rate Pricing
30 09/27/2022
08 08 Combination Pricing
09 09 Maternity Pricing
10 10 Other Pricing
11 11 Lower of Cost
12 12 Ratio of Cost
13 13 Cost Reimbursed
14 14 Adjustment Pricing
2400 HCP09 Approved Procedure Code Qualifier
HC HC HCPCS - Health Care Financing Administration Common Procedural Coding System Codes.
IV IV HIEC - Home Infusion EDI Coalition Product/Service Code
2400 HCP11 Approved Units Basis of Measurement
DA DA Days
UN UN Units
2400 HCP13 Rejection Reason Code
T1 1 Cannot Identify Provider as TPO (Third Party Organization) Participant
T2 2 Cannot Identify Payer as TPO (Third Party Organization) Participant
T3 3 Cannot Identify Insured as TPO (Third Party Organization) Participant
T4 4 Payer Name or Identifier Missing
T5 5 Certification Information Missing
T6 6 Claim Does Not Contain Enough Information for Repricing
2400 HCP14 Policy Compliance Code
1 01 Procedure Followed (Compliance)
2 02 Not Followed - Call Not Made (Non-Compliance Call Not Made)
3 03 Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4 04 Not Followed Other (Non-Compliance Other)
5 05 Emergency Admit To Non-Network Hospital
2400 HCP15 Exception Code
1 01 Non-Network Professional Provider in Network Hospital
2 02 Emergency Care
3 03 Services or Specialist not in Network
4 04 Out -of- Service Area
5 05 State Mandates
6 06 Other
31 09/27/2022
2410 CTP05-1 Drug Pricing Unit Code Qualifier

F2 F2 International Unit
GR GR Gram
ML ML Milliliter
UN UN Unit
2420A NM101 Rendering Provider Name Qualifier
82 82 Rendering Provider
2420A NM102 Provider Last Name / Organization Type Code
1 L Last Name
2 O Organization Name
2420A NM108 Tax Identification Number Qualifier
24 E Employer's Identification Number
34 S Social Security Number
2420A PRV03 Provider Taxonomy Code
* * Source:
Available From:
2420B NM101 Purchased Service Provider Name Qualifier

QB QB Purchase Service Provider
2420B NM102 Provider Last Name / Organization Type Code
1 L Last Name
2420B NM108 Tax Identification Number Qualifier
2420C NM101 Service Facility Provider Name Qualifier
77 77 Service Location
FA FA Facility
LI LI Independent Laboratory
TL TL Testing Laboratory
2420C NM102 Provider Last Name / Organization Type Code
32 09/27/2022
2420C NM108 Tax Identification Number Qualifier

2420D NM101 Supervising Provider Name Qualifier
DQ DQ Supervising Physician
2420D NM102 Provider Last Name / Organization Type Code
1 L Last Name
2420D NM108 Tax Identification Number Qualifier
2420E NM101 Ordering Provider Name Qualifier
DK DK Ordering Provider
2420E NM102 Provider Last Name / Organization Type Code
1 L Last Name
2420E NM108 Tax Identification Number Qualifier
2420F NM101 Referring Provider Name Qualifier
DN DN Referring Provider
P3 P3 Primary Care Provider
2420F NM102 Provider Last Name / Organization Type Code
1 L Last Name
2420F NM108 Tax Identification Number Qualifier
2420F PRV03 Provider Taxonomy Code
* * Source:
Available From:
2420G NM108 Other Payer Prior Authorization ID Qualifier

PI PI Payer Identification
XV XV National Payer Identifier
33 09/27/2022
2430 SVD03-1 Procedure Code Qualifier

HC HC HCPCS - Health Care Financing Administration Common Procedural Coding System Codes
IV IV Home Infusion EDI Coalition Product/Service Code
2430 CAS01 CAS Group Code
CO CO Contractual Obligations
CR CR Correction and Reversals
OA OA Other Adjustments
PI PI Payer Initiated Reductions
PR PR Patient Responsibility
2430 CAS CAS Code
* * Source:
National Health Care Claim Payment/Advice Committee Bulletins
Available from:
www.wpc-edi.com
2440 LQ01 Form Identifier Qualifier

AS AS Form Type Code
UT UT Health Care Financing Administration (HCFA) Durable Medical Equipment Regional Carrier (DMERC)
Certificate of Medical Necessity (CMN) Forms
2440 FRM02 Question Response Indicator
N N No
W W Not Applicable
Y Y Yes
34 09/27/2022
Final IB_4010x098A1_PCDS Changes
March 9, 2006
2010AA/NM109 Line# 137: ITG# 42404
Removed mapping of RT E6-11 from NM109 Loop 2010AA
2010AA/REF01 Line# 163: ITG# 42404
Added Translator Notes to E6-13 in Loop 2010AA for the Social
Security Qualifier of 'SY'
May 24, 2006

XXXXX Table Line# 75: ITG# 47321:
Added Payer ID 68036 John Muir/ Mt. Diablo Health Network to
XXXXX Table
September 7, 2006
Payer ID Line# 50: ITG# 55013
XXXXX Table **** Added Payer ID 60550 Gateway Health Plan to Payer ID
'XXXXX' Table****
September 26, 2006

2300/REF02 Line# 616: ITG# 67664
Added statement to end of logic
If Loop 2300 OR 2400 HCP Segment is present
AND REF01 = '9A' THEN map to CZ-05
Else if REF01 does not = ‘9A’ but does = ‘D9’ THEN map to CZ-
05 And clear out CZ-05 before writing out the next claim.
October 11, 2006

XXXXX Line# 51: ITG# 53942
Table Added Payer ID 25531 GHI HMO to 'XXXXX Table'
November 9, 2006
35
2010AA/B0-11 Line# 180 & 182: ITG# 72381
Added note to B0-11 for mapping of Blue Cross and Blue Shiled
Numbers (1A and 1B). We were not mapping but one if both came in
and was loosing the number.
If REF 01= '1A' and is less than 14 bytes and not previously
populated, then map to B0-11, Else map to BS Secondary ID and set
REF01 to ='1A'
If REF01 = '1A' and greater than 13 bytes, map to the first available BS
Record with a '1A' qualifier.
If REF 01= '1B', and is less than 14 bytes and not previously
populated then map to B0-11 Else map to BS Secondary ID and set
REF01 to ='1B'
If REF01 = '1B' and greater than 13 bytes, map to the first available BS
Record with a '1B' qualifier.
November 29, 2006

XXXXX Table Line# 92: ITG# 79415
Added Payer ID 36398 North American Medical Management to the
XXXXX Table
December 7, 2006
2300/REF Line#'s 603 & 607: ITG# 79454
Added dual mapping of RT D3-05 and D3-06 to Loop 2300 REF
segment for Prior Authorization and Referral Number
Janurary 3, 2007
Added Payer ID 36609 to the Payer ID 'XXXXX' Table
Janurary 15, 2007

1000A/NM109 Line# 60: ITG# 79226
Added logic to Loop 1000A NM109 segment to pull Sender ID
from ISA06 if Loop 1000A NM109 was not present.
Janurary 31, 2007

XXXXX Line#'s 46, 55, 69, 121 & 122: ITG# 84114
Table Removed Payer ID's 14162, 14163, 14164, 36405 and 59608
from XXXXX Table
March 8, 2007
36
2010AA/REF Line# 174: ITG# 100614
Added If REF01 = 'EI' and third position of REF02 = '_', strip '_' and
concatenate the number prior to mapping to BS ID.
2010AB/REF Line# 241: ITG# 100614
Added If REF01= 'EI' and third position of REF02 = '_', strip '_' and
concatenate the number prior to mapping to BU ID.
2310A/REF Line# 825: ITG# 100614
concatenate the number prior to mapping to E7 ID.
2310B/REF Line# 856: ITG# 100614
Added If REF01 = 'EI' and third position of REF02 = '_', strip '_' and
2310C/REF Line# 884: ITG# 100614
2310E/REF Line# 938: ITG# 100614
2420A/REF Line# 1500: ITG# 100614
concatenate the number prior to mapping to F7 ID.
2420B/REF Line# 1522: ITG# 100614
2420D/REF Line# 1575: ITG# 100614
2420E/REF Line# 1609: ITG# 100614
2420F/REF Line# 1660: ITG# 100614
March 23, 2007

BHT03 Line# 42: ITG# 103626
Added mapping of new record AB-06 to BHT03. BHT03 now gets
dual mapped to A0-15 and AB-06
April 11,2007
37
PS1 Line# 1433: ITG# 116656
Added additional logic to Header for PSI Segment. If provider sent an
inbound PS1 segment, the F7 information was not getting written out.
If PS1 Segment is present, Create an F6/F7 packet and set F6-05 and
F7-05 to 'QB'
April 27, 2007

Payer ID = Line# 112: ITG# 107285
XXXXX Table Added Payer ID 77303 Sutter Medical Foundation to the Payer ID =
'XXXXX' Table
May 4, 2007
Payer ID = Line# 13: ITG# 116655
XXXXX Table Added Payer ID 87265 Benesight to the Payer ID = 'XXXXX' Table
June 8, 2007
PS1 Line# 1433: ITG# 146572
If PS1 Segment is present, Create an F6/F7 packet and set F6-05
and F7-05 to 'QB'
If both PS1 and Loop 2420B are present where F7-05 = 'QB', Then
create only one F7-05 QB' per service line and make sure F6-03
and F7-03 Sequence number are same.
July 11, 2007

2310B Line#'s 842 & 844: ITG# 151579
NM108 & 109 Added new translator notes to 2310B NM108 and NM109
If Submitter ID = '332211888' or '332211999' and NM108/NM109
is present and NM103 or NM104 = 'None', then create an E6
where E6-05 = '82' and map accordingly.
October 18, 2007

**Payer ID XXXXX**
Added Payer ID 57105 Carolina Care Plan to XXXXX Logic
October 26, 2007

**Payer ID XXXXX**
Added Payer ID 38216 Health Plus of Michigan to XXXXX Logic
38
November 16, 2007
2010BA Line# 290: ITG# 186892
If SBR02 = '18', Map to D1-10 and D1-13 ,
If 2010CA NM109 is present, Do Not map D1-10 or D1-13 to
2010BA NM109.
2010BA Line# 291: ITG# 186892
If SBR02 = '18', Map to D1-13 and D1-10 ,
If 2010CA NM109 is present, Do Not map D1-10 or D1-13 to
2010BA NM109.
December 17, 2007

XXXXX Table **Added Payer ID 13335 Healthsource Hudson to Payer ID =
'XXXXX' Table**
January 10, 2008

XXXXX Table ** Removed Payer ID 04271 Harvard Pilgram Health Care from
XXXXX Table**
January 15, 2008

XXXXX Table ** Removed Payer ID 57105 Carolina Care Plan from Payer ID
'XXXXX' Table**
XXXXX Table ** Removed Payer ID 29076 MMO (Medical Mutual of Ohio)
from Payer ID 'XXXXX' Table**
January 31, 2008

N403 Loops 2010AA, AB, BA, BB, BC, CA, 2319D, and 2330A
ITG# 200669
Removed statement of: "Strip non-numeric characters and
concatenate before mapping" from N403 segments. Canada's zip
codes are A/N and we are scrubbing non numeric characters
causing rejections.
39
Feburary 13, 2008
2420G/NM109 Line# 1675: ITG# 199533
*Global* If Loop 2420G is present and NM108 = 'PI', Then map payer
id positions 1-5 left justified to KR-06
Feburary 15, 2008

2430 Line# 1687: ITG# 208746
Added to existing logic for SVD01
Map first 5 bytes
40
Payer Specific Edits
Final IB 4010 to PCDS
November 18, 2004

2310B/REF02 Line# 859: MTT# 04080927950
Payer ID 04298 Tufts
If payer ID = 04298 And REF01 = 'N5' for Loop 2310B AND
REF01 = '1G' anywhere in Loop 2310, THEN Write ID from Loop
2310B REF*N5 to E6-15 AND write ID from Loop 2310B REF to
first available PCDS RT E7-07 ELSE If REF*N5 Does Not exist in
Loop 2310B, THEN write ID from Loop 2310B REF*1G to E6-15.
November 29, 2004

2400/CR510 Line# 1209: MTT#04110437943 & MTT# 04123043243
For All Payers
If CR510 contains a "." in Loop 2400, THEN Remove the "." AND
Disgard all decimal positions past the first decimal position AND
Map the remaining value to GT-05 AND Fill GT-05 with high-
order zeros if necessary (Maxium of 3 numerals) , ELSE Fill GT-
05 with 1 low-order zero ( For the implied decimal) AND Fill GT-
05 with high-order zeros if necessary (Maxium of 3 numerals).
2400/CR511 Line# 1210: MTT#04110437943 & MTT# 04123043243

For All Payers
If CR511 contains a "." in Loop 2400, THEN Remove the "." AND
Disgard all decimal positions past the first decimal position AND
Map the remaining value to GT-06 AND Fill GT-06 with high-
order zeros if necessary (Maxium of 3 numerals) , ELSE Fill GT-
06 with 1 low-order zero ( For the implied decimal) AND Fill GT-
06 with high-order zeros if necessary (Maxium of 3 numerals).
March 25, 2005

2010AA/2310B Line#'s 188 & 854: MTT# 04110838355
REF Payer ID 04298 TUFTS
If Payer ID = 04298 AND Loop 2010AA AND Loop 2310B REF01
= 'G2', THEN map REF01 to = 'G2' AND REF02 (D0-20 ) to Both
Loops of the triggered D0 where D0-26 = 'X'
April 20, 2005
2310B/REF02 Line# 860: MTT# 05020304033
Payer ID Coventry (Multiple ID's)
If Payer ID = 25126, 25128 THEN map in this order of Qualifiers
for Loop 2310B If one is not present, move to next: IF REF01 =
'1G' , THEN map REF02 to RT E6-15, ELSE If REF01 = 'N5',
THEN map REF02 to RT E6-15, ELSE If REF01 = 'G2', THEN
map REF02 to RT E6-15, If REF01 = '1C', THEN map REF02 to
RT E6-15.
2310B/REF02 Line# 861: MTT# 05020103648
If Payer ID = 25127, 25129, 25130, 25131, 25132, 25133, 25134,
25135, 25136, 25139, 25140, 25141, 25142, 25143, 25146,
25150 THEN map in this order of Qualifiers for Loop 2310B If
one is not present, move to next: If REF01 = 'N5', THEN map
REF02 to RT E6-15, ELSE If REF01 = 'G2', THEN map REF02
to RT E6-15, If REF01 = '1C', THEN map REF02 to RT E6-15.
June 22, 2005

2010AA/2310B Line# 188 & 854: ITG# 31755
Payer ID 04298 TUFTS MTT# 04110838355 & ITG# 31755
If Payer ID = 04298 AND Loop 2010AA AND Loop 2310B
REF01 = 'G2', THEN map REF01 to = 'G2' AND REF02 (D0-
20 ) to Both Loops of the triggered D0 where D0-26 = 'X'
Loop 2010AA with REF01 = 'G2' is present AND Loop 2310B
with REF01 = 'G2' is present, THEN map D0-20 to 2310B
REF02 AND Do Not Map D0-20 to Loop 2010AA.
IF 2310B REF02 (D0-20) is not present and Loop 2010AA is
present with REF01 = 'G2', then map D0-20 to 2010AA
REF02. November 18, 2005
ISA13 See Loops
Line# 2010AA
21: ITG# & 2310B
37466
Submitter ID 223630888 PTG
If Sumbitter ID = '223630888' THEN move last 4 bytes of ISA13
to A0-16d position 157-160 AND move the same ISA13 to each
A0 record for every ST in the file until you reach a new ISA.
February 21, 2006

2310B/REF01 Line# 849: ITG# 39206
Payer ID 62179 Health Choice AZ
If Payer ID = 62179 AND D0-26 Claim Payment Trigger = 'X',
AND Loop 2310B REF01 = '1D' (Medicaid) THEN map
Secondary ID equal to 6 numeric bytes in REF02 to PCDS E6-
15 Network ID AND set E6-05 to = '82' if not previously set, ELSE
map to existing logic..
March 3, 2006
2300/REF Line# 609: ITG# 43055
Payer ID 35182 Coresource
If Submitter ID in NM109 Loop 1000A = 471980001 AND
Triggered Payer ID = 35182 AND Loop 2300 REF*9A is present
AND REF*F8 is Not Present, THEN dual map Loop 2300 REF02
where REF01=9A to PCDS EA-17 AND PCDS E1-05.
March 8, 2006
2310B/REF Line# 863: ITG# 42079
Added payer id 25149 to existing logic for Loop 2310B REF
If Payer ID = 25127, 25129, 25130, 25131, 25132, 25133, 25134,
25135, 25136, 25139, 25140, 25141, 25142, 25143, 25146,
25149, 25150 THEN map in this order of Qualifiers for Loop
2310B If one is not present, move to next: If REF01 = 'N5', THEN
map REF02 to RT E6-15, ELSE If REF01 = 'G2', THEN map
REF02 to RT E6-15, If REF01 = '1C', THEN map REF02 to RT
E6-15.
September 7, 2006
2310D Line 890: ITG# 57821
Payer ID 62308 Carle Clinic
If Payer ID = 62308 AND B0-04 Billing Provider Tax ID =
'371188284' where NM101 = 'FA', THEN map '77' to E6-05 Name
Qualifier and map according to existing logic. If '77' Address info
is written from 2010AA, THEN overwrite with 2310D information
September 12, 2006

2310B Line# 848: Modified on ITG# 61614 (9/12/06)
Payer ID 62179 Health Choice AZ ITG# 39206
If Payer ID = 62179 AND D0-26 Claim Payment Trigger = 'X',
AND any Loop 2310B REF01 = '1D' (Medicaid) THEN map
Secondary ID equal to 6 numeric bytes in REF02 to PCDS E6-
15 Network ID AND set E6-05 to = '82' if not previously set, OR If
there is no Loop 2310B REF*1D but any REF*N5 is present,
THEN map Secondary ID in REF02 to E6-15 AND set E6-05 to
= '82' if not previously set. ELSE map to existing logic.
September 22, 2006

2310B Line# 848: ITG# 64247
Payer ID's 77306, 77304, 77302, 77316, 94318, or 77318 Sutter
Medical
If Payer ID = one of the above payer id's AND E6-15 Network ID
is present where E6-05 = '82', AND more than one qualifier exist,
THEN map REF01 qualifiers in the following order: 'OB', '1C',
'1G', 'N5, and 'G2'
October 23, 2006

2010BA/NM103 Line# 272: ITG# 65801
Payer ID 00139 BCBS MA
If Payer ID = 00139 and Submitter ID = '223630888' AND NM103
= 'XX', THEN Do Not Scrub XX value and map to PCDS D0-11,
DB-07, C0-04 and CB-04 according to existing logic.
2010BA/NM104 Line# 276: ITG# 65801
DB-08, C0-05 and CB-05 according to existing logic.
2010BA/N301 Line# 293: ITG# 65801
If Payer ID = 00139 and Submitter ID = '223630888' AND N301 =
'XX', THEN Do Not Scrub XX value and map to PCDS D1-04,
C0-11 and CB-06 according to existing logic.
2010BA/N401 Line# 300: ITG# 65801
'XX' OR 'XXX', THEN Do Not Scrub XX or XXX value and map to
PCDS D1-06, C0-13 and CB-08 according to existing logic.
2010BA/N402 Line# 303: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS D1-07,
and C0-14 according to existing logic.
2010BB/NM103 Line# 328: ITG# 65801
D2-10 and DB-04 according to existing logic.
2010BC/N301 Line# 359: ITG# 65801
If Payer ID = 00139 and Submitter ID = '223630888' AND N301=
'XX', THEN Do Not Scrub XX value and map to PCDS C2-08 and
CC-06 according to existing logic.
2010BC/N401 Line# 364: ITG# 65801
'XX' OR 'XXX', THEN Do Not Scrub XX OR XXX value and map
to PCDS C2-10 and CC-08 according to existing logic.
2010CA/N301 Line# 414: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS C0-11 and
CB-06 according to existing logic.
2010CA/N401 Line# 419: ITG# 65801
'XX OR 'XXX'', THEN Do Not Scrub XX OR XXX value and map
to PCDS C0-13 and CB-08 according to existing logic.
2010CA/N402 Line# 421: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS C0-14
according to existing logic
2310A/NM103 Line# 802: ITG# 65801
If Payer ID = 00139 and Submitter ID = '223630888' AND
NM103= 'XX', THEN Do Not Scrub XX value and map to PCDS
E6-07 according to existing logic.
2310B/NM103 Line 833: ITG# 65801
2310C/NM103 Line 867: ITG# 65801
2310D/N301 Line# 900: ITG# 65801
to PCDS E8-07 according to existing logic.
2310D/N401 Line# 903: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS E8-09
according to existing logic.
2310D/N402 Line# 904: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS E8-10
2310E/NM103 Line# 920: ITG# 65801
2310E/NM104 Line# 921: ITG# 65801
2330A/NM103 Line# 1026: ITG# 65801
2330A/N401 Line# 1040: ITG# 65801
to PCDS D1-06 according to existing logic.
2330B/NM103 Line# 1051: ITG# 65801
2420A/NM103 Line# 1477: ITG# 65801
F6-07 according to existing logic.
2420C/N301 Line# 1537: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS F8-07
2420C/N401 Line# 1540: ITG# 65801
to PCDS F8-09 according to existing logic.
2420E/NM103 Line# 1583: ITG# 65801
2420E/NM104 Line# 1584: ITG# 65801
F6-08 according to existing logic
2420E/N301 Line# 1593: ITG# 65801
to PCDS F8-07 according to existing logic.
2420E/N401 Line# 1596: ITG# 65801
'XX', THEN Do Not Scrub XX value and map to PCDS F8-09
2420F/NM103 Line# 1637: ITG# 65801
2420F/NM104 Line# 1638: ITG# 65801
November 17, 2006

2010AA/REF Line# 186: ITG# 64347
Payer ID 47137 Qualchoice
If Payer ID = 41737 AND D0-26 Claim Payment Trigger = 'X'
AND Submitter ID in Sort Key position 193-201 = '800222770',
'800222771' or '223719999' AND BA-07 Billing Provider
Commercial Number is NOT present AND D0-20 Provider
Commercial Number IS present, THEN map D0-20 from 1st
claim in new unique batch to Billing Provider Loop 2010AA to
REF02 with REF01 = 'G2'
November 29, 2006

2010AA/REF02 Line 189: ITG# 77129
Submitter ID 363267380 HealthEOS ( MulitPlan and Associate
for Healthcare)
If Submitter ID = 363267380 AND B0-05 Site ID is not present,
THEN hardcode 'ZZZZ'
March 23, 2007

2310D Line# 893: ITG# 95462
Payer ID 62308 Carle Clinic
If Payer ID = 62308 AND B0-04 Billing Provider Tax ID =
'371188284' AND Loop 2310D is present where NM101 = 77,
FA, LI, or TL, THEN Map only '77' to E6-05, E7-05 and E8-05. If
Service Address (77) is written from Loop 2010AA, THEN
overwrite with 2310D information
March 28, 2007

2010BA Line# 305: ITG# 93636
Payer ID's 60054, 23222, 60055, & 57604
If Payer ID's are any of the above AND State = 'XX' AND Zip
Code ='99999' AND Country Code is present and is NOT = 'US'
or 'USA', THEN move Zip Code to D1-08 Insured Zip AND move
State to D1-07 Insured State. ELSE if Patient Relationship Code
= '18' Self THEN move Zip Code to C0-15 Patient Zip Code AND
move State Code to C0-14 Patient State
ELSE If Patient Relationship Code does NOT = '18, THEN move
State and Zip to C0-15 Patient Zip and C0-14 Patient State.
April 25, 2007
2310B/REF02 Line# 859: ITG# 103080
Payer ID 05047 Neighborhood Health Plan of Rhode Island
If Payer ID = 05047 AND Loop 2310B REF*G2 is present and
between 3 and 8 digits, THEN map to D0-20 Rendering Provider
ID AND to the first available E7 Secondary ID where E7
Secondary ID Qualifier = 'G2' and E6-05 = '82' ELSE, If Loop
2010AA REF*G2 is present and between 3 and 8 digits, THEN
map to D0-20 Rendering Provider ID AND to the first available
E7 Secondary ID where E7 Secondary ID Qualifier = 'G2' and
E6-05 = '82' ELSE If Loop 2010AA REF*BQ is present and
between 3 and 8 digits, THEN map to D0-20 Rendering Provider
ID AND to the first available E7 Secondary ID where E7
Secondary ID Qualifier = 'G2' and E6-05 = '82'
April 27, 2007

2310B/REF01 Line# 852: ITG# 123963
Added Payer ID 77303 to existing edit for Sutter Medical
Foundation
Payer ID's 77303, 77306, 77304, 77302, 77316, 94318, or 77318
Sutter Medical ITG# 64247 & ITG# 123963
If Payer ID = one of the above payer id's AND E6-15 Network ID
is present where E6-05 = '82', AND more than one qualifier exist,
THEN map REF01 qualifiers in the following order: 'OB', '1C',
'1G', 'N5, and 'G2'
June 4, 2007
2310B Line# 859: ITG# 145907
Changed digits to A/N Characters for Payer ID 05047
Neighborhood Health Plan of Rhode Island
If Payer ID = 05047 AND Loop 2310B REF*G2 is present and
between 3 and 8 A/N characters, THEN map to D0-20
Rendering Provider ID AND to the first available E7 Secondary
ID where E7 Secondary ID Qualifier = 'G2' and E6-05 = '82'
ELSE, If Loop 2010AA REF*G2 is present and between 3 and 8
A/N characters, THEN map to D0-20 Rendering Provider ID
AND to the first available E7 Secondary ID where E7 Secondary
ID Qualifier = 'G2' and E6-05 = '82' ELSE If Loop 2010AA
REF*BQ is present and between 3 and 8 A/N characters, THEN
map to D0-20 Rendering Provider ID AND to the first available
E7 Secondary ID where E7 Secondary ID Qualifier = 'G2' and
E6-05 = '82'
June 15, 2007
2310B/REF Line# 864: ITG# 141425
Payer ID 23045 Capital Blue Cross
If Payer ID = 23045 AND Loop 2310B is present AND Rendering
Provider Network ID (REF*N5) is present, THEN map to E6-15
where E6-05 = '82', ELSE If Rendering Provider Blue Cross ID
(REF*1B) is present, THEN map Blue Cross ID (1B) to E6-15
Network ID where E6-05 = '82'.
August 9, 2007
2430/KS Line# 1687: ITG# 163515
Payer ID SB701 BCMS of Mass. ITG# 163515
If Payer ID = SB701 AND Loop 2330B Other Payer ID is present
AND Loop 2430 SVD is present, THEN map the first 5 bytes only
of SVD01 to KS-05.
2010AA Line# 190: ITG# 145423
Payer ID 31472 ASK BCBS of Kansas
If Payer ID = 31472 and Sibmitter ID in Loop 1000A NM109 =
'480968999' AND B0-05 Site ID is present where REF01 = G5
AND BA-07 Commercial ID is Not present where REF01 = 'G2,
THEN map first 4 characters of Site ID to B0-05 AND map Site ID
where REF01 = 'G5 to BA-07 Commercial ID.
August 17, 2007

2300/REF Line# 630: ITG# 162438
Medi-Claim (Medifax)
If Submitter ID (ISA06) = 621249087 or 621249999, THEN map
clearinghouse original reference number REF*D9 to WebMD ID
Number X0-18 and WebMD ID Number CZ-05
October 18, 2007

2010AA/REF Line# 190: ITG# 177674
Added Do Not Map to last statement. Payer decided they did
not want information in both places.
Payer ID 31472 ASK BCBS of Kansas ITG# 145423 ITG#
177674
If Payer ID = 31472 and Sibmitter ID in Loop 1000A NM109 =
'480968999' AND B0-05 Site ID is present where REF01 = G5
AND BA-07 Commercial ID is Not present where REF01 = 'G2,
THEN map first 4 characters of Site ID to B0-05 AND Do Not
Map Site ID where REF01 = 'G5 to BA-07 Commercial ID.
November 1, 2007
2300/REF Line# 630: 178129
Medi-Claim (Medifax)
If Submitter ID (ISA06) = 621249087 or 621249999 AND
REF*D9 is present, THEN map clearinghouse original reference
number REF*D9 to Original Clearinghouse ID CZ-04.
January 11, 2008

2010AA/REF Line# 190: ITG# 196561
Payer ID not available Utah Health Information Network (UHIN)
ITG# 196561
If ISA08 receiver ID begins with 'HT', THEN Default B0-05 Site ID
and send to UHIN.
January 29, 2008

2300/REF Line# 630: ITG# 196936
If Submitter ID (ISA06) = 611340767 AND REF*D9 is present,
THEN map clearinghouse original reference number REF*D9 to
CZ-05 Submitter Unique Claim ID
Feburary 15, 2008

2430 Line# 1687: ITG# 208746
Removed Payer Specific edit
Payer ID SB701 BC of Mass. ITG# 163515
If Payer ID = SB701 AND Loop 2330B Other Payer ID is present
AND Loop 2430 SVD is present, THEN map the first 5 bytes only
of SVD01 to KS-05.
Inbound Professional 4010A1 to X12N 837 to PCDS v01.24
837 v4010 PROFESSIONAL CLAIMS ATTRIBUTES ENVOY PCDS ATTRIBUTES
Pg# Seg DE Req PIC Min Use Value Description X12 Cd ENVOY Data Dictionary Rec Fld PIC Len Frm To Inbound Translator Notes
Max Cd
INTERCHANGE CONTROL HEADER

B3 ISA M ID 3/3 R-1 ISA* Interchange Control Header
ISA01 101 M ID 2/2 R [Sel Code]* Authorization Info Qualifier
No Authorization Info. Present 00
Additional Data Identification 03
ISA02 102 M AN 10/10 R [10 spaces]*

ISA03 103 M ID 2/2 R [Sel Code]* Security Information Qualifier
No Security Information Present 00
Password 01
ISA04 104 M AN 10/10 R [10 spaces]*

ISA05 105 M ID 2/2 R ZZ* Mutually Defined ZZ
ISA06 106 M AN 15/15 R [ ]* Interchange Sender ID Must contain ID assigned by WEBMD; 9 byte
Submitter ID Submitter ID followed by 6 spaces
Same as NM109 Loop 1000 A
ISA07 105 M ID 2/2 R ZZ* Mutually Defined ZZ

ISA08 107 M AN 15/15 R 133052274* Receiver ID xmit_recv_id A0 05 9 5 32 36 Positions 1-5 Must = '13305'
xmit_recv_sub_id A0 06 x 4 37 40 Positions 6-9 Must = '2274'
file_trl_recv_id Z0 03 9 5 12 16 Positions 1-5 Must = '13305'
file_trl_recv_sub_id Z0 04 x 4 17 20 Positions 6-9 Must = '2274'
ISA09 108 M DT 6/6 R [ ]* Interchange Date Date is not mapped into Header Record. We
YYMMDD will use BHT04 Date for Header.
Must = YYMMDD
ISA10 109 M TM 4/4 R [ ]* Interchange Time Time is not mapped into Header Record. We
HHMM will use BHT05 Time for Header.
Must = HHMM
ISA11 110 M ID 1/1 R U* US EDI Community of X12, TDCC and UCS U

ISA12 111 M ID 5/5 R 00401* Interchange Control Version Number 00401
Note:
Default A0-03a positions 12-18 to '401098A'
for Professional
ISA13 112 M N0 9/9 R [ ]* Interchange Control Number
ISA14 113 M ID 1/1 R Translate* Acknowledgment Requested ack_req AA 12 x 1 89 89 Envoy will not use this to generate the 997.
We will use Control Table
See Code Table for Translation
ISA15 114 M ID 1/1 R [Sel Code]* Usage Indicator tp_flag A0 16b x 4 145 148 See Code Table for values
ISA16 115 M 1/1 R :~ Component Subelement Separator hex '1F'
B8 GS M ID 2/2 R-1 GS* Functional Group Header
GS01 479 M ID 2/2 R HC* Healthcare Claim HC
GS02 142 M AN 2/15 R [ ]* Application Sender's Code Must contain ID assigned by WEBMD
Submitter's Tax Id
GS03 124 M AN 2/15 R [133052274]* Application Receiver's Code
Receiver ID
Final IB Professional 4010A1 X12N to PCDS v01.24 52 09/27/2022

Max Cd
GS04 373 M DT 8/8 R [ ]* Creation Date

CCYYMMDD
GS05 337 M TM 4/8 R [ ]* Creation Time
HHMMSSDD
GS06 028 M N0 1/9 R [ ]* Group Control Number Must = GE02
GS07 455 M ID 1/2 R X* Accredited Standards Committee X12 X
GS08 480 M AN 1/12 R 004010x098A1~ Version / Release Industry ID Code 004010x098A1
TABLE 1 R-1 HEADER

62 ST M R-1 ST* Transaction Set Header
ST01 143 M ID 3/3 R 837* Healthcare Claim 837
ST02 329 M AN 4/9 R [ ]~ Transaction Set Control Number Must be unique. Starts with 0001, increments
by one for each new ST Segment within this
file.
Must = SE02
63 BHT M R-1 BHT* Beginning of Hierarchical Transaction

BHT01 1005 M ID 4/4 R 0019* Information Source, Subscriber, Dependent 0019 If Not '0019', Syntax Error
BHT02 353 M ID 2/2 R Translate* Transaction Set Purpose Code xmit_stat A0 14 9 1 122 122 See Code Table for Translation
BHT03 127 O AN 1/30 R [ ]* Originator Application Transaction Identifier xmit_serial_no A0 15 x 6 123 128 Move last six bytes of data
xmit_serial_no AB 06 x 30 123 152

batch_id BA 03 x 6 18 23 Translator generated.
BHT04 373 O DT 8/8 R [ ]* Transaction Set Creation Date prcss_dt A0 07 9 6 41 46 Convert CCYYMMDD to MMDDYY
BHT05 337 O TM 4/8 R [ ]* Submission Time sub_tm AA 05 x 6 44 49 Map first six bytes
HHMMSS
BHT06 640 O ID 2/2 R Translate~ Claim / Encounter Identifier batch_typ B0 02 x 3 03 05 Used to indicate an entire batch of claims or
Chargable CH 100 encounters. If mixed, use CH.
Reporting RP 102
clm_typ E0 24 x 3 130 132 Map to all Claims within this batch.

66 REF O R-1 REF* Transmission Type Identifier
REF01 128 M ID 2/3 R 87* Reference Qualifier 87 NOT MAPPED
REF02 127 X AN 1/30 R 004010x098A1~ Transmission Type Code 004010x098A1 xmit_imp_guide_id AN 06 x 15 25 39
Production Professional Guide
LOOP 1000A R-1 SUBMITTER INFORMATION
67 NM1 O R-1 NM1* Submitter Name Information
NM101 98 M ID 2/3 R 41* Name Qualifier NOT MAPPED
Submitter 41 If not = '41', do not map Submitter Info in
Loop 1000 A
NM102 1065 M ID 1/1 R [Sel Code]* Entity Identifier Code NOT MAPPED
Person 1
Non- Person 2
NM103 1035 O AN 1/35 R [ ]* Submitter Last/Org Name subm_nm A0 08 x 21 47 67 Map to both A0 and AB
nsf_subm_nm AB 02 x 35 03 37 Map to both A0 and AB
NM104 1036 O AN 1/25 S [ ]* Submitter First Name subm_fnm AN 03 x 12 05 16 Required if NM102 = "1" (Person)

Max Cd
NM105 1037 O AN 1/25 S [ ]* Submitter Middle Name subm_mi AN 04 x 1 17 17

NM106-107 N/U **
NM108 66 X ID 1/2 R 46* Reference Number Qualifier NOT MAPPED
ETIN 46
NM109 67 X AN 2/80 R [ ]~ Submitter Identifier subm_id A0 02 9 9 03 11 Same as ISA06
If Loop 1000A NM109 is not present
Then map Submitter ID from ISA06
file_trl_subm_id Z0 02 9 9 03 11
71 PER O R-2 PER* Submitter Contact Information Only one of each number should be
submitted.
If more than one interation of a Qualifier is
received, map only to first.
PER01 366 M ID 2/2 R IC* Contact Function Code NOT MAPPED
Information Contact IC
PER02 93 O AN 1/60 R [ ]* Submitter Contact Name nsf_subm_contact AB 05 x 35 88 122
PER03 365 X ID 2/2 R [Sel Code]* Communication Number Qualifier NOT MAPPED
Telephone TE
EDI Access Number ED
E-mail EM
Facsmile FX
PER04 364 X AN 1/80 R [ ]* Communication Number If not TE, ED, EM,or FX, do NOT map
Submitter Telephone Number subm_tel A0 13 9 10 112 121 IF PER03 = 'TE', strip non-numeric
characters and concatenate before mapping to
A0-13.
Submitter EDI Number subm_edi_number AN 10 x 15 160 174 If PER03 = 'ED', Map AN-10.
Submitter E-mail subm_email AN 09 x 50 110 159 If PER03 = 'EM', Map to AN-09.
Submitter FAX Number subm_fax AN 08 x 10 100 109 IF PER03 = 'TE', strip non-numeric
AN-08.
PER05 365 X ID 2/2 S [Sel Code]* Communication Number Qualifier NOT MAPPED
Telephone TE
E-mail EM
Facsmile FX
Telephone Extension EX
PER06 364 X AN 1/80 S [ ]* Communication Number If not TE, ED, EM, FX, or EX, do NOT map
A0-13.
Submitter EDI Number subm_edi_number AN 10 x 15 160 174 If PER05 = 'ED', Map to AN-10.

Max Cd
AN-08.
Submitter Telephone Extension subm_tel_ext AN 11 x 6 175 180 If PER05 = 'EX', Map AN-11.
Telephone TE
E-mail EM
Facsmile FX
Telephone Extension EX
PER08 364 X AN 1/80 S [ ]~ Communication Number If not TE, ED, EM, FX, or EX, do NOT map
A0-13.
Submitter EDI Number subm_edi_number AN 10 x 15 160 174 If PER07 = 'ED', Map to AN-10.
AN-08.
Submitter Telephone Extension subm_tel_ext AN 11 x 6 175 180 If PER07 = 'EX', Map to AN-11.
LOOP 1000B R-1 RECEIVER NAME
74 NM1 R-1 NM1* Individual or Organization Name
NM101 98 M ID 2/3 R 40* Receiver Name Information 40 NOT MAPPED
NM102 1065 M ID 1/1 R 2* Non-Person 2 NOT MAPPED
NM103 1035 O AN 1/35 R WEBMD* Receiver Last/Org Name NOT MAPPED
NM104-107 N/U **** NOT MAPPED
NM108 66 X ID 1/2 R [46]* Reference Number Qualifier 46 NOT MAPPED
ETIN
NM109 67 X AN 2/80 R 133052274~ Receiver Primary Identifier NOT MAPPED
LOOP 2000A R>1 (Max 5000) BILLING /PAY-TO PROVIDER
INFORMATION
77 HL M R-1 HL* Hierarchical Level This HL represents the beginning of a new
Batch ( B0 Record ).
HL01 628 M AN 1/12 R [ ]* Hierarchical ID Number bill_prov_hl_id_no BP 12 x 6 151 156 Unique ID number starting with 1 and
increment +1 for each HL within the Loop
HL02 N/U *
HL03 735 M ID 1/2 R 20* Hierarchical Level Code 20 NOT MAPPED
Information source If not = '20', do not map Billing Provider Info
in Loop 2000 A
HL04 736 O ID 1/1 R 1~ Heirarchical Child Code NOT MAPPED

Additional Subordinate 1
79 PRV O S-1 PRV* Billing/Pay-To Provider Specialty
Information

Max Cd
PRV01 1221 M ID 1/3 R [Sel Code ]* Provider Code

Billing BI
Pay-To PT
PRV02 128 M ID 2/3 R ZZ* Reference Number Qualifier Mutally Defined ZZ NOT MAPPED
Taxonomy Code List
PRV03 127 M AN 1/30 R [ ]~ Provider Taxonomy Code bill_prov_taxomy_cd BP 10 x 10 138 147 IF PRV01= 'BI,' map to BP-10
payto_prov_taxomy_cd BR 13 x 10 159 168 IF PRV01= 'PT,' map to BR-13
clm_prov_taxomy_cd E6 16 x 11 128 138 If Payer ID = 'XXXXX', AND Loop 2310B is
Not present, set E6-05 to '82' and map data.
81 CUR O S-1 CUR* Foreign Currency Code

CUR01 98 M ID 2/3 R 85* Entity Identifier Qualifier NOT MAPPED
Billing Provider 85
CUR02 100 M ID 3/3 R [ ]~ Currency Code bill_prov_currency_cd BP 11 x 3 148 150
LOOP 2010AA R-1 BILLING PROVIDER NAME The first time this Loop is sent, set RT B0-
INFORMATION 03 = ‘01’. For all subsequent occurrences
of this loop see the following logic:
When Batch Type (B0-02) OR Provider
Tax ID (B0-04) OR Provider Site ID (B0-
05) changes from the previous batch, the
BATCH NUMBER (B0-03) must be reset to
‘01’.
If the Batch Type (B0-02) AND Provider
Tax ID (B0-04) AND Provider Site ID (B0-
05) are identical to the previous batch, the
BATCH NUMBER (B0-03) must be one (1)
greater than the previous BATCH
NUMBER (B0-03).
84 NM1 O R-1 NM1* Billing Provider Individual or Organization The E6 Payer Information for this Loop is
Name Payer Specific , please refer to the attached
Payer TABS for the appropriate Payer
ID's.

Billing Provider 85 If not = '85', do not map Billing Provider
Name Info. In Loop 2010 AA
clm_prov_nm_qual_e6 E6 05 x 2 24 25 If Payer ID = 'XXXXX', set E6-05 to '82'.

If E7 and/or E8 are created from information
in this Loop, map this field to the E7-05
and/or E8-05.
NM102 1065 M ID 1/1 R [Sel Code ]* Entity Type Qualifier NOT MAPPED
Person 1
Non- Person 2
clm_prov_typ_cd E6 06 x 1 26 26 If Payer ID = 'XXXXX' map to E6 packet

where E6-05 = '82' and set to 'L' if '1', set to
'O' if '2'.

Max Cd
NM103 1035 O AN 1/35 R [ ]* Billing Provider Last/Org Name If Submitter ID = '332211999' or '332211888'
and if NM103 = 'None', then Do Not Map.
bill_prov_org B0 14 x 18 81 98 If NM102= 2 map to B0-14

nsf_bill_prov_org BB 04 x 35 24 58 If NM102= 2 map to BB-04
bill_prov_lnm B0 19 x 20 150 169 If NM102 =1, then map NM103 to B0-19 and
BB-12
nsf_bill_prov_lnm BB 12 x 35 158 192
clm_prov_lnm E6 07 x 35 27 61 If Payer ID = 'XXXXX map to E6 packet
where E6-05 = '82'.
clm_prov_lnm E6 07 x 35 27 61 If Payer ID = 'XXXXX' map to E6 packet

where E6-05 = '77'.
Set E6-06 value to 'O'.
NM104 1036 O AN 1/25 S [ ]* Billing Provider First Name If Submitter ID = '332211999' or '332211888'
bill_prov_fnm B0 20 x 10 170 179

nsf_bill_prov_fnm BB 05 x 12 59 70
clm_prov_fnm E6 08 x 12 62 73 If Payer ID = 'XXXXX' AND NM102 = '1',
map to E6 packet where E6-05 = '82'.
NM105 1037 O AN 1/25 S [ ]* Billing Provider Middle Name bill_prov_mi B0 21 x 1 180 180
clm_prov_mi E6 09 x 1 74 74 If Payer ID = 'XXXXX' AND NM102 = '1',
NM106 1038 N/U *
NM107 1039 O AN 1/10 S [ ]* Billing Provider Name Suffix bill_prov_suffix BA 15 x 10 174 183
clm_prov_suffix E6 10 x 10 75 84 If Payer ID = 'XXXXX' AND NM102 = '1',
NM108 66 X ID 1/2 R [Sel Code ]* Identification Code Qualifier bill_prov_tin_qual B0 06 x 1 21 21 Map only if NM108 = 24 or 34
Employer's Id Number 24 E
Social Security 34 S
NPI XX Not Mapped
clm_prov_tin_qual E6 12 x 1 100 100 If Payer ID = 'XXXXX' map to E6 packet

where E6-05 = '82'.
Map only if NM108 = '24' or '34'.
NM109 67 X AN 2/80 R [ ]~ Billing Provider Indentifier If NM108 = '24' and the third position of
NM109 = '_', strip the '_' and concatinate the
number prior to mapping to B0-04, else just
map data.
Billing Provider Tax Id bill_prov_tin B0 04 9 9 08 16 If NM108 = 24 or 34 Map to B0-04

Billing Provider NPI bill_prov_npi_id B0 08 x 10 23 32 If NM108 = XX Map to B0-08

Max Cd
clm_prov_tin E6 13 x 9 101 109 If NM108 = '24 or '34' And Payer ID =

'XXXXX' map to E6 packet where E6-05 =
'82'.
If NM108 = '24' and the third position of
number prior to mapping to E6-13, else just
map data.
88 N3 O R-1 N3* Billing Provider Address

N301 166 M AN 1/55 R [ ]* Billing Provider Address 1 If Submitter ID = '332211999' or '332211888'
and if N301 = 'None', then Do Not Map.
bill_prov_addr_1 B0 15 x 25 99 123
nsf_bill_prov_addr_1 BB 06 x 30 71 100
clm_prov_addr_1 E8 07 x 30 86 115 If Payer ID ='XXXXX' map to E6 packet
where E8-05 = '77'.
N302 166 O AN 1/55 S [ ]~ Billing Provider Address 2 bill_prov_addr_2 BA 14 x 30 144 173
clm_prov_addr_2 E8 08 x 30 116 145 If Payer ID = 'XXXXX' map to E6 packet
where E8-05 = '77'.
89 N4 O R-1 N4* Billing Provider City State and Zip
N401 19 O AN 2/30 R [ ]* Billing Provider City Name If Submitter ID = '332211999' or '332211888'
and if N401 = 'None', then Do Not Map.
bill_prov_city B0 16 x 15 124 138

nsf_bill_prov_city BB 07 x 20 101 120
clm_prov_city E8 09 x 20 146 165 If Payer ID =''XXXXX' map to E6 packet
where E8-05 = '77'.
N402 156 O ID 2/2 R [ ]* Billing Provider State / Province Code If Submitter ID = '332211999' or '332211888'
and N301 and N401 = 'NONE' and if N402 =
'TX', then Do Not Map.
bill_prov_st B0 17 x 2 139 140

clm_prov_st E8 10 x 2 166 167 If Payer ID = 'XXXXX' map to E6 packet
where E8-05 = '77'.
N403 116 O ID 3/15 R [ ]* Billing Provider Zip Code If Submitter ID = '332211999' or '332211888'
and N301 and N401 = 'NONE' and if N403 =
'75080', then Do Not Map.
bill_prov_zip B0 18 x 9 141 149

clm_prov_zip E8 11 x 9 168 176 If Payer ID = 'XXXXX' map to E6 packet
where E8-05 = '77'.
N404 26 O ID 2/3 S [ ]~ Billing Provider Country Code bill_prov_cntry_cd BP 05 x 3 20 22
clm_prov_cntry_cd E8 12 x 3 177 179 If Payer ID = 'XXXXX' map to E6 packet
where E8-05 = '77'.

Max Cd
91 REF O S-8 REF* Billing Provider Secondary Identification Assumption is that only 1 of each qualifier
Numbers will be used. If 2 of the same qualifer come
in, overwrite the previous.
The E6 Payer Information for this Loop is
Payer Specific , please refer to the attached
Payer TABS for the appropriate Payer
ID's.
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier bill_prov_sec_id_qual BS 04 x 2 18 19 Do NOT map if BS Qualifiers equals 0B;
Facility ID Number 1J 06 x 2 50 51 1A; 1B; 1D; 1G; 1H; G2; U3 or G5.
PPO Number B3 08 x 2 82 83 If qualifier equals EI or SY look at the
HMO Code Number BQ 10 x 2 114 115 NM108 preceeding this REF.
Clinic Number FH 12 x 2 146 147
Location Number LU
State Industrial Accident X5
Medicare Number 1C
Employer's ID EI bill_prov_sec_id_qual See REF01 for Positions If B0-06 is present, then map 'EI' to first
available BS Record
clm_prov_tin E6 13 x 9 101 109 If NM108 = 'XX' And Payer ID = 'XXXXX'
If the third position of REF02 = '-', strip the
'-' and concatinate the number prior to
mapping to E6-13, else just map data.
Set E6-12 to = 'E'
bill_prov_tin_qual B0 06 x 1 21 21 If B0-06 is not present, then map 'E' to B0-06
Social Security Number SY bill_prov_sec_id_qual See REF01 for Positions If B0-06 is present, then map 'SY' to first
available BS Record
If no REF 'EI' is present and NM108 = 'XX'
And Payer ID = 'XXXXX' map to E6 packet
where E6-05 = '82'.
Set E6-12 to = 'S'
bill_prov_tin_qual B0 06 x 1 21 21 If B0-06 is not present, then map 'S' to B0-06
State License Number 0B Do NOT map.

Blue Cross Number 1A Do NOT map.
Blue Shield Number 1B Do NOT map.
Medicaid Number 1D Do NOT map.
UPIN Number 1G Do NOT map.
USIN Number U3 Do NOT map.
Commercial Number G2 Do NOT map.
Site Number G5 Do NOT map.
CHAMPUS Id Number 1H Do NOT map.

Max Cd
bill_prov_medicare_id_flag B0 26 x 1 192 192 If REF01 equals '1C', then map 'Y' to B0-26
REF02 127 X AN 1/30 R [ ]~ Billing Provider Secondary Identifier bill_prov_sec_id BS 05 x 30 20 49 Do NOT map if REF qualifer equals 0B; 1D;
07 x 30 52 81 1G; U3; G2; G5; or 1H
09 x 30 84 113 If REF01 = 'EI' and third position of REF02 =
11 x 30 116 145 '_', strip '_' and concatenate the number prior
13 x 30 148 177 to mapping to BS ID.
Employer's ID bill_prov_sec_id See REF02 for positions If B0-04 is present, then map to first available
BS Record
bill_prov_tin B0 04 9 9 08 16 If B0-04 is not present, then map to B0-04
Social Security Number bill_prov_sec_id See REF02 for positions If B0-04 is present, then map to first
available BS Record
bill_prov_tin B0 04 9 9 08 16 If B0-04 is not present,then map to B0-04
State License Number bill_prov_st_lic BA 11 x 15 111 125 If REF 01= '0B', then map to BA-11
Blue Cross Number bill_prov_bcbs_id B0 11 x 13 49 61 If REF 01= '1A' and is less than 14 bytes and
not previously populated, then map to B0-11,
Else map to BS Secondary ID and set REF01
to ='1A'
If REF01 = '1A' and greater than 13 bytes,
map to the first available BS Record with a
'1A' qualifier.
bill_prov_bc_flag B0 25 x 1 191 191 If REF01 = '1A', Map 'Y' to B0-25

Blue Shield Number bill_prov_bcbs_id B0 11 x 13 49 61 If REF 01= '1B', and is less than 14 bytes and
not previously populated then map to B0-11
Else map to BS Secondary ID and set REF01
to ='1B'
If REF01 = '1B' and greater than 13 bytes,
'1B' qualifier.
Medicaid Number bill_prov_mcaid_id B0 09 x 12 33 44 If REF 01= '1D', and is less than 13 bytes,
then map to B0-09
If REF01 = '1D' and greater than 12 bytes,
'1D' qualifier.
UPIN Number bill_prov_upin_id BA 04 x 6 24 29 If REF 01= 'IG', then map to BA-04

USIN Number bill_prov_usin_id BA 16 x 6 184 189 If REF 01= 'U3', then map to BA-16
Commercial Number bill_prov_comm_no BA 07 x 15 51 65 If REF 01= 'G2', then map to BA-07
clm_prov_ntwrk_id E6 15 x 15 113 127 If REF01 = 'G2' AND Payer ID = 'XXXXX',


Max Cd
pyr_prov_id D0 20 x 13 148 160 If REF01 = 'G2' AND Payer ID = 'ZZZZZ'

AND Loop 2310B is Not present, map to D0-
20.
Site Number bill_prov_site_id B0 05 x 4 17 20 If REF 01= 'G5', then map to B0-05
CHAMPUS ID Number bill_prov_champ_no BA 06 x 15 36 50 If REF 01='1H', then map to BA-06

If REF01 = '1H' and data in REF02 is greater
than 15 bytes, map the first 15 bytes to BA-06
postions 36-50 AND all of data to the first
available BS Secondary ID with the
corresponding BS Secondary ID Qualifier =
'1H'.
Dual map only if data in REF02 is greater than
15 bytes.
94 REF O S-8 REF* Billing Provider Credit / Debit Card Billing

Information
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier bill_prov_cr_deb_qual BV 05 x 2 13 14 Map to first available BV Record
07 x 2 45 46
09 x 2 77 78
11 x 2 109 110
REF02 127 X AN 1/30 R [ ]~ Billing Provider Credit Card Identifier bill_prov_cr_deb_no BV 06 x 30 15 44 Map to first available BV Record
08 x 30 47 76
10 x 30 79 108
12 x 30 111 140
96 PER O S-2 PER* Billing Provider Contact Informtion Assumption is that only 1 of each qualifier
will be used.
Information Contact IC If not = IC, do not map Billing Provider
Contact Info. In Loop 2010 AA
PER02 93 O AN 1/60 R [ ]* Contact Name bill_prov_contact_nm BP 07 x 60 28 87

Max Cd
Electronic Mail EM If 2 of the same qualifer come in, overwrite
Facsimile FX the previous.
Telephone TE
PER04 364 X AN 1/80 R [ ]* Communication Number If not EX, EM, FX, or TE, do not map
Billing Provider Email bill_prov_email BP 09 x 40 98 137 IF PER03 = 'EM', Map to BP-09
Billing Provider FAX bill_prov_fax BP 08 x 10 88 97 IF PER03 = 'FX', strip non-numeric
BP-08.
Billing Provider Telephone bill_prov_tel_no B0 13 9 10 71 80 IF PER03 = 'TE', strip non-numeric

B0-13.
Phone Extension EX
Electronic Mail EM
Facsimile FX
Telephone TE
PER06 364 X AN 1/80 S [ ]* Communication Number If not EX, EM, FX, or TE, do not map
Billing Provider Telephone Extention bill_prov_tel_ext BP 06 x 5 23 27 IF PER05 = 'EX', Map to BP-06
BP-08.

B0-13.
Phone Extension EX
Electronic Mail EM
Facsimile FX
Telephone TE
PER08 364 X AN 1/80 S [ ]~ Communication Number If not EX, EM, FX, or TE, do not map
Billing Provider Telephone Extention bill_prov_tel_ext BP 06 x 5 23 27 IF PER07 = 'EX', Map to BP-06
BP-08.

B0-13.
LOOP 2010AB S-1 PAY- TO PROVIDER INFORMATION

99 NM1 O S-1 NM1* Pay-To Provider Name Information

Max Cd

Pay-To Provider 87 If not = '87', do not map Pay-To Provider Info.
In Loop 2010 AB
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier NOT MAPPED
Person 1
Non- Person 2
NM103 1035 O AN 1/35 R [ ]* Pay-To Provider Last/Org Name payto_prov_org_lnm BR 04 x 35 18 52

NM104 1036 O AN 1/25 S [ ]* Pay-To Provider First Name payto_prov_fnm BR 05 x 12 53 64
NM105 1037 O AN 1/25 S [ ]* Pay-To Provider Middle Name payto_prov_mi BR 06 x 1 65 65
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Name Suffix payto_prov_suffix BR 09 x 10 129 138
NM108 66 X ID 1/2 R Translate* Identification Code Qualifier payto_prov_tin_qual BR 10 x 1 139 139 Map only if NM108 = 24 or 34
Employer's ID Number 24 E
Social Security Number 34 S
NPI XX Not Mapped
NM109 67 X AN 2/80 R [ ]~ Pay-To Provider Identifier

Pay-To Provider Tax Id payto_prov_tin BR 11 9 9 140 148 If NM108 = '24' or '34' move NM109 to BR-
11
Pay -To Provider NPI payto_prov_npi BR 12 x 10 149 158 If NM108 = 'XX', move NM109 to BR-12
103 N3 O R-1 N3* Pay-To Provider Address
N301 166 M AN 1/55 R [ ]* Pay-To Provider Address 1 payto_prov_addr_1 BC 04 x 30 18 47
N302 166 O AN 1/55 S [ ]~ Pay-To Provider Address 2 payto_prov_addr_2 BC 05 x 30 48 77
104 N4 O R-1 N4* Pay-To Provider City / State/Zip Code
N401 19 O AN 2/30 R [ ]* Pay- To Provider City Name payto_prov_city BC 06 x 20 78 97
N402 156 O ID 2/2 R [ ]* Pay-To Provider State/Province Code payto_prov_st BC 07 x 2 98 99
N403 116 O ID 3/15 R [ ]* Pay-To Provider Zip Code payto_prov_zip BC 08 x 9 100 108
N404 26 O ID 2/3 S [ ]~ Pay-To Provider Country Code payto_prov_cntry_cd BR 07 x 3 66 68
106 REF O S-5 REF* Pay-To Provider Secondary Reference
Numbers

Max Cd
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier payto_prov_sec_id_qual BU 04 x 2 18 19 Map REF01 to first available BU Record even
State License Number 0B 06 x 2 50 51 those not listed
Blue Cross Provider Number 1A 08 x 2 82 83
Blue Shield Provider Number 1B 10 x 2 114 115
Medicare Provider Number 1C 12 x 2 146 147
Medicaid Provider Number 1D
Provider UPIN Number 1G
CHAMPUS Id Number 1H
Facility Id Number 1J
PPO Number B3
HMO Number BQ
Clinic Number FH
Commercial Number G2
Provider Site Number G5
Location Number LU
Unique Supplier Id Number U3
State Industrial Accident No. X5
Employer's ID EI payto_prov_sec_id_qual See REF01 for positions If BR-10 is present, then map 'EI' to first
available BU Record
If REF01 = 'EI' and BR-10 is not present
Then map 'EI' to the first available RT BU
Qualifier and map the associated RT BU Sec
Id to REF02
Else map 'E' to BR-10 and map value in BR-
11 to REF02
payto_prov_tin_qual BR 10 x 1 139 139 If BR-10 is not present, then map 'E' to BR-10
Social Security Number SY payto_prov_sec_id_qual See REF01 for positions If BR-10 is present, then map 'SY' to first
available BU Record
If REF01 = 'SY' and BR-10 is not present
Then map 'SY' to the first available BU
Qualifier and map the associated RT BU Sec
Id to REF02
Else map 'S' to BR-10 and map value in BR-
11 to REF02
payto_prov_tin_qual BR 10 x 1 139 139 If BR-10 is not present, then map 'S' to BR-10
REF02 127 X AN 1/30 R [ ]~ Pay-To Provider Additional Identifier payto_prov_sec_id BU 05 x 30 20 49 Map REF02 to first available BU Record
07 x 30 52 81 If REF01= 'EI' and third position of REF02 =
09 x 30 84 113 '_', strip '_' and concatenate the number prior
11 x 30 116 145 to mapping to BU ID.
13 x 30 148 177
LOOP 2000B R>1 SUBSCRIBER HIERARCHIAL LEVEL

Max Cd
108 HL M R-1 HL* Hierarchical Level

HL01 628 M AN 1/12 R [ ]* Hierarchical ID Number ins_hl_id_no DN 14 x 6 156 161 Always map. The Insured Info in this Loop
will be used for all Claims within this Loop
pat_hl_id_no CN 06 x 6 88 93 Map to CN-06 only if SBR02 = 18
HL02 734 O AN 1/12 R [ ]* Hierarchical Parent ID Number ins_hl_par_id_no DN 15 x 6 162 167 Always map
pat_hl_par_id_no CN 07 x 6 94 99 Map to CN-07 only if SBR02 = 18
HL03 735 M ID 1/2 R 22* Hierarchical Level Code NOT MAPPED
Subscriber 22
HL04 736 O ID 1/1 R [Sel Code]~ Hierarchical Child Code NOT MAPPED
No Subordinate 0
Additional Subordinate 1
110 SBR O R-1 SBR* Subscriber Information If SBR02 is not used, map only to Insured
Fields if = 18 map to Insured and Patient
fields
pyr_flag D0 26 x 1 192 192 Set D0-26 to 'X'
SBR01 1138 M ID 1/1 R [Translate]* Payer Responsibility Sequence Number Code pyr_resp_cd D0 02 9 2 03 04 This loop is the destination payer. Other D0
Primary P 01 records are in the 2320 loop.
Secondary S 02 The D0 Packets must be in sequential order
Tertiary T 03 before presenting to Validation.
If more than one SBR segment is present and
= 'T', the first tertiary payer sequence number
will = '03' and all subsequent payers will have
sequence numbers of 04-11.
If value does not = 'P', 'S', or 'T', map as the
last previous D0 sequence number and
increment by +1.
SBR02 1069 O ID 2/2 S 18* Relationship Code pat_rel_cd D0 17 9 2 137 138 If '18', Map all Patient Information to both
Self 18 01 Insured and Patient Fields. If blank, map only
to insured information as the Patient
Information will be in the following Loop.
SBR03 127 O AN 1/30 S [ ]* Insured Group or Policy Number ins_plan_no D0 09 x 20 66 85

SBR04 93 O AN 1/60 S [ ]* Group or Plan Name ins_grp_nm D0 10 x 17 86 102
nsf_grp_nm DB 05 x 35 60 94
SBR05 1336 O ID 1/3 S [Sel Code]* Insurance Type Code ins_typ_cd D0 22 x 2 163 164 See Code Table for values
SBR06-08 N/U ***

SBR09 1032 O ID 1/2 S Translate* Claim Filing Indicator Code sop_cd D0 04 x 1 22 22 See Code Table for Translation
114 PAT O S-1 PAT* Patient Information

PAT01-04 N/U ****
PAT05 1250 X ID 2/3 S D8* DTP Qualifier NOT MAPPED
Date in CCYYMMDD D8
PAT06 1251 X AN 1/35 S [ ]* Patient Death Date pat_dod C0 21 9 8 143 150

Max Cd
D pat_dth_cd C0 19 x 1 141 141 If D0-17 = '18' and If C0-21 is present, map

and set C0-19 to 'D', Else Do Not Map
PAT07 355 X ID 2/2 S 01* Unit or Basis for Measurement Code 01 pat_wt_basis_meas CP 04 x 2 25 26
PAT08 81 X R 1/10 S [ ]* Patient Weight pat_wt CP 05 x 4 27 30 If CP-05 is present, map digits to the left of
decimel AND do not map the decimel or
digits to the right of the decimal.
PAT09 1073 O ID 1/1 S Y~ Pregnancy Indicator Y preg_flag CP 06 x 1 31 31 Map only if 'Y', else don't map
LOOP 2010BA R-1 SUBSCRIBER INFORMATION

117 NM1 O R-1 NM1* Subscriber Name Information
NM101 98 M ID 2/3 R IL* Name Qualifier NOT MAPPED
Insured or Subscriber IL If not = 'IL', do not map Subscriber Name
Info in Loop 2010 BA
NM102 M ID 1/1 R [Sel Code]* Entity Type Qualifier NOT MAPPED

Person 1
Non- Person 2
NM103 1035 O AN 1/35 R [ ]* Subscriber Last Name ins_lnm D0 11 x 20 103 122 Always Map
nsf_ins_lnm DB 07 x 35 120 154 Always Map

pat_lnm C0 04 x 20 22 41 If SBR02 ='18', Map to C0-04
nsf_pat_lnm CB 04 x 35 25 59 If SBR02 = '18', Map to CB-04
NM104 1036 O AN 1/25 S [ ]* Subscriber First Name ins_fnm D0 12 x 10 123 132 Always Map
nsf_ins_fnm DB 08 x 12 155 166 Always Map

pat_fnm C0 05 x 10 42 51 If SBR02 = '18', Map to C0-05
nsf_pat_fnm CB 05 x 12 60 71 If SBR02 = '18', Map to CB-05
NM105 1037 O AN 1/25 S [ ]* Subscriber Middle Name ins_mi D0 13 x 1 133 133 Always Map
pat_mi C0 06 x 1 52 52 If SBR02 = '18', Map to C0-06
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Name Suffix ins_suffix DA 26 x 10 167 176 Always Map
pat_suffix C0 23 x 10 171 180 If SBR02 = '18', Map to C0-23
NM108 66 X ID 1/2 S [Sel Code]* Identification Code Qualifier ins_id_qual D0 23 x 2 165 166 Always Map
Member Identification Number MI
Mutually Defined ZZ
pat_id_qual D1 12 x 2 136 137 If SBR02 = '18', Map to D1-12

NM109 67 X AN 2/80 S [ ]~ Subscriber Primary Identifier ins_id D0 07 x 17 32 48 Always Map
nsf_ins_id DB 06 x 25 95 119 Always Map

Max Cd
pat_id D1 10 x 10 116 125 If SBR02 = '18', Map to D1-10 and D1-13 ,

If 2010CA NM109 is present, Do Not map
D1-10 or D1-13 to 2010BA NM109.
nsf_pat_id D1 13 x 30 138 167 If SBR02 = '18', Map to D1-13 and D1-10 ,

If 2010CA NM109 is present, Do Not map
D1-10 or D1-13 to 2010BA NM109.
ihs_res_cd CA 13 9 7 93 99 Only map if an REF01=23 is present in this

Loop
121 N3 O S-1 N3* Subscriber Address
N301 166 M AN 1/55 R [ ]* Subscriber Address 1 ins_addr_1 D1 04 x 30 22 51 Always Map
pat_addr_1 C0 11 x 18 67 84 Only if SBR02='18'

nsf_pat_addr_1 CB 06 x 30 72 101 Only if SBR02='18'
N302 166 O AN 1/55 S [ ]~ Subscriber Address 2 ins_addr_2 D1 05 x 30 52 81 Always Map
pat_addr_2 C0 12 x 18 85 102 Only if SBR02='18'
nsf_pat_addr_2 CB 07 x 30 102 131 Only if SBR02='18'
122 N4 O S-1 N4* Subscriber City/State/Zip Code
N401 19 O AN 2/30 R [ ]* Subscriber City Name ins_city D1 06 x 20 82 101 Always Map
pat_city C0 13 x 15 103 117 Only if SBR02='18'

nsf_pat_city CB 08 x 20 132 151 Only if SBR02='18'
N402 156 O ID 2/2 R [ ]* Subscriber State/Prov Code ins_st D1 07 x 2 102 103 Always Map
pat_st C0 14 x 2 118 119 Only if SBR02='18'

N403 116 O ID 3/15 R [ ]* Subscriber Zip Code ins_zip D1 08 x 9 104 112
pat_zip C0 15 x 9 120 128 Map to C0-15 only if SBR02='18'

N404 26 O ID 2/3 S [ ]~ Subscriber Country Code ins_cntry_cd D1 09 x 3 113 115 Always Map
pat_cntry_cd CN 05 x 3 85 87 Only if SBR02='18'
124 DMG O S-1 DMG* Subscriber Demographic Information
DMG01 1250 X ID 2/3 R D8* DTP Qualifier D8 NOT MAPPED
DMG02 1251 X AN 1/35 R [ ]* Subscriber Birth Date ins_dob D0 19 9 8 140 147 Always Map

Max Cd
pat_dob C0 08 9 8 54 61 Only if SBR02='18'

DMG03 1068 O ID 1/1 R [Sel Code]~ Gender Code ins_sex D0 14 x 1 134 134 Always Map
See Code Table for values
pat_sex C0 07 x 1 53 53 Only if SBR02='18'
126 REF O S-4 REF* Subscriber Secondary Identification
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier ins_sec_id_qual DN 06 x 2 88 89 IG is also in SBR03 (D0-09).
08 x 2 105 106 This Policy number will go to generic REF
10 x 2 122 123 Record.
12 x 2 139 140 Do NOT Map if = '23'
Map to first available DN Record
pat_sec_id_qual DR 06 x 2 37 38 Do NOT Map if = '23'

08 x 2 69 70 If SBR02 = '18', then map to first available
10 x 2 101 102 DR Record
REF02 127 X AN 1/30 R [ ]~ Subscriber Secondary Id ins_sec_id DN 07 x 15 90 104 Do NOT Map if = '23'
09 x 15 107 121 Map to first available DN Record
11 x 15 124 138
13 x 15 141 155
pat_sec_id DR 07 x 30 39 68 Do NOT Map if = '23'

09 x 30 71 100 If SBR02 = '18', then map to first available
11 x 30 103 132 DR Record
Client ID ihs_health_rec CA 14 9 6 100 105 If REF01='23', map to CA-14

(IHS Health Record Number)
128 REF O S-1 REF* Property and Casualty Claim Number
REF01 128 M ID 2/3 R Y4* Reference Number Qualifier NOT MAPPED
Agency Claim Number Y4
REF02 127 X AN 1/30 R [ ]~ Property Casuality Claim Number pat_pc_clm_no CN 08 x 25 100 124
LOOP 2010BB R-1 PAYER INFORMATION
130 NM1 O R-1 NM1* Payer Name Information
NM101 98 M ID 2/3 R PR* Name Qualifier PR NOT MAPPED
NM102 1065 M ID 1/1 R 2* Entity Type Code 2 NOT MAPPED
NM103 1035 O AN 1/35 R [ ]* Payer Last/Org Name pyr_nm D0 08 x 17 49 65 Always Map
pyr_prnt_nm D2 10 x 30 116 145 Always Map

nsf_pyr_nm DB 04 x 35 25 59 Always Map
NM104-107 N/U ****
NM108 66 X ID 1/2 R [Sel Code]* Primary Payer Identifier NOT MAPPED
Payer Identification PI
PLANID XV
NM109 67 X AN 2/80 R [ ]~ Payer Primary Identifier pyr_id D0 05 x 5 23 27

134 N3 O S-1 N3* Payer Address Information

Max Cd
N301 166 M AN 1/55 R [ ]* Payer Address 1 pyr_addr_1 D2 04 x 30 22 51

N302 166 O AN 1/55 S [ ]~ Payer Address 2 pyr_addr_2 D2 05 x 30 52 81
135 N4 O S-1 N4* Payer City/State/Zip
N401 19 O AN 2/30 R [ ]* Payer City Name pyr_city D2 06 x 20 82 101
N402 156 O ID 2/2 R [ ]* Payer State/Prov Code pyr_st D2 07 x 2 102 103
N403 116 O ID 3/15 R [ ]* Payer Zip Code pyr_zip D2 08 x 9 104 112
N404 26 O ID 2/3 S [ ]~ Payer Country Code pyr_cntry_cd D2 09 x 3 113 115
137 REF O S-3 REF* Payer Secondary Reference Numbers
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier pyr_sec_id_qual DP 06 x 2 88 89 If not FY, Map to first available DP Record
08 x 2 105 106 See Code Table for values
10 x 2 122 123
REF02 127 X AN 1/30 R [ ]~ Payer Additional Identifier pyr_sec_id DP 07 x 15 90 104 If not FY, Map to first available DP Record
09 x 15 107 121
11 x 15 124 138
pyr_clm_ofc D0 06 x 4 28 31 If REF01 = FY , Map to D0-06

tpo_id_prim D6 05 x 9 23 31 If REF01 = '2U', map to D6-05
LOOP 2010BC S-1 RESPONSIBLE PARTY INFORMATION
139 NM1 O S-1 NM1* Individual or Organizational Name
NM101 98 M ID 2/3 R QD* Name Qualifier lgl_rep_flag C2 04 x 1 22 22 If 'QD', Map 'Y' to C2-04
Responsible Party QD
Person 1
Non-Person Entity 2
NM103 1035 O AN 1/35 R [ ]* Resp Party Last/Org Name lgl_rep_lnm C2 05 x 20 23 42

nsf_lgl_rep_lnm CC 04 x 35 25 59
NM104 1036 O AN 1/25 S [ ]* Resp Party First Name lgl_rep_fnm C2 06 x 10 43 52
nsf_lgl_rep_fnm CC 05 x 12 60 71
NM105 1037 O AN 1/25 S [ ]* Resp Party Middle Name lgl_rep_mi C2 07 x 1 53 53
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]~ Resp Party Suffix Name lgl_rep_suffix C2 14 x 10 126 135
143 N3 O R-1 N3* Responsible Party Address Information
N301 166 M AN 1/55 R [ ]* Resp Party Address 1 lgl_rep_addr_1 C2 08 x 18 54 71
nsf_lgl_rep_addr_1 CC 06 x 30 72 101
N302 166 O AN 1/55 S [ ]~ Resp Party Address 2 lgl_rep_addr_2 C2 09 x 18 72 89
nsf_lgl_rep_addr_2 CC 07 x 30 102 131
144 N4 O R-1 N4* Responsible Party City State and Zip
N401 19 O AN 2/30 R [ ]* Resp Party City Name lgl_rep_city C2 10 x 15 90 104
nsf_lgl_rep_city CC 08 x 20 132 151

Max Cd
N402 156 O ID 2/2 R [ ]* Resp Party State/Prov Code lgl_rep_st C2 11 x 2 105 106
N403 116 O ID 3/15 R [ ]* Resp Party Zip Code lgl_rep_zip C2 12 x 9 107 115
N404 26 O ID 2/3 S [ ]~ Resp Party Country Code lgl_rep_cntry_cd C2 15 x 3 136 138
LOOP 2010BD S-1 CREDIT/DEBIT CARDHOLDER
INFORMATION
146 NM1 O S-1 NM1* Credit/Debit Cardholder Name
NM101 98 M ID 2/3 R AO* Name Qualifier A0 NOT MAPPED
NM103 1035 O AN 1/35 R [ ]* Credit/Debit CardHolder Last/Org Name clm_cr_deb_lnm DV 04 x 35 25 59
NM104 1036 O AN 1/25 S [ ]* Credit /Debit CardHolder First Name clm_cr_deb_fnm DV 05 x 25 60 84
NM105 1037 O AN 1/25 S [ ]* Credit /Debit CardHolder Middle Name clm_cr_deb_mi DV 06 x 1 85 85
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Credit /Debit CardHolder Suffix clm_cr_deb_suffix DV 07 x 10 86 95
NM108 66 X ID 1/2 R MI* Member Identification Number MI
NM109 67 X AN 2/80 R [ ]~ Credit or Debit Card Number clm_cr_deb_crd_no DV 08 x 20 96 115
150 REF O S-2 REF* Credit / Debit Cardholder Reference
Information
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier AB clm_cr_deb_auth_qual DV 09 x 2 116 117
BB DV 12 x 2 156 157
REF02 127 X AN 1/30 R [ ]~ Credit/Debit Card Authorization Number DV 10 x 30 118 147
DV 13 x 30 158 187
LOOP 2000C S->1 PATIENT HIERARCHICAL
INFORMATION
152 HL M S-1 HL* Hierarchical Level
HL01 628 M AN 1/12 R [ ]* Hierarchical ID Number pat_hl_id_no CN 06 x 6 88 93 Always Map.
The Patient Information in this Loop will be
used for all Claims within this Loop
HL02 734 O AN 1/12 R [ ]* Hierarchical Parent ID Number pat_hl_par_id_no CN 07 x 6 94 99

HL03 735 M ID 1/2 R 23* Hierarchical Level Code 23 NOT MAPPED
HL04 736 O ID 1/1 R 0~ Hierarchical Child Code 0 NOT MAPPED
154 PAT O R-1 PAT* Patient Information
PAT01 1069 O ID 2/2 R [Sel Code]* Individual Relationship Code pat_rel_cd D0 17 9 2 137 138 See Appendix for Codes Translation
PAT02-03 **
PAT04 1220 O ID 1/1 S [Sel Code]* Student Status Code pat_studnt_stat_cd C0 18 x 01 140 140 This field is not supported by HIPAA but is
required by WebMD.
During Implementation, it will be used.
PAT05 1250 X ID 2/3 S D8* DTP Qualifier D8 NOT MAPPED

PAT06 1251 X AN 1/35 S [ ]* Patient Death Date pat_dod C0 21 9 8 143 150
D pat_dth_cd C0 19 x 1 141 141 If D0-17 does not = '18' and If C0-21 is
present, map and set C0-19 to 'D', Else Do Not
Map

Max Cd
PAT07 355 X ID 2/2 S 01* Unit or Basis for Measurement Code pat_wt_basis_meas CP 04 x 2 25 26
01
PAT08 81 X R 1/10 S [ ]* Patient Weight pat_wt CP 05 x 4 27 30 If CP-05 is present, map digits to the left of
decimel AND do not map the decimel or
digits to the right of the decimal.
PAT09 1073 O ID 1/1 S Y~ Pregnancy Indicator preg_flag CP 06 x 1 31 31 Map only if 'Y', else don't map.
Yes Y
LOOP 2010CA R-1 PATIENT INFORMATION

157 NM1 O R-1 NM1* Patient Name Information
NM101 98 M ID 2/3 R QC* Name Qualifier NOT MAPPED
Patient QC If not = to 'QC', do not map Patient
Information Info in Loop 2010 CA
NM102 1065 M ID 1/1 R 1* Person 1 NOT MAPPED

NM103 1035 O AN 1/35 R [ ]* Patient Last Name pat_lnm C0 04 x 20 22 41
nsf_pat_lnm CB 04 x 35 25 59
NM104 1036 O AN 1/25 R [ ]* Patient First Name pat_fnm C0 05 x 10 42 51
nsf_pat_fnm CB 05 x 12 60 71
NM105 1037 O AN 1/25 S [ ]* Patient Middle Name pat_mi C0 06 x 1 52 52
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Patient Name Suffix pat_suffix C0 23 x 10 171 180
NM108 66 X ID 1/2 S [Sel Code]* Identification Code Qualifier pat_id_qual D1 12 x 2 136 137
Member Identification Number MI
Mutually Defined ZZ
NM109 67 X AN 2/80 S [ ]~ Patient Primary Identifier pat_id D1 10 x 10 116 125 Map to both D1-10 and D1-13
nsf_pat_id D1 13 x 30 138 167
161 N3 O R-1 N3* Patient Address
N301 166 M AN 1/55 R [ ]* Patient Address 1 pat_addr_1 C0 11 x 18 67 84
nsf_pat_addr_1 CB 06 x 30 72 101
N302 166 O AN 1/55 S [ ]~ Patient Address 2 pat_addr_2 C0 12 x 18 85 102
nsf_pat_addr_2 CB 07 x 30 102 131
162 N4 O R-1 N4* Patient City / State/Zip Code
N401 19 O AN 2/30 R [ ]* Patient City Name pat_city C0 13 x 15 103 117
nsf_pat_city CB 08 x 20 132 151

N402 156 O ID 2/2 R [ ]* Patient State/Prov Code pat_st C0 14 x 2 118 119

Max Cd
N403 116 O ID 3/15 R [ ]* Patient Zip Code pat_zip C0 15 x 9 120 128

N404 26 O ID 2/3 S [ ]~ Patient Country Code pat_cntry_cd CN 05 x 3 85 87
164 DMG O R-1 DMG* Patient Demographic Information
DMG02 1251 X AN 1/35 R [ ]* Patient Birth Date pat_dob C0 08 9 8 54 61
DMG03 1068 O ID 1/1 R [Sel Code]~ Gender Code pat_sex C0 07 x 1 53 53 See Code Table for values
166 REF O S-5 REF* Patient Secondary Identification
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier pat_sec_id_qual DR 06 x 2 37 38 Map to first available DR Record.
08 x 2 69 70 Do not map if = '23'
REF02 127 X AN 1/30 R [ ]~ Reference Identification Number pat_sec_id DR 07 x 30 39 68 Map to first available DR Record
09 x 30 71 100
11 x 30 103 132
Client ID ihs_health_rec CA 14 9 6 100 105 If REF01='23', map to CA-14

(IHS Health Record #) If already mapped from 2010 BA Loop,
overwrite.
168 REF O S-1 REF* Property and Casualty Claim Number

REF01 128 M ID 2/3 R Y4* Agency Claim Number Y4 NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Property Casualty Claim Number pat_pc_clm_no CN 08 x 25 100 124
LOOP 2300 R-100 CLAIM INFORMATION
170 CLM O R-1 Health Claim
CLM01 1028 M AN 1/38 R [ ]* Patient Account Number pat_ctrl_no C0 03 x 17 05 21 Map to both C0-03 & C0-22.
pat_hipaa_ctrl_no C0 22 x 20 151 170 Use this information on all subsequent records
within the claim. Must be unique for each
patient claim.
CLM02 782 O R 1/18 R [ ]* Total Submitted Charges clm_tot_chrg_amt E0 27 9v99 10 151 160 Note: If the charge is '$0.00', then the
submitter should put *0*.
Define as 'Real'
If > 9(8)v99, move 'Too Big'
trl_tot_chrg_amt X0 13 9v99 10 67 76 Note: If the charge is '$0.00', then the

submitter should put *0*.
Define as 'Real'
CLM03 -04 N/U **

CLM05 C023 O R Place Of Service Code
CLM05-1 1331 M AN 1/2 R [Sel Code]: clm_pl_serv EN 04 x 2 25 26 CLM-05 applies to all service lines unless it
is over written at the line level SV1-05
CLM05-2 1332 N/U : Facility Type Code

CLM05-3 1325 O ID 1/1 R [Sel Code]* Claim Submission Reason clm_freq_cd EN 05 x 1 27 27 See Code table for Source

Max Cd
CLM06 1073 O ID 1/1 R [Sel Code]* Provider Signature On File N clm_prov_sig_flag EA 11 x 1 57 57 Map only if 'Y' or 'N' , else don't map
Y
CLM07 1359 O ID 1/1 R Translate* Medicare Assignment Code prov_accpt_asgn E0 04 x 1 22 22 Translate "C" to "N", else move code as
received
See Code Table for complete code list
CLM08 1073 O ID 1/1 R Translate* Assignment of Benefits Indicator asgn_ben_flag D0 16 x 1 136 136 Translate 'Y' to 'A', else move 'N'
CLM09 1363 O ID 1/1 R Translate* Release of Information Code rls_info_cd D0 15 x 1 135 135 Translate "M" to "R", else move code as
received
CLM10 1351 O ID 1/1 S Translate* Patient Signature Source Code pat_sig_flag D0 18 x 1 139 139 Translate 'C' to 'Y' or 'P' to 'N', else map as
received
CLM11 C024 O S Accident/Employment / Related Causes

CLM11-1 1362 M ID 2/3 R [Sel Code]: Related-Causes Code
clm_acc_cd E0 13 x 1 73 73 If CLM11-1 =
Auto Accident AA A AA, Map 'A' to E0-13
Another Party Responsible AP P AP, Map 'P' to E0-13
Other Accident OA N OA, Map 'N' to E0-13
Employment EM Y clm_emplt_rel_flag E0 17 x 1 88 88 If CLM11-1= EM , Set E0-17 to 'Y'

Blank N If CLM11-1, CLM11-2 or CLM11-3 is not =
U 'EM', default E0-17 to 'N'
CLM11-2 1362 M ID 2/3 S [Sel Code]: Related-Causes Code Same as CLM11-1. If Cause Code already
exist, Do not map
clm_acc_cd EN 18 x 1 141 141 If CLM11-2 =
Auto Accident AA A AA, Map 'A' to EN-18
Another Party Responsible AP P AP, Map 'P' to EN-18
Other Accident OA N OA, Map 'N' to EN-18

CLM11-3 1362 M ID 2/3 S [Sel Code]: Related-Causes Code Same as CLM11-1. If Cause Code already
exist, Do not map
clm_acc_cd EN 19 x 1 142 142 If CLM11-3 =
Auto Accident AA A AA, Map 'A' to EN-19
Another Party Responsible AP P AP, Map 'P' to EN-19
Other Accident OA N OA, Map 'N' to EN-19

CLM11-4 156 O ID 2/2 S [ ]: Auto Accident State/Prov Code clm_acc_st E0 16 x 2 86 87

CLM11-5 26 O ID 2/3 S [ ]* Country Code clm_auto_acc_cntry_cd EN 06 x 3 28 30
CLM12 1366 O ID 2/3 S [Sel Code]* Special Program Code clm_pgm_handicap_flag EB 21 x 2 162 163 See Code Table for values

Max Cd
CLM13-15 N/U ***

CLM16 1360 O ID 1/1 S P* Participation Agreement P clm_part_agree_cd EN 07 x 1 31 31
CLM17-19 N/U ***

CLM20 1514 O ID 1/2 S [Sel Code]~ Delay Reason Code clm_dlay_reas_cd EN 08 x 2 32 33 See Code Table for values
182 DTP O S-1 Date - Initial Treatment
DTP01 374 M ID 3/3 R 454* DTP Qualifier 454 NOT MAPPED
DTP02 1250 M ID 2/3 R D8* DTP Format Qualifier D8 NOT MAPPED
DTP03 1251 M AN 1/35 R [ ]~ Initial Treatment Date clm_chiro_init_trmt_dt ER 15 x 8 67 74 If ER-15 is "blank" and GR-15 is present And
GR-02 And GR-03 = '01', then write GR-15 to
Loop 2300 where DTP01 = '454' and Do Not
Map GR-15 to Loop 2400 DTP.
186 DTP O S-1 Date - Date Last Seen

DTP03 1251 M AN 1/35 R [ ]~ Last Seen Date clm_last_seen_dt EA 18 x 8 80 87

188 DTP O S-1 Date - Onset of Current Symptoms or
Illness
DTP01 374 M ID 3/3 R 431* DTP Qualifier clm_frst_sym_ill E0 11 9 1 64 64 If DTP01= 431, map '1' to E0-11
Onset of Current Symptoms or Illness 431
DTP03 1251 M AN 1/35 R [ ]~ Onset of Current Symptoms or Illness Date clm_frst_ill_dt E0 12 9 8 65 72

190 DTP O S-5 Date - Acute Manifestation
DTP03 1251 M AN 1/35 R [ ]~ Acute Manifestation Date clm_chiro_man_dt_1 ER 16 x 8 75 82 If present, map to first available ER Record,
clm_chiro_man_dt_2 17 x 8 83 90 else do not map.
clm_chiro_man_dt_3 18 x 8 91 98
192 DTP O S-10 Date - Similar Illness / Symptom Onset

DTP 1 of 10
DTP01 374 M ID 3/3 R 438* DTP Qualifier clm_sim_sym_flag E0 09 x 1 55 55 If first occurrence of DTP01= 438, map 'Y'
Onset of Similar Symptoms or Illness 438 to E0-09
DTP03 1251 M AN 1/35 R [ ]~ Similar Illness or Symptom Date clm_sim_sym_dt EA 06 x 8 40 47

DTP 2 of 10

Max Cd
DTP01 374 M ID 3/3 R 438* DTP Qualifier clm_dtp_qual EM 05 x 3 27 29 Map to first available EM Record
Onset of Similar Symptoms or Illness 438 08 x 3 42 44
11 x 3 57 59
14 x 3 72 74
17 x 3 87 89
20 x 3 102 104
23 x 3 117 119
26 x 3 132 134
DTP03 1251 M AN 1/35 R [ ]~ Similar Illness or Symptom Date clm_dt EM 06 x 8 30 37 Map to first available EM Record
09 x 8 45 52
12 x 8 60 67
15 x 8 75 82
18 x 8 90 97
21 x 8 105 112
24 x 8 120 127
27 x 8 135 142
194 DTP O S-10 Date - Accident

DTP 1 of 10
DTP01 374 M ID 3/3 R 439* DTP Qualifier NOT MAPPED
Accident 439
DTP02 1250 M ID 2/3 R [Sel Code]* DTP Format Qualifier D8 NOT MAPPED
DT
DTP03 1251 M AN 1/35 R [ ]~ Accident Date clm_acc_dt E0 14 9 8 74 81 Map only 1st 8 bytes to E0-14
Accident Hour clm_acc_hr E0 15 x 4 82 85 If DTP02= DT, map ony last 4 bytes to E0-15
DTP 2 of 10
Accident 439 08 x 3 42 44
11 x 3 57 59
14 x 3 72 74
17 x 3 87 89
20 x 3 102 104
23 x 3 117 119
26 x 3 132 134
DTP02 1250 M ID 2/3 R [Sel Code]* DTP Format Qualifier D8 NOT MAPPED
DT

Max Cd
DTP03 1251 M AN 1/35 R [ ]~ Accident Date clm_dt EM 06 x 8 30 37 If DTP02= 'DT', map only first 8 bytes to first
09 x 8 45 52 available EM Record
12 x 8 60 67
15 x 8 75 82
18 x 8 90 97
21 x 8 105 112
24 x 8 120 127
27 x 8 135 142
Accident Hour clm_dtp_hr EM 07 x 4 38 41 If DTP02= 'DT', map only last 4 bytes to EM

10 x 4 53 56 Record
13 x 4 68 71
16 x 4 83 86
19 x 4 98 101
22 x 4 113 116
25 x 4 128 131
28 x 4 143 146
196 DTP O S-1 Last Menstrual Period Date

DTP01 374 M ID 3/3 R 484* DTP Qualifier clm_frst_sym_ill E0 11 9 1 64 64 If DTP01= 484, map '2' to E0-11
Last Menstrual Period 484
DTP03 1251 M AN 1/35 R [ ]~ Last Menstrual Period Date clm_frst_ill_dt E0 12 9 8 65 72

197 DTP O S-1 Date - Last X-Ray
DTP03 1251 M AN 1/35 R [ ]~ Last X-Ray Date clm_chiro_lst_xray_dt ER 14 x 8 59 66

200 DTP O S-1 Date - Hearing and Vision Prescription Date
DTP01 374 M ID 3/3 R 471* Prescription 471 clm_dtp_qual EM 05 x 3 27 29 Map to first available EM Record
08 x 3 42 44
11 x 3 57 59
14 x 3 72 74
17 x 3 87 89
20 x 3 102 104
23 x 3 117 119
26 x 3 132 134
DTP02 1250 M ID 2/3 R D8* DTP Format Qualifier NOT MAPPED

Date expressed CCYYMMDD D8

Max Cd
DTP03 1251 M AN 1/35 R [ ]~ Prescription Date clm_dt EM 06 x 8 30 37 Map to first available EM Record
09 x 8 45 52
12 x 8 60 67
15 x 8 75 82
18 x 8 90 97
21 x 8 105 112
24 x 8 120 127
27 x 8 135 142
201 DTP O S-5 Date - Disability Begin

DTP 1 of 5
DTP03 1251 M AN 1/35 R [ ]~ Disability Begin clm_unwrk_beg_dt E0 21 9 8 106 113

DTP 2 of 5
Disability Begin 360 08 x 3 42 44
11 x 3 57 59
14 x 3 72 74
17 x 3 87 89
20 x 3 102 104
23 x 3 117 119
26 x 3 132 134
DTP02 1250 M ID 2/3 R D8* DTP Format Qualifier D8
DTP03 1251 M AN 1/35 R [ ]~ Disability Begin Date clm_dt EM 06 x 8 30 37 Map to first available EM Record
09 x 8 45 52
12 x 8 60 67
15 x 8 75 82
18 x 8 90 97
21 x 8 105 112
24 x 8 120 127
27 x 8 135 142
203 DTP O S-5 Date - Disability End This DTP should be immediately following
the DTP for the associated Begin.
DTP 1 of 5
DTP01 374 M ID 3/3 R 361* Disability End 361 NOT MAPPED
DTP03 1251 M AN 1/35 R [ ]~ Disability End Date clm_unwrk_end_dt E0 22 9 8 114 121

DTP 2 of 5

Max Cd
DTP01 374 M ID 3/3 R 361* DTP Qualifier 361 clm_dtp_qual EM 05 x 3 27 29 Map to first available EM Record
Disability End 08 x 3 42 44
11 x 3 57 59
14 x 3 72 74
17 x 3 87 89
20 x 3 102 104
23 x 3 117 119
26 x 3 132 134
DTP03 1251 M AN 1/35 R [ ]~ Disability End Date clm_dt EM 06 x 8 30 37 Map to first available EM Record
09 x 8 45 52
12 x 8 60 67
15 x 8 75 82
18 x 8 90 97
21 x 8 105 112
24 x 8 120 127
27 x 8 135 142
205 DTP O S-1 Date - Last Worked

Date Last Worked 297 08 x 3 42 44
11 x 3 57 59
14 x 3 72 74
17 x 3 87 89
20 x 3 102 104
23 x 3 117 119
26 x 3 132 134

Date expressed CCYYMMDD D8
DTP03 1251 M AN 1/35 R [ ]~ Date Time Period clm_dt EM 06 x 8 30 37 Map to first available EM Record
09 x 8 45 52
12 x 8 60 67
15 x 8 75 82
18 x 8 90 97
21 x 8 105 112
24 x 8 120 127
27 x 8 135 142
206 DTP O S-1 Date - Authorized Return To Work

DTP03 1251 M AN 1/35 R [ ]~ Work Return Date clm_ret_wrk_dt EB 05 x 8 42 49

208 DTP O S-1 Date - Admission

Max Cd

DTP03 1251 M AN 1/35 R [ ]~ Admission Date clm_confine_adm_dt E0 19 9 8 90 97
210 DTP O S-1 Date - Discharge
DTP03 1251 M AN 1/35 R [ ]~ Related Hospital Discharge Date clm_confine_dchrg_dt E0 20 9 8 98 105
212 DTP O S-2 Date - Assumed and Relinquished Care
Dates
DTP 1 of 2
Report Start 090
DTP03 1251 M AN 1/35 R [ ]~ Assumed Care Date clm_care_assume_dt EB 12 x 8 107 114
DTP 2 of 2
Report End 091
DTP03 1251 M AN 1/35 R [ ]~ Relinquished Care Date clm_relinq_care_dt EA 24 x 8 121 128
214 PWK O S-10 Claim Supplemental Information
PWK O 1 of 10
PWK01 755 M ID 2/2 R [Sel Code]* Report Type Code clm_attach_cd E0 33 x 2 191 192 Map first occurrence of PWK to E0-33.
PWK02 756 O ID 1/2 R [Sel Code]* Report Transmission Code clm_trans_cd E0 30 x 2 172 173 See Code Table for values
PWK03-04 N/U **
PWK05 66 X ID 1/2 S AC* Identification Code Qualifier AC NOT MAPPED
PWK06 67 X AN 2/80 S [ ]~ Attachment Control Number clm_attach_ctrl_no EA 25 x 35 129 163
PWK O 2 of 10
PWK01 755 M ID 2/2 R [Sel Code]* Report Type Code clm_attach_cd EW 05 x 2 27 28 Map to first available EW Record
11 x 2 105 106
14 x 2 144 145
sub_seq_no EW 03 9 2 5 6
PWK02 756 O ID 1/2 R [Sel Code]* Report Transmission Code clm_trans_cd EW 06 x 2 29 30 Map to first available EW Record
12 x 2 107 108
15 x 2 146 147
PWK03-04 N/U **
PWK05 66 X ID 1/2 S AC* Identification Code Qualifier AC NOT MAPPED
PWK06 67 X AN 2/80 S [ ]~ Attachment Control Number clm_attach_ctrl_no EW 07 x 35 31 65 Map to first available EW Record
10 x 35 70 104
13 x 35 109 143
16 x 35 148 182

Max Cd
217 CN1 O S-1 Contract Information

CN101 1166 M ID 2/2 R [Sel Code]* Contract Type Code clm_contr_typ_cd EN 11 x 2 66 67 See Code Table for values
CN102 782 O R 1/18 S [ ]* Monetary Amount clm_contr_amt EN 12 9v99 10 68 77 Define as 'Real'
CN103 332 O R 1/6 S [ ]* Contract Percent clm_contr_allow_chrg_percnt EN 13 x 6 78 83
CN104 127 O AN 1/30 S [ ]* Contract Code clm_contr_cd EN 14 x 30 84 113
CN105 338 O R 1/6 S [ ]* Terms Discount Percent clm_contr_disc_percnt EN 15 x 6 114 119
CN106 799 O AN 1/30 S [ ]~ Contract Version Identifier clm_contr_ver EN 16 x 20 120 139
219 AMT O S-1 Credit/Debit Card Maximum Amount
AMT01 522 M ID 1/3 R MA* Amount Qualifier MA NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Credit or Debit Card Maximum Amount clm_cr_deb_max_amt DV 11 9v99 8 148 155 Define as 'Real'
220 AMT O S-1 Patient Amount Paid
AMT01 522 M ID 1/3 R F5* Amount Qualifier F5 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Patient Amount Paid clm_pat_pd_amt E0 28 9v99 10 161 170 Define as 'Real'
If >9(8)v99, move 'Too Big'
trl_pat_pd_amt X0 15 9v99 10 79 88 Define as 'Real'
If >9(8)v99, move 'Too Big'
221 AMT O S-1 Total Purchased Service Amount
AMT01 522 M ID 1/3 R NE* Amount Qualifier NE NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Total Purchased Service Amount clm_tot_purch_amt EA 10 9v99 6 51 56 Define as 'Real'
If < 9(4)v99, move 'Too Big'
222 REF O S-1 Service Authorization Exception Code
REF01 128 M ID 2/3 R 4N* Reference Number Qualifier 4N NOT MAPPED
REF02 127 X AN 1/30 R [Sel Code]~ Reference Identification clm_serv_auth_excp_cd EN 17 x 1 140 140 See Code Table for values
224 REF O S-1 Mandatory Medicare (Section 4081) Map to Triggered D0 Records.
Crossover Indicator
REF01 128 M ID 2/3 R F5* Reference Number Qualifier F5 NOT MAPPED
REF02 127 X AN 1/30 R [Sel Code]~ Reference Identification assign_4081_flag DD 05 x 1 50 50 See Code Table for values
226 REF O S-1 Mammography Certification Number
REF01 128 M ID 2/3 R EW* Reference Number Qualifier clm_ref_qual E4 06 x 2 26 27 Map to first available E4 Qualifier.
Mammography Certification Number EW 08 x 2 58 59 If more than 5 REF's map to this record ,
10 x 2 90 91 create another E4 record and increment +1 the
12 x 2 122 123 E4-03 Sub-Sequence Number.
14 x 2 154 155
sub_seq_no E4 03 9 2 5 6
REF02 127 X AN 1/30 R [ ]~ Reference Identification clm_ref_no E4 07 x 30 28 57 Map to the first available E4
Mammography Certification Number 09 x 30 60 89
11 x 30 92 121
13 x 30 124 153
15 x 30 156 185
227 REF O S-2 Prior Authorization or Referral Number
REF O 1 of 2

Max Cd
REF01 128 M ID 2/3 R 9F* Reference Number Qualifier 9F NOT MAPPED

Referral Number
REF02 127 X AN 1/30 R [ ]~ Referral Number clm_referral_no E0 31 x 15 174 188
pyr_referral_no D3 05 x 30 24 53 If REF*9F is present, Then map to both E0-31
and D3-05
REF O 2 of 2
REF01 128 M ID 2/3 R G1* Reference Number Qualifier GI NOT MAPPED
Prior Authorization Number
REF02 127 X AN 1/30 R [ ]~ Prior Authorization Number clm_pri_auth_no E0 25 x 15 133 147
pyr_pri_auth_no D3 06 x 30 54 83 If REF*G1 is present, Then map to both E0-
25 and D3-06
229 REF O S-1 Original Reference Number (ICN/DCN)
REF01 128 M ID 2/3 R F8* Reference Number Qualifier F8 NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Claim Original Reference Number clm_resub_ref_no EA 17 x 15 65 79
231 REF O S-3 CLIA Number

REF01 128 M ID 2/3 R X4* Reference Number Qualifier X4 clm_ref_qual E4 06 x 2 26 27 Map to first available E4 Qualifier.
08 x 2 58 59 If more than 5 REF's map to this record, create
10 x 2 90 91 another E4 record and increment +1 the E4-
12 x 2 122 123 03 Sub-Sequence Number
14 x 2 154 155
sub_seq_no E4 03 9 2 05 06
REF02 127 X AN 1/30 R [ ]~ Reference Identification clm_ref_no E4 07 x 30 28 57 Map to the first available E4
CLIA Number 09 x 30 60 89
11 x 30 92 121
13 x 30 124 153
15 x 30 156 185
233 REF O S-1 Repriced Claim Number

REF01 128 M ID 2/3 R 9A* Reference Number Qualifier 9A NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Repriced Claim Reference Number clm_tpo_ref_no E1 05 x 15 31 45
clm_orig_clear_id CZ 05 x 30 45 74 If Loop 2300 OR 2400 HCP Segment is
present
AND REF01 = '9A' THEN map to CZ-05
Else if REF01 does not = ‘9A’ but does =
‘D9’ THEN map to CZ-05 And clear out CZ-
05 before writing out the next claim.
235 REF O S-1 Adjusted Repriced Claim Number

REF01 128 M ID 2/3 R 9C* Reference Number Qualifier 9C NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Adjusted Repriced Claim Reference Number clm_tpo_adj_ref_no E1 22 x 15 172 186
236 REF O S-1 Investigational Device Exemption Number

Max Cd
REF01 128 M ID 2/3 R LX* Reference Number Qualifier LX clm_ref_qual E4 06 x 2 26 27 Map to first available E4 Qualifier.
Qualified Products List 08 x 2 58 59 If more than 5 REF's map to this record, create
12 x 2 122 123 03 Sub-Sequence Number.
14 x 2 154 155
sub_seq_no E4 03 9 2 05 06
REF02 127 X AN 1/30 R [ ]~ Investigational Device Exemption Identifier clm_ref_no E4 07 x 30 28 57 Map to the first available E4
09 x 30 60 89
11 x 30 92 121
13 x 30 124 153
15 x 30 156 185
238 REF O S-1 Claim Id Number for Clearinghouses

REF01 128 M ID 2/3 R D9* Reference Number Qualifier D9 NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Value Added Network Trace Number trl_env_id_no X0 18 9 15 178 192 Position 1-6 will contain WebMd processing
date. Position 7 will =5, and positions 8-15
will be a sequential number assigned to
incoming claims.
240 REF O S-4 Ambulatory Patient Group (APG)

REF01 128 M ID 2/3 R 1S* Reference Number Qualifier clm_ref_qual E4 06 x 2 26 27 Map to first available E4 Qualifier.
Ambulatory Patient Group (APG) Number 1S 08 x 2 58 59 If more than 5 REF's map to this record, create
14 x 2 154 155
sub_seq_no E4 03 9 2 05 06
REF02 127 X AN 1/30 R [ ]~ Reference Number Qualifer clm_ref_no E4 07 x 30 28 57 Map to the first available E4
Ambulatory Patient Group Number 09 x 30 60 89
11 x 30 92 121
13 x 30 124 153
15 x 30 156 185
241 REF O S-1 Medical Record Number

REF01 128 M ID 2/3 R EA* Reference Number Qualifier EA NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Reference Number Qualifier clm_mrec EB 04 x 17 25 41
Medical Record Number
242 REF O S-1 Demonstration Project Identifier
REF01 128 M ID 2/3 R P4* Reference Number Qualifier clm_ref_qual E4 06 x 2 26 27 Map to first available E4 Qualifier.
Project Code P4 08 x 2 58 59 If more than 5 REF's map to this record, create
14 x 2 154 155
sub_seq_no E4 03 9 2 05 06

Max Cd
REF02 127 X AN 1/30 R [ ]~ Demonstration Project Identifier clm_ref_no E4 07 x 30 28 57 Map to the first available E4
09 x 30 60 89
11 x 30 92 121
13 x 30 124 153
15 x 30 156 185
244 K3 O S-10 File Information

K301 449 M AN 1/80 R [ ]~ Fixed Format Information k3_info EK 05 x 80 27 106 Map to first available K3 segments to EK and
06 x 80 107 186 set the EK-03 Sub-Sequence Number to '01'.
If more than 2 K3 segments, create another

EK record and increment +1 the Sub-
Sequence Number up to 5 repeats.
sub_seq_no EK 03 9 2 05 06
246 NTE O S-1 Claim Note
NTE01 363 O ID 3/3 R [Sel Code]* Note Reference Code clm_note_qual EY 05 x 3 27 29 See Code Table for values
NTE02 352 M AN 1/80 R [ ]~ Claim Note Text clm_note EY 06 x 80 30 109
248 CR1 O S-1 Ambulance Transport Information
CR101 355 X ID 2/2 S LB* Pound LB NOT MAPPED
CR102 81 X R 1/10 S [ ]* Patient Weight clm_amb_pat_wt EP 04 x 4 25 28
CR103 1316 O ID 1/1 R [Sel Code]* Ambulance Transport Code clm_amb_cd EP 05 x 1 29 29 See Code Table for values
CR104 1317 O ID 1/1 R [Sel Code]* Ambulance Transport Reason Code clm_amb_rsn_cd EP 06 x 1 30 30 See Code Table for values
CR105 355 X ID 2/2 R DH* Miles DH NOT MAPPED
CR106 380 X R 1/15 R [ ]* Transport Distance clm_amb_dist EP 07 x 4 31 34
CR107-108 N/U **
CR109 352 O AN 1/80 S [ ]* Round Trip Purpose Description clm_amb_purp EP 08 x 79 35 113
CR110 352 O AN 1/80 S [ ]~ Stretcher Purpose Description clm_amb_stretch_purp EP 09 x 79 114 192
251 CR2 O S-1 Spinal Manipulation Service Information
CR201-CR207 N/U *******

CR208 1342 O ID 1/1 R [Sel Code]* Nature of Condition Code clm_chiro_pat_cnd_cd ES 05 x 1 27 27 See Code Table for values
CR209 N/U *
CR210 352 O AN 1/80 S [ ]* Patient Condition clm_chiro_pat_cnd_desc ES 06 x 80 28 107
Description -1
CR211 352 O AN 1/80 S [ ]* Patient Condition clm_chiro_pat_cnd_desc ES 07 x 80 108 187
Description -2
CR212 1073 O ID 1/1 S [Sel Code]* X-Ray Availablitiy Indicator N clm_chiro_xray_flag ER 13 x 1 58 58 Map only if 'Y' or 'N' , else don't map
Y
257 CRC O S-3 Ambulance Conditions Indicator Assumption would be not to get vision and
ambulance on same claim.
CRC 1 of 3
CRC01 1136 M ID 2/2 R 07* Code Category 07 clm_cnd_cat_cd EQ 04 x 2 25 26
CRC02 1073 M ID 1/1 R [Sel Code]* Certification Condition Indicator N clm_cnd_cert_flag EQ 05 x 1 27 27 Map only if 'Y' or 'N' , else don't map
Y
CRC03 1321 M ID 2/2 R [Sel Code]* Condition Code clm_cnd_cd EQ 06 x 2 28 29 See Code Table for values

Max Cd
CRC04 1321 M ID 2/2 S [Sel Code]* Condition Code clm_cnd_cd EQ 07 x 2 30 31 See Code Table for values
CRC07 1321 M ID 2/2 S [Sel Code]~ Condition Code clm_cnd_cd EQ 10 x 2 36 37 See Code Table for values
CRC 2 of 3
Y
CRC 3 of 3
Y
260 CRC O S-3 Vision Conditions Indicator
CRC 1 of 3
CRC01 1136 M ID 2/2 R [Sel Code]* Code Category clm_cnd_cat_cd EQ 04 x 2 25 26 See Code Table for values
Y
CRC 2 of 3
Y
CRC 3 of 3

Max Cd
Y
263 CRC O S-1 CRC* Homebound Indicator
CRC01 1136 M ID 2/2 R 75* Code Category 75 NOT MAPPED
CRC02 1073 M ID 1/1 R Y* Certification Condition Indicator Y clm_hmbnd_flag EA 20 x 1 96 96 If 'Y' move 'Y' to EA-20, else do not map.
CRC03 1321 M ID 2/2 R IH~ Condition Code IH NOT MAPPED
261 CRC O S-1 CRC* ESPDT Referral

CRC01 1136 M ID 2/2 R ZZ* Code Category ZZ clm_cnd_cat_cd EQ 04 x 2 25 26
CRC02 1073 M ID 1/1 R [Sel Code]* Certification Condition Ind. N clm_cnd_cert_flag EQ 05 x 1 27 27 Map only if 'Y' or 'N' , else don't map.
Y
CRC04 1321 O ID 2/2 S [Sel Code]* Condition Code clm_cnd_cd EQ 07 x 2 30 31 See Code Table for values
CRC05 1321 O ID 2/2 S [Sel Code]~ Condition Code clm_cnd_cd EQ 08 x 2 32 33 See Code Table for values
265 HI O S-1 HI* Health Care Diagnosis Code
HI01 C022 M R HealthCare Code Information
HI01-1 1270 M ID 1/3 R BK: Code List Qualifier BK BF clm_dx_qual E0 26 x 3 148 150 Translate "BK" to "BF"
HI01-2 1271 M AN 1/30 R [ ]* Diagnosis Code clm_dx_1 E0 05 x 8 23 30 If decimal point is received, strip in translator
HI01-3-7 N/U :
HI02 C022 O S HealthCare Code Information
HI02-1 1270 M ID 1/3 R BF: Code List Qualifier NOT MAPPED
HI02-3-7 N/U :
HI03-3-7 N/U :
HI04-3-7 N/U :

Max Cd
HI05-2 1271 M AN 1/30 R [ ]* Diagnosis Code clm_dx_5 EB 13 x 8 115 122 If decimal point is received, strip in translator
HI05-3-7 N/U :
HI06-3-7 N/U :
HI07-3-7 N/U :
HI08-2 1271 M AN 1/30 R [ ]~ Diagnosis Code clm_dx_8 EB 16 x 8 139 146 If decimal point is received, strip in translator
271 HCP O S-1 Claim Pricing/Repricing Information

HCP01 1473 X ID 2/2 R [Sel Code]* Pricing Methodology clm_tpo_pric_meth E1 08 x 2 67 68 See Code Table for values
HCP02 782 O R 1/18 R [ ]* Repriced Allowed Amount clm_tpo_allow_amt E1 09 9v99 8 69 76 Define as 'Real'
HCP03 782 O R 1/18 S [ ]* Repriced Savings Amount clm_tpo_sav_amt E1 10 9v99 8 77 84 Define as 'Real'
HCP04 127 O AN 1/30 S [ ]* Repricing Organization ID clm_tpo_id E1 04 x 9 22 30
HCP05 118 O R 1/9 S [ ]* Repricing Per Diem or Flat Rate Amount clm_tpo_price_rate E1 19 9v99 8 153 160 Define as 'Real'
HCP06 127 O AN 1/30 S [ ]* Repriced APG Code clm_tpo_apg_cd E1 20 x 3 161 163
HCP07 782 O R 1/18 S [ ]* Repriced Approved Ambulatory Patient Group clm_tpo_apg_amt E1 21 9v99 8 164 171
Amount
HCP08-HCP12 N/U *****
HCP13 901 X ID 2/2 S Translate* Reject Reason Code clm_tpo_rej_msg E1 06 x 1 46 46 See Code Table for Translation
HCP14 1526 O ID 1/2 S Translate* Policy Compliance Code clm_tpo_pol_comp_cd E1 17 x 2 149 150 See Code Table for Translation
HCP15 1527 O ID 1/2 S Translate~ Exception Code clm_tpo_except_cd E1 18 x 2 151 152 See Code Table for Translation
LOOP 2305 S-6 HOME HEALTH CARE PLAN
INFORMATION
276 CR7 O S-1 CR7* Home Health Treatment Plan Certification
Information
CR701 921 M ID 2/2 R [Sel Code]* Discipline Type Code clm_hh_typ_cd EX 05 x 2 27 28 See Code Table for values
CR702 1470 M N0 1/9 R [ ]* Total Visits Rendered Count clm_hh_tot_vst_rend EX 06 9 4 29 32
CR703 1470 M N0 1/9 R [ ]~ Certification Period Projected Visit Count clm_hh_tot_vst_ct EX 07 9 4 33 36
278 HSD O S-3 HSD* Home Health Care Services Delivery
Information
HSD 1 of 3
HSD01 673 X ID 2/2 S VS* Quantity Qualifier VS NOT MAPPED

Max Cd
HSD02 380 X R 1/15 S [ ]* Number Of Visits clm_hh_no_vst_1 EX 08 x 4 37 40

HSD03 355 O ID 2/2 S [Sel Code]* Modulus UBM Code clm_hh_ubm_1 EX 09 x 2 41 42 See Code Table for values
HSD04 1167 O R 1/6 S [ ]* Modulus, Amount clm_hh_mdl_amt_1 EX 10 x 6 43 48
HSD05 615 X ID 1/2 S [Sel Code]* Time Period Qualifier clm_hh_dtp_qual_1 EX 11 x 2 49 50 See Code Table for values
HSD06 616 O N0 1/3 S [ ]* Number of Periods clm_hh_no_per_ct_1 EX 12 x 3 51 53
HSD07 678 O ID 1/2 S [Sel Code]* Calendar Pattern Code clm_hh_cal_cd_1 EX 13 x 2 54 55 See Code Table for values
HSD08 679 O ID 1/1 S [Sel Code]~ Delivery Pattern Time Code clm_hh_dtp_cd_1 EX 14 x 1 56 56 See Code Table for values
HSD 2 of 3
HSD 3 of 3
LOOP 2310A S-2 REFERRING/PCP PROVIDER Each Loop represents a new Packet with
INFORMATION the Sub-Sequence number the same for
each record within that Packet.
282 NM1 O S-1 NM1* Refering/PCP Provider Name Information
NM101 98 M ID 2/3 R [Sel Code]* Name Qualifier clm_prov_nm_qual_e6 E6 05 x 2 24 25 If E7 and/or E8 are created from information
Referring Provider DN in this Loop, Map this field to the E6-05 , E7-
Primary Care Provider P3 05 and/ or E8-05
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier clm_prov_typ_cd E6 06 x 1 26 26 If 1 map 'L'
Person 1 L If 2 map 'O'
Non-Person Entity 2 O
NM103 1035 O AN 1/35 R [ ]* Referring/PCP Provider Last Name clm_prov_lnm E6 07 x 35 27 61
NM104 1036 O AN 1/25 S [ ]* Referring/PCP Provider First Name clm_prov_fnm E6 08 x 12 62 73

NM105 1037 O AN 1/25 S [ ]* Referring/PCP Provider Middle Name clm_prov_mi E6 09 x 1 74 74
NM106 N/U *

Max Cd
NM107 1039 O AN 1/10 S [ ]* Referring /PCP Provider Name Suffix clm_prov_suffix E6 10 x 10 75 84

NM108 66 X ID 1/2 S [Sel Code]* Identification Code Qualifier clm_prov_tin_qual E6 12 x 1 100 100 Map only if NM108 = 24 or 34
EIN 24 E
SSN 34 S
NPI XX Not Mapped
NM109 67 X AN 2/80 S [ ]~ Referring/PCP Provider Identifier If NM108 = '24' and the third position of
map data.
clm_prov_npi E6 11 x 15 85 99 If 'XX' in NM108, Map to E6-11

clm_prov_tin E6 13 x 9 101 109 If 24 or 34 in NM108 Map to E6-13
285 PRV O S-1 Referring/PCP Provider Specialty
Information
PRV01 1221 M ID 1/3 R RF* Provider Code NOT MAPPED
PRV02 128 M ID 2/3 R ZZ* Mutually Defined Provider Taxonomy Code NOT MAPPED
PRV03 127 M AN 1/30 R [ ]~ Provider Taxonomy Code clm_prov_taxomy_cd E6 16 x 11 128 138 See Code Table for Source
clm_prov_spec_cd E6 14 x 3 110 112
288 REF O S-5 REF* Referring/PCP Provider Secondary Assumption is that only 1 of each qualifier
Identification Numbers will be used. If 2 of the same qualifier
comes in, overwrite the previous.
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier clm_prov_sec_id_qual E7 06 x 2 26 27 Map the NM101 qualifier to E7-06 and map
Location Number LU 08 x 2 43 44 the same Sub-Sequence number used in
State Industrial Accident X5 10 x 2 60 61 previous E6-06 generated from this Loop.
Medicare Number 1C 12 x 2 77 78 If E6 not generated, increment by 1.
State License Number 0B 14 x 2 94 95 Do NOT map if N5.
Blue Shield Number 1B Map Qualifier to first available E7-06
Medicaid Number 1D Qualifier even those not listed.
UPIN 1G If qualifer equals EI or SY, look at the NM108
Commercial Number G2 preceeding this REF
Champus Number 1H
Employer's ID EI clm_prov_sec_id_qual See REF01 for positions If NM108 equals 24 or 34 map 'EI' to E7-06
clm_prov_tin_qual E6 12 x 1 100 100 If NM108 equals XX map 'E' to E6-12

Social Security Number SY clm_prov_sec_id_qual See REF01 for positions If NM108 equals 24 or 34 map 'SY' to E7-06
clm_prov_tin_qual E6 12 x 1 100 100 If NM108 equals XX map 'S' to E6-12

Network Id Number N5 Do NOT map.

Max Cd
REF02 127 X AN 1/30 R [ ]~ Provider Secondary Identifier clm_prov_sec_id E7 07 x 15 28 42 Do not map if = N5

Location Number 09 x 15 45 59 Map to E7-07. If qualifer equals 'EI' or 'SY',
State Industrial Accident 11 x 15 62 76 look to see if E6-12 and E6-13 have been
Medicare Number 13 x 15 79 93 populated
State License Number 15 x 15 96 110 If REF01= 'EI' and third position of REF02 =
Blue Shield Number '_', strip '_' and concatenate the number prior
Medicaid Number to mapping to E7 ID.
UPIN
Commercial Number
Champus Number
Employer's ID clm_prov_sec_id See REF02 for positions If E6-12 is present, then map to first available
E7 ID Number
clm_prov_tin E6 13 x 9 101 109 If E6-12 is not present, then map to E6-13
Social Security Number clm_prov_sec_id See REF02 for positions If REF 01 = SY
and NM108 equals 24 or 34 map to E7-07

Network ID clm_prov_ntwrk_id E6 15 x 15 113 127 If REF01=N5
LOOP 2310B S-1 RENDERING PROVIDER
INFORMATION
291 NM1 O S-1 NM1* Rendering Provider Name Information
NM101 98 M ID 2/3 R 82* Name Qualifier 82 clm_prov_nm_qual_e6 E6 05 x 2 24 25 If E7 and/or E8 are created from information
Rendering Provider in this Loop, Map this field to the E7-05 and/
or E8-05
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier clm_prov_typ_cd E6 06 x 1 26 26 If "1", map L
Person 1 L If "2", map O
Non-Person Entity 2 O If data already present, re-initialize field with
spaces and map with data from this element.
NM103 1035 O AN 1/35 R [ ]* Last Name or Organization Name clm_prov_lnm E6 07 x 35 27 61 If Submitter ID = '332211999' or '332211888'
If data already present, re-initialize field with
NM104 1036 O AN 1/25 S [ ]* Rendering Provider First Name clm_prov_fnm E6 08 x 12 62 73 If Submitter ID = '332211999' or '332211888'
NM105 1037 O AN 1/25 S [ ]* Rendering Provider Middle Name clm_prov_mi E6 09 x 1 74 74 If data already present, re-initialize field with

Max Cd
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Rendering Provider Name Suffix clm_prov_suffix E6 10 x 10 75 84 If data already present, re-initialize field with
NM108 66 X ID 1/2 R [Sel Code]* Identification Code Qualifier clm_prov_tin_qual E6 12 x 1 100 100 If Submitter ID = '332211888' or '332211999'
EIN 24 E and NM108 is present and NM103 or NM104
SSN 34 S = 'None', then create an E6 where E6-05 = '82'
NPI XX Not and map accordingly.
Mapped Map only if NM108 = 24 or 34
NM109 67 X AN 2/80 R [ ]~ Rendering Provider ID If NM108 = '24' and the third position of
map data.
clm_prov_tin E6 13 x 9 101 109 If Submitter ID = '332211888' or '332211999'

and NM109 is present and NM103 or NM104
= 'None', then create an E6 where E6-05 = '82'
and map accordingly.
If 24 or 34 in NM108 Map to E6-13
clm_prov_npi E6 11 x 15 85 99 If 'XX' in NM108 Map to E6-11

293 PRV O S-1 PRV* Rendering Provider Specialty Information
PRV01 1221 M ID 1/3 R PE* Provider Code NOT MAPPED

PRV02 128 M ID 2/3 R ZZ* Mutually Defined Provider Taxonomy Code NOT MAPPED
PRV03 127 M AN 1/30 R [ ]~ Provider Taxonomy Code clm_prov_taxomy_cd E6 16 x 11 128 138 See Code Table for Source
296 REF O S-5 REF* Rendering Provider Secondary Assumption is that only 1 of each qualifier
Identification Numbers will be used. If 2 of the same qualifer come

Max Cd
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier clm_prov_sec_id_qual E7 06 x 2 26 27 If E7 and/or E8 are created from information
Location Number LU 08 x 2 43 44 in this Loop, Map this field to the E7-05 and/
State Industrial Accident X5 10 x 2 60 61 or E8-05
Medicare Number 1C 12 x 2 77 78 Do not map if = N5
State License Number 0B 14 x 2 94 95 Map Qualifier to E7-06 even those not listed.
Blue Shield Number 1B If qualifer equals 'EI' , 'SY' or TJ, look to see
Medicaid Number 1D if E6-12 and E6-13 have been populated
UPIN 1G
Champus Number 1H
Employer's ID EI clm_prov_sec_id_qual See REF01 for positions If E6-12 is present, map 'EI' to E7-06
clm_prov_tin_qual E6 12 x 1 100 100 If E6-12 is not present, map 'E' to E6-12
Social Security Number SY clm_prov_sec_id_qual See REF01 for positions If E6-12 is present, map 'SY' to E7-06
clm_prov_tin_qual E6 12 x 1 100 100 If is not present, map 'S' to E6-12
State License Number 15 x 15 96 110 If REF01 = 'EI' and third position of REF02 =
Blue Shield Number '_', strip '_' and concatenate the number prior
Medicaid Number to mapping to E7 ID.
UPIN
Commercial Number
Champus Number
pyr_prov_id D0 20 x 13 148 160 If E7 Qualifier = 'G2', map to D0-20 Provider

ID and first available E7 Identifier, else Do
Not Map.
Employer's ID clm_prov_sec_id See REF02 for positions If E6-13 is present, then map to first available
E7 Record
Social Security Number clm_prov_sec_id See REF02 for positions If E6-13 is present, then map to first available
E7 Record
clm_prov_tin E6 13 x 9 101 109 Else if E6-13 is not present, map to E6-13

Max Cd

LOOP 2310C S-1 PURCHASE SERVICE PROVIDER

INFORMATION
298 NM1 O S-1 NM1* Purchase Service Provider Name
Information
NM101 98 M ID 2/3 R QB* Name Qualifier clm_prov_nm_qual_e6 E6 05 x 2 24 25 If not = 'QB', then do not map Purchase
Purchase Service Provider Service Provider Name Information in Loop
2310 C
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier clm_prov_typ_cd E6 06 x 1 26 26

Person 1 L If 1 map 'L'
Non-Person Entity 2 O If 2 map 'O'
NM103 1035 O AN 1/35 R [ ]* Name Last or Organization Name clm_prov_lnm E6 07 x 35 27 61
NM104 1036 O AN 1/25 S [ ]* Purchase Service Provider First Name clm_prov_fnm E6 08 x 12 62 73

NM105 1037 O AN 1/25 S [ ]* Purchase Service Provider Middle Name clm_prov_mi E6 09 x 1 74 74
NM106-NM107 N/U **
EIN 24 E
SSN 34 S
NPI XX
NM109 67 X AN 2/80 S [ ]~ Purchase/Service Provider Identifier If NM108 = '24' and the third position of
map data.

Max Cd
clm_prov_tin E6 13 x 9 101 109 If 23 or 34 in NM108 Map to E6-13

301 REF O S-5 REF* Purchase Service Provider Secondary Assumption is that only 1 of each qualifier
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier clm_prov_sec_id_qual E7 06 x 2 26 27 Map the NM101 qualifier to E7-06 and map
Location Number LU 08 x 2 43 44 the same Sub-Sequence number used in
State Industrial Accident X5 10 x 2 60 61 previous E6-06 generated from this Loop.
Medicare Number 1C 12 x 2 77 78 If E6 not generated, increment by 1.
State License Number 0B 14 x 2 94 95 Do NOT map if N5.
Blue Cross Number 1A Map Qualifier to E7-06 Qualifier even those
Blue Shield Number 1B not listed.
Medicaid Number 1D If qualifer equals EI or SY you need to look at
UPIN 1G the NM108 preceding this REF
USIN U3
Champus Number 1H
clm_prov_tin_qual E6 12 x 1 100 100 If E6-12 is not present, map 'S' to E6-12
Blue Cross Number '_', strip '_' and concatenate the number prior
Blue Shield Number to mapping to E7 ID.
Medicaid Number
UPIN
USIN
Commercial Number
Champus Number
Employer's ID clm_prov_sec_id See REF02 for positions If REF 01 = 'EI' and NM108 equals 24 or 34
map to E7-07
clm_prov_tin E6 13 x 9 101 109 Else If NM108 equals 'XX' map to E6-13

Social Security Number clm_prov_sec_id See REF02 for positions If REF 01 = 'SY' and NM108 equals 24 or 34
map to E7-07

LOOP 2310D S-1 SERVICE FACILIITY INFORMATION

Max Cd
303 NM1 O S-1 NM1* Service Facility Name Information

NM101 98 M ID 2/3 R [SelCode]* Name Qualifier clm_prov_nm_qual_e6 E6 05 x 2 24 25 If E7 and or E8 are created from this Loop,
Service Location 77 map this to the E7-05 or E8-05
Facility FA
Independent Lab LI
Testing Lab TL
clm_lab_flag EA 08 x 1 49 49 If NM101 ='LI', set EA-08 to 'Y'.

NM102 1065 M ID 1/1 R 2* Entity Type Qualifier 2 O clm_prov_typ_cd E6 06 x 1 26 26 Default 'O'.
NM103 1035 O AN 1/35 S [ ]* Laboratory or Facility Name clm_prov_lnm E6 07 x 35 27 61 If data already present, re-initialize field with
NM104-07 NU ****
EIN 24 E
SSN 34 S
NPI XX Not
Mapped
NM109 67 X AN 2/80 S [ ]~ Lab/Facility ID If NM108 = '24' and the third position of

map data.

clm_prov_tin E6 13 x 9 101 109 If '24' or '34' in NM108 Map to E6-13
307 N3 O R-1 N3* Service Facility Location Address
N301 166 M AN 1/55 R [ ]* Laboratory or Facility Address Line 1 clm_prov_addr_1 E8 07 x 30 86 115 If data already present, re-initialize field with
N302 166 O AN 1/55 S [ ]~ Laboratory or Facility Address Line 2 clm_prov_addr_2 E8 08 x 30 116 145 If data already present, re-initialize field with
308 N4 O S-1 N4* Service Facility Location City/State/Zip

Code
N401 19 O AN 2/30 R [ ]* Laboratory or Facility City Name clm_prov_city E8 09 x 20 146 165 If data already present, re-initialize field with

Max Cd
N402 156 O ID 2/2 R [ ]* Laboratory or Facility State/Province Name clm_prov_st E8 10 x 2 166 167 If data already present, re-initialize field with
N403 116 O ID 3/15 R [ ]* Laboratory or Facility Zip Code clm_prov_zip E8 11 x 9 168 176 If data already present, re-initialize field with
N404 26 O ID 2/3 S [ ]~ Laboratory or Facility Country Code clm_prov_cntry_cd E8 12 x 3 177 179 If data already present, re-initialize field with
310 REF O S-5 REF* Service Facility Location Secondary Assumption is that only 1 of each qualifier
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier clm_prov_sec_id_qual E7 06 x 2 26 27 Do NOT map if N5. Map Qualifier to E7-06
Location Number LU 08 x 2 43 44 even those not listed.
State Industrial Accident X5 10 x 2 60 61 If qualifer equals 'TJ' you need to look at the
Medicare Number 1C 12 x 2 77 78 NM108 preceding this REF
State License Number 0B 14 x 2 94 95
Blue Cross Number 1A
Blue Shield Number 1B
Medicaid Number 1D
UPIN 1G
Champus Number 1H
CLIA Number X4
Federal Tax ID Number TJ clm_prov_sec_id_qual See REF01 for positions If NM108 equals '24' or '34' map 'TJ ' to E7-
06
clm_prov_tin_qual E6 12 x 1 100 100 If NM108 equals 'XX' map 'E' to E6-12
Location Number 09 x 15 45 59 Map to E7-07
State Industrial Accident 11 x 15 62 76
Medicare Number 13 x 15 79 93
State License Number 15 x 15 96 110
Blue Shield Number
Medicaid Number
UPIN
Commercial Number
Champus Number
Federal Tax ID Number clm_prov_sec_id E7 07 x 15 28 42 If REF 01 = 'TJ' and NM108 equals ' 2'4' or
'34' map to E7-07

Max Cd

LOOP 2310E S-1 SUPERVISING PROVIDER
INFORMATION
312 NM1 O S-1 NM1* Supervision Provider Name Information
NM101 98 M ID 2/3 R DQ* Name Qualifer clm_prov_nm_qual_e6 E6 05 x 2 24 25 If not = 'DQ', do mot map Supervising
Supervising Physician DQ Provider Name Information in Loop 2310 E
NM102 1065 M ID 1/1 R 1* Entity Type Qualifier clm_prov_typ_cd E6 06 x 1 26 26 Convert "1" to "L"
Person 1 L
NM103 1035 O AN 1/35 R [ ]* Supervising Provider Last Name clm_prov_lnm E6 07 x 35 27 61
NM104 1036 O AN 1/25 R [ ]* Supervising Provider First Name clm_prov_fnm E6 08 x 12 62 73
NM105 1037 O AN 1/25 S [ ]* Supervising Provider Middle Name clm_prov_mi E6 09 x 1 74 74

NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Supervising Provider Name Suffix clm_prov_suffix E6 10 x 10 75 84
NM108 66 X ID 1/2 S [Sel Code]* Identification Code Qualifier clm_prov_tin_qual E6 12 x 1 100 100 Map only if NM108 = '24' or '34'
EIN 24 E
SSN 34 S
NPI XX Not
Mapped
NM109 67 X AN 2/80 S [ ]~ Supervising Provider Primary Identifier If NM108 = '24' and the third position of
map data.

clm_prov_tin E6 13 x 9 101 109 If '24' or '34' in NM108 Map to E6-13
316 REF O S-5 REF* Supervising Provider Secondary Assumption is that only 1 of each qualifier

Max Cd
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier clm_prov_sec_id_qual E7 06 x 2 26 27 Do NOT map if N5. Map Qualifier to E7-06
State Industrial Accident X5 10 x 2 60 61 If qualifer equals 'EI' or 'SY' you need to look
Medicare Number 1C 12 x 2 77 78 at the NM108 preceding this REF
Medicaid Number 1D
UPIN 1G
Champus Number 1H
clm_prov_tin_qual E6 12 x 1 100 100 If is not present, map 'S' to E6-12
Location Number 09 x 15 45 59 Map to E7-07.
State Industrial Accident 11 x 15 62 76 If qualifer equals 'EI' or 'SY', look to see if
Medicare Number 13 x 15 79 93 E6-12 and E6-13 have been populated
Blue Cross Number '_', strip '_' and concatenate the number prior
Blue Shield Number to mapping to E7 ID.
Medicaid Number
UPIN
Commercial Number
Champus Number
CLIA Number
Employer's ID clm_prov_sec_id See REF02 for positions If REF 01 = 'EI 'and NM108 equals '24' or
'34', map to E7-07
clm_prov_tin E6 13 x 9 101 109 Else If NM108 equals 'XX', map to E6-13

Social Security Number clm_prov_sec_id See REF02 for positions If REF 01 = 'SY'
and NM108 equals '24' or '34', map to E7-07
clm_prov_tin E6 13 x 9 101 109 Else If NM108 equals 'XX', map to E6-13

LOOP 2320 S-10 OTHER SUBSCRIBER INFORMATION This Loop is the non-destination payer.
Therefore the Payer Flag will be blank for
all D0 Records created from this Loop.
Each repeat of the 2320 Loop generates a
separate D0 Packet.
318 SBR O S-1 SBR* Subscriber Information

Max Cd
SBR01 1138 M ID 1/1 R [Sel Code]* Payer Responsibility Sequence Number Code pyr_resp_cd D0 02 9 2 03 04 If SBR01 = 'T' , begin with 03
Primary P 01 If SBR01 in Loop 2000 B was not 'T',else
Secondary S 02 begin with 04.
Tertiary T 03, 04, 05
SBR02 1069 O ID 2/2 R Translate* Individual Relationship Code pat_rel_cd D0 17 9 2 137 138 See Code Table for Translation
SBR03 127 O AN 1/30 S [ ]* Insured Group or Policy Number ins_plan_no D0 09 x 20 66 85
SBR04 93 O AN 1/60 S [ ]* Group or Plan Name ins_grp_nm D0 10 x 17 86 102
nsf_grp_nm DB 05 x 35 60 94
SBR05 1336 O ID 1/3 R Translate* Insurance Type Code ins_typ_cd D0 22 x 2 163 164 See Code Table for Translation
SBR06-08 N/U ***
SBR09 1032 O ID 1/2 S Translate~ Claim Filing Indicator Code sop_cd D0 04 x 1 22 22 See Code Table for Translation
326 CAS O S-5 CAS* Claim Level Adjustments
CAS01 1033 M ID 1/2 R [Sel Code]* Claim Adjustment Group Code clm_cas_grp_cd DT 05 x 2 27 28 See Code Table for values
CAS02 1034 M ID 1/5 R [Sel Code]* Adjustment Reason Code clm_cas_cd DT 06 x 5 29 33 See Code Table for Source
CAS03 782 M R 1/18 R [ ]* Adjustment Amount clm_cas_amt DT 07 9v99 8 34 41 Define as 'Real'
CAS04 380 O R 1/15 S [ ]* Adjustment Quantity clm_cas_qty DT 08 x 14 42 55
CAS05 1034 X ID 1/5 S [Sel Code]* Adjustment Reason Code clm_cas_cd DT 09 x 5 56 60 See Code Table for values
CAS06 782 X R 1/18 S [ ]* Adjustment Amount clm_cas_amt DT 10 9v99 8 61 68 Define as 'Real'
CAS07 380 X R 1/15 S [ ]* Adjustment Quantity clm_cas_qty DT 11 x 14 69 82
CAS19 380 X R 1/15 S [ ]~ Adjustment Quantity clm_cas_qty DT 23 x 14 177 190
333 AMT O S-1 AMT* Coordination of Benefits (COB) Payer Paid
Amount
AMT01 522 M ID 1/3 R D* Amount Qualifier Code D NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Payer Paid Amount clm_cob_pd_amt D0 25 9v99 10 182 191 Define as 'Real'
334 AMT O S-1 AMT* Coordination of Benefits (COB) Approved
Amount

Max Cd
AMT01 522 M ID 1/3 R AAE* Amount Qualifier Code AAE NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Approved Amount clm_cob_apprv_amt DD 19 9v99 9 165 173 Define as 'Real'
335 AMT O S-1 AMT* Coordination of Benefits (COB) Allowed
Amount
AMT01 522 M ID 1/3 R B6* Amount Qualifier Code B6 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Allowed Amount clm_cob_allow_amt DA 13 9v99 7 91 97 Define as 'Real'
336 AMT O S-1 AMT* Coordination of Benefits (COB) Patient
Responsibility Amount
AMT01 522 M ID 1/3 R F2* Amount Qualifier Code F2 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Patient Responsibility Amount clm_cob_pat_resp_amt DU 04 9V99 9 25 33 Define as 'Real'
337 AMT O S-1 AMT* Coordination of Benefits (COB) Covered
Amount
AMT01 522 M ID 1/3 R AU* Amount Qualifier Code AU NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Covered Amount clm_cob_cvrd_amt DU 05 9v99 9 34 42 Define as 'Real'
338 AMT O S-1 AMT* Coordination of Benefits (COB) Discount
Amount
AMT01 522 M ID 1/3 R D8* Amount Qualifier Code D8 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Discount Amount clm_cob_disc_amt DU 06 9v99 9 43 51 Define as 'Real'
339 AMT O S-1 AMT* Coordination of Benefits (COB) Per Day
Limit Amount
AMT01 522 M ID 1/3 R DY* Amount Qualifier Code DY NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Per Day Limit Amount clm_cob_pyr_per_day_lmt DU 07 9V99 9 52 60 Define as 'Real'
340 AMT O S-1 AMT* Coordination of Benefits (COB) Patient Paid
Amount
AMT01 522 M ID 1/3 R F5* Amount Qualifier Code F5 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Patient Paid Amount clm_cob_pd_to_pat_amt DU 23 9v99 9 180 188 Define as 'Real'
341 AMT O S-1 AMT* Coordination of Benefits (COB) Tax
Amount
AMT01 522 M ID 1/3 R T* Amount Qualifier Code T NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Tax Amount clm_cob_tax_amt DU 08 9v99 9 61 69 Define as 'Real'
341 AMT O S-1 AMT* Coordination of Benefits (COB) Total Claim

Before Taxes Amount
AMT01 522 M ID 1/3 R T2* Total Claim Before Taxes T2 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Other Payer Pre-Tax Claim Total Amount clm_cob_pretax_amt DU 10 9v99 9 106 114 Define as 'Real'
342 DMG O S-1 DMG* Subscriber Demographic Information

Max Cd

DMG02 1251 X AN 1/35 R [ ]* Subscriber Birth Date ins_dob D0 19 9 8 140 147
DMG03 1068 O ID 1/1 R [Sel Code]~ Other Subscriber Gender Code ins_sex D0 14 x 1 134 134 See Code Table for values
345 OI O R-1 OI* Other Insurance Coverage Information
OI01-02 N/U **
OI03 1073 O ID 1/1 R [Sel Code]* Benefits Assignment Certification Indicator N asgn_ben_flag D0 16 x 1 136 136 Map only if 'Y' or 'N' , else don't map
Y
OI04 1351 O ID 1/1 S Translate* Patient Signature Source Code pat_sig_flag D0 18 x 1 139 139 Translate 'C' to 'Y' or 'P' to 'N', else map as
received
OI05 N/U *
OI06 1363 O ID 1/1 R Translate~ Release of Information Code rls_info_cd D0 15 x 1 135 135 Translate "M' to "R", else move as received
348 MOA O S-1 MOA* Medicare OutPatient Adjudication
Information
MOA01 954 O R 1/10 S [ ]* Reimbursement Rate clm_moa_remb_rate DU 12 9v99 9 116 124 Define as 'Real'
MOA02 782 O R 1/18 S [ ]* HCPCS Payable Amount clm_moa_hcpcs_pay_amt DU 13 9v99 9 125 133 Define as 'Real'
MOA03 127 O R 1/30 S [ ]* Claim Payment Remark Code clm_moa_rem_cd_1 DU 14 x 5 134 138 See Code Table for Source
MOA04 127 O AN 1/30 S [ ]* Claim Payment Remark Code clm_moa_rem_cd_2 DU 15 x 5 139 143 See Code Table for Source
MOA08 782 O R 1/18 S [ ]* End Stage Renal Disease Payment Amount clm_moa_esrd_pd_amt DU 19 9v99 9 159 167 Define as 'Real'
MOA09 782 O R 1/18 S [ ]~ Nonpayable Professional Component Billed clm_moa_prof_amt DU 20 9v99 9 168 176 Define as 'Real'
Amount If > 9(7)v99, move 'Too Big'
LOOP 2330A R-1 OTHER SUBSCRIBER NAME This Loop is the non-destination payer.
Therefore the Payer Flag will be blank for
all D0 Records created from this Loop.
Each repeat of the 2330 Loop generates a
separate D0 Packet.
350 NM1 O R-1 NM1* Individual or Organization Name

NM101 98 M ID 2/3 R IL* Name Qualifier . If not = to 'IL, do not map Subscriber Info.in
IL Loop 2330 A
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier 1 If D0-12 is present, map '1'. Else map '2'.
2
NM103 1035 O AN 1/35 R [ ]* Other Subscriber Last Name ins_lnm D0 11 x 20 103 122 Always Map
nsf_ins_lnm DB 07 x 35 120 154 Always Map

NM104 1036 O AN 1/25 S [ ]* Other Subscriber First Name ins_fnm D0 12 x 10 123 132 Always Map

Max Cd
nsf_ins_fnm DB 08 x 12 155 166 Always Map

NM105 1037 O AN 1/25 S [ ]* Other Subscriber Middle Name ins_mi D0 13 x 1 133 133 Always Map
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Name Suffix ins_suffix DA 26 x 10 167 176 Always Map
NM108 66 X ID 1/2 R [Sel Code]* Identification Number Qualifier ins_id_qual D0 23 x 2 165 166 Always Map
Member Identofication Number MI
Mutually Defined ZZ
NM109 67 X AN 2/80 R [ ]~ Other Subscriber Primary Identifier ins_id D0 07 x 17 32 48 Always Map

nsf_ins_id DB 06 x 25 95 119 Always Map
354 N3 O S-1 N3* Other Subscriber Address
N301 166 M AN 1/55 R [ ]* Other Insured Address Line 1 ins_addr_1 D1 04 x 30 22 51
N302 166 O AN 1/55 S [ ]~ Other Insured Address Line 2 ins_addr_2 D1 05 x 30 52 81
355 N4 O S-1 N4* Other Subscriber City /State /Zip Code
N401 19 O AN 2/30 R [ ]* Other Insured City Name ins_city D1 06 x 20 82 101
N402 156 O ID 2/2 R [ ]* Other Insured State Code ins_st D1 07 x 2 102 103
N403 116 O ID 3/15 R [ ]* Other Insured Zip Code ins_zip D1 08 x 9 104 112
N404 26 O ID 2/3 S [ ]~ Subscriber Country Code ins_cntry_cd D1 09 x 3 113 115
357 REF O S-3 REF* Other Subscriber Secondary Information
REF01 128 M ID 2/3 R [Sel Code]* Reference Id Qualifier ins_sec_id_qual DN 06 x 2 88 89 Map to first available DN Record
10 x 2 122 123
12 x 2 139 140
REF02 127 X AN 1/30 R [ ]~ Other Subscriber Secondary ID ins_sec_id DN 07 x 15 90 104 Map to first available DN Record
09 x 15 107 121
11 x 15 124 138
13 x 15 141 155
LOOP 2330B R-1 OTHER PAYER NAME

360 NM1 O R-1 NM1* Other Payer Name
NM101 98 M ID 2/3 R PR* Name Qualifier PR If not = 'PR', do not map Other Payer Name in
Loop 2330 B
NM102 1065 M ID 1/1 R 2* Entity Type Qualifier 2 NOT MAPPED
NM103 1035 O AN 1/35 R [ ]* Other Payer Last/Org Name pyr_nm D0 08 x 17 49 65
nsf_pyr_nm DB 04 x 35 25 59
NM104-07 N/U ****

Max Cd
NM108 66 X ID 1/2 R [Sel Code]* Identification Code Qualifier NOT MAPPED

Payor Identification
Health Care Financing Administration PlanID PI
XV
NM109 67 X AN 2/80 R [ ]~ Other Payer Primary Identifier pyr_id D0 05 x 5 23 27

363 PER O S-2 PER* Other Payer Contact Information Only one of each number should be
submitted
If more than one interation of a Qualifier is
received, map only the first

PER02 93 O AN 1/60 R [ ]* Other Payer Contact Name pyr_contact_nm DQ 09 x 60 116 175
EDI Number ED
Electronic Mail EM
Facsimile FX
Telephone TE
PER04 364 X AN 1/80 R [ ]* Communication Number If not 'ED', 'EM', 'FX, 'TE', do not map.
Payer EDI Access Number pyr_edi_number DQ 07 x 15 95 109 If PER03 = 'ED', map to DQ-07
Payer E-Mail pyr_email DQ 06 x 50 45 94 If PER03 = 'EM', map to DQ-06
Payer Facimile pyr_fax DQ 05 x 10 35 44 IF PER03 = 'FX', strip non-numeric
DQ-05.
Payer Telephone pyr_tel_no DQ 04 9 10 25 34 IF PER03 = 'TE', strip non-numeric

DQ-04.
EDI Number
Electronic Mail ED
Telephone Extension EM
Facsimile EX
Telephone FX
TE
PER06 364 X AN 1/80 S [ ]* Communication Number If not 'ED', 'EM', 'EX','FX','TE', do not map.
pyr_edi_number DQ 07 x 15 95 109 If PER05 = 'ED', map to DQ-07

pyr_email DQ 06 x 50 45 94 If PER05 = 'EM', map to DQ-06
pyr_tel_ext DQ 08 x 6 110 115 If PER05= 'EX', map to DQ-08
pyr_fax DQ 05 x 10 35 44 IF PER05 = 'FX', strip non-numeric
DQ-05.
pyr_tel_no DQ 04 9 10 25 34 IF PER05 = 'TE', strip non-numeric

DQ-04.

Max Cd
EDI Number
Electronic Mail ED
Telephone Extension EM
Facsimile EX
Telephone FX
TE
PER08 364 X AN 1/80 S [ ]~ Communication Number If not 'ED', 'EM', 'EX','FX, 'TE', do not map.
pyr_edi_number DQ 07 x 15 95 109 If PER07 = 'ED', map to DQ-07

pyr_email DQ 06 x 50 45 94 If PER07 = 'EM', map to DQ-06
pyr_tel_ext DQ 08 x 6 110 115 If PER07= 'EX', map to DQ-08
pyr_fax DQ 05 x 10 35 44 IF PER07 = 'FX', strip non-numeric
DQ-05.
pyr_tel_no DQ 04 9 10 25 34 IF PER07 = 'TE', strip non-numeric

DQ-04.
366 DTP O S-1 DTP* Claim Adjudication Date

DTP03 1251 M AN 1/35 R [ ]~ Adjudication or Payment Date eomb_dt DD 07 x 8 52 59
368 REF O S-2 REF* Other Payer Secondary Identifier
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier pyr_sec_id_qual DP 06 x 2 88 89 Map to first available DP Record
08 x 2 105 106 Do not map if "FY"
REF02 127 X AN 1/30 R [ ]~ Other Payer Secondary Identifier pyr_sec_id DP 07 x 15 90 104 Map to first available DP Record
09 x 15 107 121
pyr_clm_ofc D0 06 x 4 28 31 If REF01 = FY map to D0-06
370 REF O S-2 Prior Authorization or Referral Number
REF O 1 of 2
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier NOT MAPPED
Referral Number 9F
Prior Authorization Number G1
REF02 127 X AN 1/30 R [ ]~ Referral Number pyr_referral_no D3 05 x 30 24 53 If REF01 = 9F map to D3-05

Prior Authorization Number pyr_pri_auth_no D3 06 x 30 54 83 If REF01 = G1 map to D3-06
REF O 2 of 2
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier NOT MAPPED
Referral Number 9F
Prior Authorization Number G1

Max Cd
REF02 127 X AN 1/30 R [ ]~ Referral Number pyr_referral_no D3 07 x 30 84 113 If REF01 = 9F map to D3-07
Prior Authorization Number pyr_pri_auth_no D3 08 x 30 114 143 If REF01 = G1 map to D3-08
372 REF O S-2 REF* Other Payer Claim Adjustment Indicator
REF01 128 M ID 2/3 R T4* Reference Number Qualifier T4 NOT MAPPED

REF02 127 X AN 1/30 R [ ]~ Other Payer Claim Adjustment Indicator pyr_adju_flag DA 28 x 1 184 184 Map to first available DA Record
29 x 1 185 185
LOOP 2330C S-1 OTHER PAYER PATIENT

INFORMATION
374 NM1 O S-1 NM1* Individual or Organization Name Always map if Loop is present.
NM101 98 M ID 2/3 R QC* Name Qualifier QC If not = 'QC, do not map Other Payer Patient
Info in Loop 2330 C
NM102 1065 M ID 1/1 R 1* Person 1 NOT MAPPED
NM103-07 N/U *****
NM108 66 X ID 1/2 R MI* Identification Code Qualifier MI pat_id_qual D1 12 x 2 136 137
NM109 67 X AN 2/80 R [ ]~ Other Payer Patient Primary Identifier pat_id D1 10 x 10 116 125 Map to both D1-10 and D1-13
nsf_pat_id D1 13 x 30 138 167
376 REF O S-3 REF* Other Payer Patient Identification
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier pat_sec_id_qual DR 06 x 2 37 38 Map to first available DR Record
10 x 2 101 102
REF02 127 X AN 1/30 R [ ]~ Other Payer Patient Secondary Identifier pat_sec_id DR 07 x 30 39 68 Map to first available DR Record
09 x 30 71 100
11 x 30 103 132
LOOP 2330 D S-2 OTHER PAYER REFERRING/PCP Each Loop creates a new DS Record within
PROVIDER INFORMATION this 2320 D0 Packet sequence number that
matches the D0 Record. The sub-sequence
number is a physcial count of DS Records
within each D0 packet.
378 NM1 O S-1 NM1* Other Payer Referring/PCP Provider Name

Information
NM101 98 M ID 2/3 R [Sel Code]* Name Qualifier DN pyr_prov_nm_qual DS 05 x 2 27 28
P3
NM102 1065 M ID 1/1 R [Sel Code]~ Entity Type Qualifier DS 06 x 35 29 63 If 1 map 'L'
381 REF O S-3 REF* Other Payer Referring/PCP Provider

Secondary Identification Numbers

Max Cd
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier pyr_prov_sec_id_qual DS 07 x 2 64 65 Map to first available DS Record where DS-
09 x 2 96 97 05 is equal to value in NM101. If one does not
11 x 2 128 129 exist, create the DS Record and set DS-05 to
'DN' or 'P3'
REF02 127 X AN 1/30 R [ ]~ Provider Secondary Identifier pyr_prov_sec_id DS 08 x 30 66 95 Map to first available DS Record
Number 10 x 30 98 127
12 x 30 130 159
LOOP 2330E S-1 OTHER PAYER RENDERING

PROVIDER INFORMATION
NM101 98 M ID 2/3 R 82* Name Qualifier pyr_prov_nm_qual DS 05 x 2 27 28
Rendering Provider 82
NM102 1065 M ID 1/1 R [Sel Code ]* Entity Type Qualifier 1 NOT MAPPED
2
384 REF O S-3 REF* Other Payer Rendering Provider Secondary
Identification Numbers
09 x 2 96 97 05 is equal to '82'. If one does not exist, create
11 x 2 128 129 the DS record and set DS-05 to '82'
Number 10 x 30 98 127
12 x 30 130 159
LOOP 2330F S-1 OTHER PAYER PURCHASE SERVICE

386 NM1 O S-1 NM1* Other Payer Purchase Service Provider
Name Information
NM101 98 M ID 2/3 R QB* Name Qualifier QB pyr_prov_nm_qual DS 05 x 2 27 28
Purchase Service Provider
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier 1 NOT MAPPED
2
388 REF O S-3 REF* Other Payer Purchase Service Provider
09 x 2 96 97 05 is equal to 'QB'. If one does not exist,
11 x 2 128 129 create the DS record and set DS-05 to 'QB'
Number 10 x 30 98 127
12 x 30 130 159
LOOP 2330G S-1 OTHER PAYER SERVICE FACILIITY

INFORMATION
390 NM1 O S-1 NM1* Other Payer Service Facility Name
Information

Max Cd
NM101 98 M 2/3 R [Sel Code]* Name Qualifier 77 pyr_prov_nm_qual DS 05 x 2 27 28

FA
LI
TL

392 REF O S-3 REF* Other Payer Service Facility Secondary
Identification Numbers
09 x 2 96 97 05 is equal to value in NM101. If one does not
11 x 2 128 129 exist, create the DS Record and set DS-05 to
''77', 'FA', 'LI', or 'TL'.
Number 10 x 30 98 127
12 x 30 130 159
LOOP 2330H S-1 OTHER PAYER SUPERVISING

394 NM1 O S-1 NM1* Other Payer Supervising Provider Name
Information
NM101 98 M ID 2/3 R DQ* Name Qualifier pyr_prov_nm_qual DS 05 x 2 27 28 If not = 'DQ', do not map Other Payer
Supervising Provider DQ Supervising Info. in Loop 2330 H
396 REF O S-3 REF* Other Payer Supervising Provider
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier pyr_prov_sec_id_qual DS 07 x 2 64 65 Map to first available DS Record where DS-
09 x 2 96 97 05 is equal to 'DQ'. If one does not exist,
11 x 2 128 129 create the DS record and set DS-05 to 'DQ'
Number 10 x 30 98 127
12 x 30 130 159
LOOP 2400 R-50 SERVICE LINE NUMBER

398 LX O R-1 LX* Service Line Assigned Number
LX01 554 M N0 1/6 R [ ]~ Assigned Number Begin with '1' and increment by one for each
2400 Loop
NOT MAPPED
400 SV1 O R-1 SV1* Professional Service

SV101 C003 M R Composite Medical Procedure Identifier
SV101-1 235 M ID 2/2 R [Sel Code]* Product or Service ID Qualifier svl_proc_qual F0 10 x 2 65 66 See Code Table for values
SV101-2 234 M AN 1/48 R [ ]: Procedure Code svl_proc_cd F0 11 x 5 67 71 If "HC", "IV", or "ZZ" map to F0-11
SV101-3 1339 O AN 2/2 S [ ]: Procedure Modifier 1 svl_proc_cd_mod_1 F0 12 x 2 72 73

Max Cd
SV101-7 N/U :
SV102 782 O R 1/18 R [ ]* Line Item Charge Amount svl_chrg_amt F0 16 9v99 8 80 87 For Encounter transmission. Zero ( 0 ) may be
a valid amount
Define as 'Real'
SV103 355 X ID 2/2 R [Sel Code]* UBM Service Units svl_units_serv_qual F0 22 x 2 94 95 If SV103 or SV104 is present, then the other
is required
SV104 380 X R 1/15 R [ ]* Service Unit Count svl_units_serv F0 23 9v9 15 96 110 Convert from data type real to implied
decimal (9v9)
SV105 1331 O AN 1/2 S [Sel Code]* Facility Code Value svl_pl_serv F0 08 x 2 61 62 See Code Table for values
SV106 [ ]* Type of Service Code This field , Type of Service Code, is not
supported by Hipaa but will be required by
WebMd for all submitters.
See Code Table for Source
SV107 C004 O S Diagnosis Code Pointer See Code Table for values
SV107-1 1328 M NO 1/2 R [ ]: Diagnosis Code Pointer svl_dx_pt_1 F0 18 x 1 90 90
SV107-2 1328 O NO 1/2 S [ ]: Diagnosis Code Pointer svl_dx_pt_2 F0 19 x 1 91 91
SV107-3 1328 O NO 1/2 S [ ]: Diagnosis Code Pointer svl_dx_pt_3 F0 20 x 1 92 92
SV107-4 1328 O NO 1/2 S [ ]* Diagnosis Code Pointer svl_dx_pt_4 F0 21 x 1 93 93
SV108 1/18 N/U *
SV109 1073 O ID 1/1 S Y* Emergency Indicator Y svl_er_flag FA 04 x 1 25 25 Map only if 'Y', else don't map
SV110 N/U *
SV111 1073 O ID 1/1 S Y* EPSDT Indicator Y svl_epsdt_flag FB 15 x 1 80 80 Map only if 'Y' , else don't map
SV112 1073 O ID 1/1 S Y* Family Planning Indicator Y svl_fp_flag FB 16 x 1 81 81 Map only if 'Y' , else don't map
SV113-114 N/U **
SV115 1327 O ID 1/1 S 0~ Copay Status Code 0 svl_copay_flag FB 14 x 1 79 79
409A SV5 O S-1 SV5 Durable Medical Equipment Service
SV501 C003 M R Composite Medical Procedure Identifier
SV501-1 235 M ID 2/2 R HC: Product / Service ID NOT MAPPED
HCPCS HC
SV501-2 234 M AN 1/48 R Procedure Code svl_dme_proc_cd G0 11 x 5 156 160
SV501-3 SV501-7 N/ *****
U
SV502 355 M ID 2/2 R DA* Unit or Basis For Measurement Code NOT MAPPED
DA
Days
SV503 380 M R 1/15 R [ ]* Length of Medical Necessity svl_dme_lth_med_nec G0 05 9 3 39 41
SV504 782 X R 1/18 S [ ]* DME Rental Amount svl_dme_rent_pric G0 09 9v99 6 50 55 Define as 'Real'
SV505 782 X R 1/18 S [ ]* DME Purchase Price svl_dme_purch_pric G0 06 9v99 6 42 47 Define as 'Real'
SV506 594 O ID 1/1 S Translate~ Rental Unit Price Indicator svl_dme_unit_rent_pric_flag G0 08 x 1 49 49 See Code Table for Translation
410 PWK O S-1 PWK* DMERC CMN Indicator
PWK01 755 M ID 2/2 R CT* Report Type Code CT NOT MAPPED

Max Cd
PWK02 756 O ID 1/2 R [Sel Code]~ Attachment Transmission Code svl_dmerc_attach_xmit_cd GQ 26 x 2 144 145 See Code Table for values
412 CR1 O S-1 CR1* Ambulance Transport Information
CR101 355 X ID 2/2 S LB* Unit or Basis For Measurement Code LB NOT MAPPED
CR102 81 X R 1/10 S [ ]* Patient Weight svl_amb_pat_wt GP 04 x 4 25 28
CR103 1316 O ID 1/1 R [Sel Code]* Ambulance Transport Code svl_amb_cd GP 05 x 1 29 29 See Code Table for values
CR104 1317 O ID 1/1 R [Sel Code]* Ambulance Transport Reason Code svl_amb_rsn_cd GP 06 x 1 30 30 See Code Table for values
CR105 355 X ID 2/2 R DH* UBM DH NOT MAPPED
CR106 380 X R 1/15 R [ ]* Transport Distance svl_amb_dist GP 07 x 4 31 34
CR107-108 N/U **
CR109 352 O AN 1/80 S [ ]* Round Trip Purpose Description svl_amb_purp GP 08 x 80 35 114
CR110 352 O AN 1/80 S [ ]~ Stretcher Purpose Description svl_amb_stretch_purp GQ 25 x 80 64 143
415 CR2 O S-5 CR2* Spinal Manipulation Service Information
CR201-207 N/ *******
U
CR208 1342 O ID 1/1 R [Sel Code]* Nature of Condition Code svl_chiro_pat_cnd_cd GS 05 x 1 27 27 If GS-05 = ES-05 then do not map, else map.
CR209 N/U *
CR210 352 O AN 1/80 S [ ]* Patient Condition Description svl_chiro_pat_cnd_desc GS 06 x 80 28 107
CR211 352 O AN 1/80 S [ ]* Patient Condition Description svl_chiro_pat_cnd_desc GS 07 x 80 108 187
CR212 1073 O ID 1/1 S [Sel Code]~ X-Ray Availability Indicator N svl_chiro_xray_flag GR 13 x 1 59 59 Map only if 'Y' or 'N' , else don't map
Y
421 CR3 O S-1 CR3* Durable Medical Equipment Certification
CR301 1322 O ID 1/1 R [Sel Code]* Certification Type Code svl_dmerc_cert_typ_cd GQ 30 x 1 170 170 See Code Table for values
CR302 355 X ID 2/2 R MO* Months MO NOT MAPPED
CR303 380 X R 1/15 R [ ]~ Durable Medical Equipment Duration svl_dmerc_lth_med_nec GQ 31 9 3 171 173
423 CR5 O S-1 CR5* Home Oxygen Therapy Information
CR501 1322 O ID 1/1 R [Sel Code]* Certification Type Code oxy_cert_typ_cd GT 11 x 1 37 37 See Code Table for values
CR502 380 O R 1/15 R [ ]* Treatment Period Count oxy_trmt_ct GT 04 x 2 25 26
CR503-509 N/U *******
CR510 380 O R 1/15 S [ ]* Arterial Blood Gas Quantity oxy_art_bld_gas_qty GT 05 x 3 27 29
CR511 380 O R 1/15 S [ ]* Oxygen Saturation Quantity oxy_sat_qty GT 06 x 3 30 32
CR512 1349 O ID 1/1 R [Sel Code]* Oxygen Test Condition Code oxy_tst_cnd_cd GT 07 x 1 33 33 See Code Table for values
CR513 1350 O ID 1/1 S 1* Oxygen Test Finding Code 1 oxy_tst_find_cd_1 GT 08 x 1 34 34
CR514 1350 O ID 1/1 S 2* Oxygen Test Finding Code 2 oxy_tst_find_cd_2 GT 09 x 1 35 35

Max Cd
CR515 1350 O ID 1/1 S 3~ Oxygen Test Findings Code 3 oxy_tst_find_cd_3 GT 10 x 1 36 36

427 CRC O S-3 CRC* Ambulance Certification The CRC Segments may occur only 3 times
per 2400 Loop. Submitters may mix and
match any of the three types.
CRC 1 of 3 Map to the first available GQ-04 , GQ-11,
or GQ-18 Record packets per qualifier
received
CRC01 1136 M ID 2/2 R 07* Code Category svl_cnd_cat_cd GQ 04 x 2 25 26
07
CRC02 1073 M ID 1/1 R [ Sel Code ]* Certification Condition Indicator N svl_cnd_cert_flag GQ 05 x 1 27 27 Map only if 'Y' or 'N' , else don't map
Y
CRC03 1321 M ID 2/2 R [Sel Code]* Condition Code svl_cnd_cd GQ 06 x 2 28 29 See Code Table for values
CRC04 1321 O ID 2/2 S [Sel Code]* Condition Code svl_cnd_cd GQ 07 x 2 30 31 See Code Table for values
CRC07 1321 O ID 2/2 S [Sel Code]~ Condition Code svl_cnd_cd GQ 10 x 2 36 37 See Code Table for values
CRC 2 of 3
07
CRC02 1073 M ID 1/1 R [ Sel Code ]* Certification Condition Indicator N svl_cnd_cert_flag GQ 12 x 1 40 40 Map only if 'Y' or 'N' , else don't map
Y
CRC 3 of 3
07
CRC02 1073 M ID 1/1 R [ Sel Code ]* Certification Condition Indicator svl_cnd_cert_flag GQ 19 x 1 53 53 Map only if 'Y' or 'N' , else don't map
N
Y
430 CRC O S-1 CRC* Hospice Employee Indicator
CRC01 1136 M ID 2/2 R 70* Code Category 70 NOT MAPPED
CRC02 1073 M ID 1/1 R [Sel Code]* Hospice Employee Provider Indicator Y svl_hospice_flag FA 16 x 1 70 70 Map only if 'Y' or 'N' , else don't map
N
CRC03 1321 M ID 2/2 R 65~ Condition Indicator NOT MAPPED

Max Cd
432 CRC O S-2 CRC* DMERC Condition Indicator The CRC Segments may occur only 3 times
per 2400 Loop. Submitters may mix and
match any of the three types.
CRC 1 of 2
CRC01 1136 M ID 2/2 R [Sel Code]* Code Category svl_cnd_cat_cd GQ 04 x 2 25 26 Map to the first available GQ-04 , GQ-11, or
GQ-18 Record packets per qualifier received
CRC02 1073 M ID 1/1 R [Sel Code]* Certification Code Indicator Y svl_cnd_cert_flag GQ 05 x 1 27 27 Map only if 'Y' or 'N' , else don't map
N
svl_dme_rx_med_rec_flag G0 12 x 1 161 161 Map if GQ-04= 09 and GQ-06 = 38, and data
is present in GQ-05.
CRC03 1321 M ID 2/2 R [Sel Code]* Condition Indicator svl_cnd_cd GQ 06 x 2 28 29 See Code Table for values
CRC04 1321 O ID 2/2 S [Sel Code]* Condition Indicator svl_cnd_cd GQ 07 x 2 30 31 See Code Table for values
CRC07 1321 O ID 2/2 S [Sel Code]~ Condition Indicator svl_cnd_cd GQ 10 x 2 36 37 See Code Table for values
CRC 2 of 2
CRC01 1136 M ID 2/2 R [Sel Code]* Code Category svl_cnd_cat_cd GQ 11 x 2 38 39 See Code Table for values
CRC02 1073 M ID 1/1 R [Sel Code]* Certification Condition Indicator Y svl_cnd_cert_flag GQ 12 x 1 40 40 Map only if 'Y' or 'N' , else don't map
N
svl_dme_rx_med_rec_flag G0 12 x 1 161 161 Map if GQ-11= 09 and GQ-13 = 38, and data
is present in GQ-12.
435 DTP O R-1 DTP* Service Line Date or Time or Period
Service 472
DTP02 1250 M ID 2/3 R [ ]* Date Time Period Format Qualifier R8 NOT MAPPED
RD8
DTP03 1251 M AN 1/35 R [ ]~ Service Date Begin svl_beg_dt F0 06 9 8 45 52 If DTP02 = D8, Map to F0-06 only.
If DTP02 = RD8, parse first 8 bytes to F0-06
and next to F0-07
svl_end_dt F0 07 9 8 53 60
437 DTP O S-1 DTP* Date - Certification Revision Date
607
Certification
D8
DTP03 1251 M AN 1/35 R [ ]~ Certification Revision Date svl_dmerc_cert_rev_dt GQ 27 x 8 146 153

Max Cd
440 DTP O S-1 DTP* Date - Begin Therapy Date

463
Begin Therapy
D8
DTP03 1251 M AN 1/35 R [ ]~ Begin Therapy Date svl_dmerc_bgn_ther_dt GQ 28 x 8 154 161

442 DTP O S-1 DTP* Date - Last Certification Date
461
Last Certification
D8
DTP03 1251 M AN 1/35 R [ ]~ Last Certification Date svl_dmerc_lst_cert_dt GQ 29 x 8 162 169

445 DTP O S-1 DTP* Date - Date Last Seen
Latest Visit or Consultation 304

D8
DTP03 1251 M AN 1/35 R [ ]~ Treatment or Therapy Date svl_dt_last_seen FN 06 x 8 41 48

447 DTP O S-2 DTP* HGB Date - Test
DTP 1 of 2
Hemoglobin 738

D8
DTP03 1251 M AN 1/35 R [ ]~ Most recent HGB/HGT svl_hgb_hct_dt FA 17 x 8 71 78 If DTP01 = '738', map to FA-17
DTP 2 of 2
Most Recent Serum Creatine 739

D8
DTP03 1251 M AN 1/35 R [ ]~ Serum Creatin Date svl_serm_creatine_dt FA 19 x 8 82 89 If DTP01 = '739', map to FA-19
449 DTP O S-3 DTP* Date - Oxygen Saturation/Arterial Blood
Gas Test
DTP 1 of 3
DTP01 374 M ID 3/3 R 119* Date Time Qualifier NOT MAPPED
Test Performed 119

D8
DTP03 1251 M AN 1/35 R [ ]~ Test Performed oxy_tst_perf_dt GT 13 x 8 49 56 If DTP01 = '119', Map to GT-13
DTP 2 of 3
Arterial Blood Gas Test 480

D8

Max Cd
DTP03 1251 M AN 1/35 R [ ]~ Arterial Blood Gas Test Date oxy_art_bld_gas_tst_dt GT 14 x 8 57 64 If DTP01 = '480' , Map to GT-14
DTP 3 of 3
Oxygen Saturation Test 481

D8
DTP03 1251 M AN 1/35 R [ ]~ Oxygen Saturation Test Date oxy_sat_tst_dt GT 15 x 8 65 72 If DTP01= '481' , Map to GT-15
451 DTP O S-1 DTP* Date - Shipped
Shipped 011
DTP02 1250 M ID 2/3 R D8* Date Expressed in Format D8 NOT MAPPED

DTP03 1251 M AN 1/35 R [ ]~ Shipped Date svl_ship_dt FN 09 x 8 65 72
452 DTP O S-1 DTP* Date - Onset of Current Symptom / Illness

Onset 431

D8
DTP03 1251 M AN 1/35 R [ ]~ Onset Date svl_onset_dt FN 10 x 8 73 80

454 DTP O S-1 DTP* Date - Last X-Ray
DTP01 374 M ID 3/3 R 455* Last X-Ray 455 NOT MAPPED
D8
DTP03 1251 M AN 1/35 R [ ]~ Last X-Ray Date svl_chiro_lst_xray_dt GR 14 x 8 60 67 If GR-14 = ER-14 then do not map, else map
456 DTP O S-1 DTP* Date - Acute Manifestation

DTP01 374 M ID 3/3 R 453* Acute Manifestation of a Chronic Condition 453 NOT MAPPED
D8
DTP03 1251 M AN 1/35 R [ ]~ Acute Manifestation Date svl_chiro_acute_man_dt GR 16 x 8 76 83

458 DTP O S-1 DTP* Date - Initial Treatment
DTP01 374 M ID 3/3 R 454* Initial Treatment 454 NOT MAPPED
D8
DTP03 1251 M AN 1/35 R [ ]~ Initial Treatment Date svl_chiro_init_trmt_dt GR 15 x 8 68 75 If GR-15 = ER-15 then do not map, else map.
460 DTP O S-1 DTP* Date - Similar Illness/Symptom Onset

DTP01 374 M ID 3/3 R 438* Onset of Similar Symptom or Illness 438 NOT MAPPED
D8
DTP03 1251 M AN 1/35 R [ ]~ Similar Illness or Symptom Date svl_sim_sym_dt FN 11 x 8 81 88

464 MEA O S-20 MEA* Test Result

Max Cd
MEA O 1 of 5 Repeat GU Record as needed up to 4 times
MEA01 737 O ID 2/2 R [Sel Code]* Measurement Reference Identification tst_id_cd GU 05 x 2 27 28 See Code Table for values
MEA02 738 O ID 1/3 R [Sel Code]* Measurement Qualifier tst_qual GU 06 x 3 29 31 See Code Table for values
MEA03 739 X R 1/20 R [ ]~ Test Results tst_result GU 07 x 20 32 51
sub_seq_no GU 03 9 2 05 06 Increment sub-sequence no by 1 for each GU

Record used
MEA O 2 of 5
MEA O 3 of 5
MEA O 4 of 5
MEA O 5 of 5
466 CN1 O S-1 CN1* Contract Information

CN101 1166 M ID 2/2 R [Sel Code]* Contract Type Code svl_contr_typ_cd FP 06 x 2 65 66 See Code Table for values
CN102 782 O R 1/18 S [ ]* Contract Amount svl_contr_amt FP 07 9v99 18 67 84 Define as 'Real'

Max Cd
CN103 332 O R 1/6 S [ ]* Contract Percentage svl_contr_allow_chrg_percnt FP 08 x 6 85 90
CN104 127 O AN 1/30 S [ ]* Contract Code svl_contr_cd FP 09 x 30 91 120

CN105 338 O R 1/6 S [ ]* Terms Discount Percentage svl_disc_percnt FP 10 x 6 121 126
CN106 799 O AN 1/30 S [ ]~ Contract Version Identifier svl_contr_ver FP 11 x 30 127 156
468 REF O S-1 REF* Repriced Line Item Reference Number
REF01 128 M ID 2/3 R 9B* Reference Qualifier 9B NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Repriced Line Item Reference Number svl_reprice_ref_no FP 04 x 20 25 44
469 REF O S-1 REF* Adjusted Repriced Line Item Reference
Number
REF01 128 M ID 2/3 R 9D* Reference Qualifier 9D NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Adjusted Repriced Line Item Reference svl_adj_reprice_item_ref_no FP 05 x 20 45 64
Number
470 REF O S-2 REF* Prior Authorization or Referral Number
REF O 1 of 2
REF01 128 M ID 2/3 R [Sel Code]* Reference Qualifier 9F svl_ref_qual F4 06 x 2 26 27 Map to first available F4 Record
G1 08 x 2 58 59 Repeat Record as necessary.
10 x 2 90 91 Increment F4-03 Sub-Sequence Number +1
12 x 2 122 123
14 x 2 154 155
F4 03 9 2 05 06 Increment by 1 for each F4 Record

sub_seq_no
REF02 127 X AN 1/30 R [ ]~ Referral Number svl_ref_no F4 07 x 30 28 57 Map to first available F4 Record
09 x 30 60 89 Repeat Record as necessary.
11 x 30 92 121 Increment F4-03 Sub-Sequence Number +1.
13 x 30 124 153
15 x 30 156 185
REF O 2 of 2
REF01 128 M ID 2/3 R [Sel Code]* Reference Qualifier 9F svl_ref_qual F4 06 x 2 26 27 Map to first available F4 Record
G1 08 x 2 58 59 Repeat Record as necessary.
12 x 2 122 123
14 x 2 154 155
REF02 127 X AN 1/30 R [ ]~ Prior Authorization Number svl_ref_no F4 07 x 30 28 57 Map to first available F4 Record
09 x 30 60 89 Repeat Record as necessary.
13 x 30 124 153
15 x 30 156 185
472 REF O S-1 REF* Line Item Control Number

REF01 128 M ID 2/3 R 6R* Reference Qualifier 6R NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Line Item Control Number svl_ln_item_ctrl_no F0 05 x 20 25 44
474 REF O S-1 REF* Mammography Certification Number
REF01 128 M ID 2/3 R EW* Reference Qualifier EW NOT MAPPED

Max Cd
REF02 127 X AN 1/30 R [ ]~ Mammography Certification Number svl_mammo_cert_no FA 10 x 10 31 40

475 REF O S-1 REF* CLIA Number
REF01 128 M ID 2/3 R X4* Reference Qualifier X4 NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ CLIA Identification svl_clia_no FA 13 x 15 53 67
477 REF O S-1 REF* Referring CLIA Number
REF01 128 M ID 2/3 R F4* Reference Qualifier F4 NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Referring CLIA Number svl_ref_clia_no FN 22 x 14 109 122
478 REF O S-1 REF* Immunization Batch Number
REF01 128 M ID 2/3 R BT* Reference Qualifier BT NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Immunization Batch Number svl_immun_batch_no FN 23 x 30 123 152
479 REF O S-4 REF* Ambulatory Patient Group (APG) Number
REF O 1 of 4
REF01 128 M ID 2/3 R IS* Reference Qualifier IS NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Ambulatory Patient Group Number svl_apg_no FN 24 x 3 153 155 Map the 1st occurrence of the REF01 = 1S to
FN 24.
REF O 2 of 4
REF02 127 X AN 1/30 R [ ]~ Ambulatory Patient Group Number svl_apg_no FN 25 x 3 156 158 Map the 2nd occurrence of the REF01 = 1S to
FN 25.
REF O 3 of 4
REF02 127 X AN 1/30 R [ ]~ Ambulatory Patient Group Number svl_apg_no FN 26 x 3 159 161 Map the 3rd occurrence of the REF01 = 1S to
FN 26.
REF O 4 of 4
REF02 127 X AN 1/30 R [ ]~ Ambulatory Patient Group Number svl_apg_no FN 27 x 3 162 164 Map the 4th occurrence of the REF01 = 1S to
FN 27.
480 REF O S-1 REF* Oxygen Flow Rate
REF01 128 M ID 2/3 R TP* Reference Qualifier TP NOT MAPPED
REF02 127 X AN 1/30 R [ ]~ Oxygen Flow Rate oxy_flow_rate GT 16 x 3 73 75
482 REF O S-1 REF* Universal Product Number (UPN)
REF01 128 M ID 2/3 R [Sel Code]* Reference Qualifier OZ svl_prod_cd_qual FA 29 x 2 141 142
VP
REF02 127 X AN 1/30 R [ ]~ Universal Product Number svl_upn FA 30 x 14 143 156
484 AMT O S-1 AMT* Sales Tax Amount
AMT01 522 M ID 1/3 R T* Amount Qualifier T NOT MAPPED

Max Cd
AMT02 782 M R 1/18 R [ ]~ Sales Tax Amount svl_sales_tx_amt F0 39 9v99 8 183 190 Define as 'Real'
485 AMT O S-1 AMT* Approved Amount
AMT01 522 M ID 1/3 R AAE* Amount Qualifier AAE NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Approved Amount svl_apprv_amt KP 08 9v99 7 94 100 Define as 'Real'
486 AMT O S-1 AMT* Postage Claimed Amount
AMT01 522 M ID 1/3 R F4* Amount Qualifier F4 NOT MAPPED
AMT02 782 M R 1/18 R [ ]~ Postage Claimed Amount svl_pstg_amt FN 28 9v99 7 165 171 Define as 'Real'
487 K3 O S-10 K3* File Information
K301 449 M ID 1/80 R [ ]~ Fixed Format Information svl_st_data_req FK 05 x 80 27 106 Repeat FK Record as necessary up to 5 times.
svl_st_data_req FK 06 x 80 107 186

sub_seq_no FK 03 x 02 05 06
488 NTE O S-1 NTE* Line Note
NTE01 363 O ID 3/3 R [Sel Code]* Note Reference Code svl_narr_qual H0 06 x 3 27 29 See Code Table for values
NTE02 352 M AN 1/80 R [ ]~ Line Note Text svl_narr H0 07 x 80 30 109
489 PS1 O S-1 PS1* Purchased Service Information If PS1 Segment is present, Create an F6/F7
packet and set F6-05 and F7-05 to 'QB'
If both PS1 and Loop 2420B are present
where F7-05 = 'QB', Then create only one
F7-05 QB' per service line and make sure
F6-03 and F7-03 Sequence number are
same.
PS101 127 M ID 1/30 R [ ]* Purchased Service Provider Identifier svl_prov_nm_qual_f7 F7 05 x 02 24 25 Default 'QB'
svl_sec_id_qual F7 06 x 02 26 27 Default 'QB'
This default is for internal PCDS use only for
this Segment
svl_sec_id F7 07 x 15 28 42
PS102 782 M R 1/18 R [ ]~ Purchased Service Charge Amount svl_purch_serv_chrg FB 04 9v99 7 25 31 Define as 'Real'
491 HSD O S-1 HSD* Health Care Services Delivery
HSD01 673 X ID 2/2 S VS* Quanitity Qualifier NOT MAPPED
Visits VS
HSD02 380 X R 1/15 S [ ]* Service Unit Count (Visit Count) svl_hh_no_vst GX 08 x 4 37 40

HSD03 355 O ID 2/2 S [Sel Code]* Unit or Basis for Measurement Code svl_hh_ubm GX 09 x 2 41 42 See Code Table for values
HSD04 1167 O R 1/6 S [ ]* Sample Selection Modulus svl_hh_freq_ct GX 10 x 6 43 48
HSD05 615 X ID 1/2 S [Sel Code]* Time Period Qualifier svl_hh_units_qual GX 11 x 2 49 50 See Code Table for values
HSD06 616 O N0 1/3 S [ ]* Period Count svl_hh_no_per_ct GX 12 x 3 51 53
HSD07 678 O ID 1/2 S [Sel Code]* Ship/Delivery or Calendar Pattern Code svl_hh_cal_cd GX 13 x 2 54 55 See Code Table for values
HSD08 679 O ID 1/1 S [Sel Code]~ Delivery Pattern Time Code svl_hh_dtp_cd GX 14 x 1 56 56 See Code Table for values
495 HCP O S-1 HCP* Line Pricing / Repricing Information

Max Cd
HCP01 1473 X ID 2/2 R [Sel Code]* Pricing Methodology svl_tpo_pric_meth F1 08 x 2 67 68 See Code Table for values
HCP02 782 O R 1/18 R [ ]* Repriced Allowed Amount svl_tpo_allow_amt F1 09 9v99 8 69 76 Define as 'Real'
HCP03 782 O R 1/18 S [ ]* Repriced Savings Amount svl_tpo_sav_amt F1 10 9v99 8 77 84 Define as 'Real'
HCP04 127 O AN 1/30 S [ ]* Repricing Organization ID svl_tpo_id F1 04 x 9 22 30
HCP05 118 O R 1/9 S [ ]* Repricing Per Diem or Flat Rate Amount svl_tpo_price_rate F1 19 9v99 8 153 160 Define as 'Real'
HCP06 127 O AN 1/30 S [ ]* Repriced APG Code svl_tpo_apg_cd F1 20 x 3 161 163
HCP07 782 O R 1/18 S [ ]* Repriced Approved Ambulatory Patient Group svl_tpo_apg_amt F1 21 9v99 8 164 171
Amount
HCP08 N/U *
HCP09 235 X ID 2/2 S [Sel Code]* Product or Service ID Qualifier svl_tpo_apprv_proc_qual F1 11 x 2 85 86 See Code Table for values
HCP10 234 X AN 1/48 S [ ]* Procedure Code svl_tpo_apprv_proc_cd F1 13 x 5 88 92
HCP11 355 X ID 2/2 S [Sel Code]* Unit or Basis for Measurement Code svl_tpo_apprv_ubm F1 14 x 2 93 94 See Code Table for values
HCP12 380 X R 1/15 S [ ]* Repriced Approved Service Unit Count svl_tpo_apprv_units F1 15 9 4 95 98
HCP13 901 X ID 2/2 S Translate* Reject Reason Code svl_tpo_rej_msg F1 06 x 1 46 46 See Code Table for Translation
HCP14 1526 O ID 1/2 S Translate* Policy Compliance Code svl_tpo_pol_comp_cd F1 17 x 2 149 150 See Code Table for Translation
HCP15 1527 O ID 1/2 S Translate~ Exception Code svl_tpo_except_cd F1 18 x 2 151 152 See Code Table for Translation
LOOP 2410 S-25 DRUG IDENTIFICATION The GV Record can repeat up to 13 times.
500A LIN O S-1 LIN

LIN01 N/U *
LIN02 235 M ID 2/2 R N4* Product / Service ID Qualifier ndc_cd_qual GV 06 x 2 57 58 Map to the first available GV Record
National Drug Code N4 ndc_cd_qual GV 12 x 2 117 118 Create new GV Record up to 13 times for the
Loop.
LIN03 234 M AN 1/48 R [ ]~ National Drug Code ndc_cd GV 07 x 11 59 69 Map to the first available GV Record
ndc_cd GV 13 x 11 119 129 Create new GV Record up to 13 times for the
Loop.
500B CTP O S-1 Drug Pricing

CTP01-02 N/U **
CTP03 212 X R 1/17 R [ ]* Unit Price / Drug Unit Price ndc_amt GV 08 9v99 8 70 77 Map to the first available GV Record
ndc_amt GV 14 9v99 8 130 137 Create new GV Record up to 13 times for the
Loop.
CTP04 380 X R 1/15 R [ ]* Quantity / National Drug Unit Ct. ndc_qty GV 10 9v9 7 80 86 Map to the first available GV Record
ndc_qty GV 16 9v9 7 140 146 Create new GV Record up to 13 times for the
Loop.
CTP05 C001 R [ ]* Composite Unit of Measure

Max Cd
CTP05-01 648 M ID 2/2 R [Sel Code]~ Code Qualifier ndc_qty_qual GV 09 x 2 78 79 Map to the first available GV Record
ndc_qty_qual GV 15 x 2 138 139 Create new GV Record up to 13 times for the
Loop
See Code Table for values.
500C REF O S-1 Prescription Number
REF01 128 M ID 2/3 R XZ* Code Qualifier NOT MAPPED
Pharmacy Prescription Number XZ
REF02 127 X AN 1/30 R [ ]~ Reference ID ndc_rx_no GV 05 x 30 27 56 Map to the first available GV Record
Prescription Number ndc_rx_no GV 11 x 30 87 116 Create new GV Record up to 13 times for the
Loop.
LOOP 2420A S-1 RENDERING PROVIDER This Loop defines information in the F6
INFORMATION Packett.This F6 Packet contains F6, F7, and
F8 Records.Each Loop represents a new
Packet with Sub-Sequence the same as F6,
F7 and F8.

NM101 98 M ID 2/3 R 82* Name Qualifier svl_prov_nm_qual_f6 F6 05 x 2 24 25 If F7 and/or F8 are created from information
Rendering Provider 82 in this Loop, Map this field to the F7-05 and/
or F8-05
NM102 1065 M ID 1/1 R [ ]* Entity Type Qualifier svl_prov_typ_cd F6 06 x 1 26 26 If 1 map' L'

Person 1 If 2 map 'O'
Non-Person Entity 2
NM103 1035 O AN 1/35 R [ ]* Last Name or Organization Name svl_prov_lnm F6 07 x 35 27 61
NM104 1036 O AN 1/25 S [ ]* Rendering Provider First Name svl_prov_fnm F6 08 x 12 62 73

NM105 1037 O AN 1/25 S [ ]* Rendering Provider Middle Name svl_prov_mi F6 09 x 1 74 74
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Rendering Provider Name Suffix svl_prov_suffix F6 10 x 10 75 84
NM108 66 X ID 1/2 R [Sel Code]* Identification Code Qualifier svl_prov_tin_qual F6 12 x 1 100 100 Map only if NM108 = '24' or '34'
EIN 24 E
SSN 34 S
NPI XX
NM109 67 X AN 2/80 R [ ]~ Rendering Provider ID If NM108 = '24' and the third position of
number prior to mapping to F6-13, else just
map data.
svl_prov_tin F6 13 x 9 101 109 If '24' or '34' in NM108 , Map to F6-13

svl_prov_npi F6 11 x 15 85 99 If 'XX' in NM108 , Map to F6-11
504 PRV O S-1 PRV* Rendering Provider Specialty Information
PRV01 1221 M ID 1/3 R PE* Provider Code PE NOT MAPPED

PRV02 128 M ID 2/3 R ZZ* Mutually Defined NOT MAPPED

Max Cd
PRV03 127 M AN 1/30 R [ ]~ Provider Taxonomy Code svl_prov_taxomy_cd F6 16 x 11 128 138 See Code Table for Source
507 REF O S-5 REF* Rendering Provider Secondary Assumption is that only 1 of each qualifier
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier svl_sec_id_qual F7 06 x 2 26 27 Map Qualifier to F7-06 even those not listed.
Location Number LU 08 x 2 43 44 If qualifer equals 'EI' , 'SY' or 'TJ', look at the
State Industrial Accident X5 10 x 2 60 61 NM108 preceeding this REF
Medicare Number 1C 12 x 2 77 78
Medicaid Number 1D
UPIN 1G
Champus Number 1H
Employer's ID EI svl_sec_id_qual See REF01 for positions If F6-12 is present, map 'EI' to F7-06
svl_prov_tin_qual F6 12 x 1 100 100 If F6-12 is not present, map 'E' to F6-12
Social Security Number SY svl_sec_id_qual See REF01 for positions If F6-12 is present, map 'SY' to F7-06
svl_prov_tin_qual F6 12 x 1 100 100 If F6-12 is not present, map 'S' to F6-12
REF02 127 X AN 1/30 R [ ]~ Reference Number Qualifier svl_sec_id F7 07 x 15 28 42 Do not map if N5
Location Number 09 x 15 45 59 Map to F7-07. If qualifer equals 'EI' or 'SY'
State Industrial Accident 11 x 15 62 76 look at the F6-12 preeceding this REF.
Medicare Number 13 x 15 79 93 If REF01= 'EI' and third position of REF02 =
State License Number 15 x 15 96 110 '_', strip '_' and concatenate the number prior
Blue Shield Number to mapping to F7 ID.
Medicaid Number
UPIN
Commercial Number
Champus Number
Employer's ID svl_sec_id See REF02 for positions If REF 01 = EI

and NM108 equals '24' or '34', map to F7-07
svl_prov_tin F6 13 x 9 101 109 If F6-13 is not present, then map to F6-13

Social Security Number svl_sec_id See REF02 for positions If REF 01 = SY

Network ID svl_prov_ntwrk_id F6 15 x 15 113 127 If REF01=N5
LOOP 2420B S-1 PURCHASE SERVICE PROVIDER This Loop defines information in the F6
INFORMATION Packett. This F6 Packet contains F6, F7,
and F8 Records. Each Loop represents a
new Packet with Sub-Sequence the same as
F6, F7 and F8.

Max Cd
509 NM1 O S-1 NM1* Purchase Service Provider Name

Information
NM101 98 M ID 2/3 R QB* Name Qualifier QB svl_prov_nm_qual_f6 F6 05 x 2 24 25 If F7 and/or F8 are created from information
Purchase Service Provider in this Loop, Map this field to the F7-05
and/or F8-05
NM102 1065 M ID 1/1 R [Sel Code]* Entity Type Qualifier svl_prov_typ_cd F6 06 x 1 26 26 If 1 map 'L'
NM103-107 N/U *****

NM108 66 X ID 1/2 S [Sel Code]* Identification Code Qualifier svl_prov_tin_qual F6 12 x 1 100 100 Map only if NM108 = '24' or '34'
EIN 24 E
SSN 34 S
NPI XX
map data.
svl_prov_npi F6 11 x 15 85 99 If 'XX' in NM108 Map to F6-11

svl_prov_tin F6 13 x 9 101 109 If 24 or 34 in NM108 Map to F6-13
512 REF O S-5 REF* Purchase Service Provider Secondary Assumption is that only 1 of each qualifier
REF01 128 M ID 2/3 R [Sel Code ]* Reference Number Qualifier svl_sec_id_qual F7 06 x 2 26 27 Do NOT map if N5. Map Qualifier to F7-06
State Industrial Accident X5 10 x 2 60 61 If qualifer equals EI or SY you need to look at
Medicare Number 1C 12 x 2 77 78 the NM108 preceding this REF
Medicaid Number 1D
UPIN 1G
USIN U3
Champus Number 1H
Employer's ID EI svl_sec_id See REF01 for positions If F6-12 is present, map 'EI' to F7-06

Max Cd
REF02 127 X AN 1/30 R [ ]~ Provider Secondary Identifier svl_sec_id F7 07 x 15 28 42 Do not map if N5

Medicaid Number
UPIN
Commercial Number
Champus Number
Employer's ID svl_sec_id See REF02 for positions If REF 01 = EI


Social Security Number svl_sec_id See REF02 for positions If REF 01 = 'SY' and NM108 equals '24' or
'34', map to F7-07
LOOP 2420C S-1 SERVICE FACILIITY INFORMATION This Loop defines information in the F6
Packett.This F6 Packet contains F6, F7, and
F7 and F8.
514 NM1 O S-1 NM1* Service Facility Name Information

NM101 98 M ID 2/3 R [Sel Code]* Name Qualifier svl_prov_nm_qual_f6 F6 05 x 2 24 25 If F7 and/or F8 are created from information
in this Loop, Map this field to the F7-05 and/
or F8-05.
NM102 1065 M ID 1/1 R 2* Entity Type Qualifier svl_prov_typ_cd F6 06 x 1 26 26 Map 'O'

NM103 1035 O AN 1/35 S [ ]* Laboratory or Facility Name svl_prov_lnm F6 07 x 35 27 61
NM104-07 NU ****
NM108 66 X ID 1/2 S [Sel Code]* Identification Code Qualifier svl_prov_tin_qual F6 12 x 1 100 100 Map only if NM108 = 'XX'
EIN 24 E
SSN 34 S
NPI XX
NM109 67 X AN 2/80 R [ ]~ Purchase/Service Provider Identifier If NM108 = '24' and the third position of
map data.
svl_prov_npi F6 11 x 15 85 99 Map only if NM108 = '24' or '34'

svl_prov_tin F6 13 x 9 101 109 If '24' or '34' in NM108, Map to F6-13
518 N3 O R-1 N3* Service Facility Location Address

Max Cd
N301 166 M AN 1/55 R [ ]* Laboratory or Facility Address Line 1 svl_prov_addr_1 F8 07 x 30 86 115
N302 166 O AN 1/55 S [ ]~ Laboratory or Facility Address Line 2 svl_prov_addr_2 F8 08 x 30 116 145
519 N4 O S-1 N4* Service Facility Location City/State/Zip
Code
N401 19 O AN 2/30 R [ ]* Laboratory or Facility City Name svl_prov_city F8 09 x 20 146 165
N402 156 O ID 2/2 R [ ]* Laboratory or Facility State/Province Name svl_prov_st F8 10 x 2 166 167
N403 116 O ID 3/15 R [ ]* Laboratory or Facility Zip Code svl_prov_zip F8 11 x 9 168 176
N404 26 O ID 2/3 S [ ]~ Laboratory or Facility Country Code svl_prov_cntry_cd F8 12 x 3 177 179
521 REF O S-5 REF* Service Facility Location Secondary Assumption is that only 1 of each qualifier
State Industrial Accident X5 10 x 2 60 61 If qualifer equals 'TJ' you need to look at the
Medicare Number 1C 12 x 2 77 78 NM108 preceding this REF
Medicaid Number 1D
UPIN 1G
Champus Number 1H
CLIA Number X4
Federal Tax ID Number TJ svl_sec_id_qual See REF01 for positions If F6-12 equals '24' or '34', map 'TJ' to F7-06
svl_prov_tin_qual F6 12 x 1 100 100 If F6-12 equals 'XX', map 'E' to F6-12

Medicare Number 13 x 15 79 93
State License Number 15 x 15 96 110
Blue Shield Number
Medicaid Number
UPIN
Commercial Number
Champus Number

Max Cd
Federal Tax ID Number svl_sec_id See REF02 for positions If REF 01 = 'EI'

Network ID svl_prov_ntwrk_id F6 15 x 15 113 127 If REF 01 = 'SY' and NM108 equals '24' or
'34', map to F7-07
LOOP 2420D S-1 SUPERVISING PROVIDER This Loop defines information in the F6
F7 and F8.
523 NM1 O S-1 NM1* Supervising Provider Name Information

NM101 98 M ID 2/3 R DQ* Name Qualifer svl_prov_nm_qual_f6 F6 05 x 2 24 25 If F7 and/or F8 are created from information
Supervising Physician DQ in this Loop, Map this field to the F7-05
and/or F8-05
NM102 1065 M ID 1/1 R 1* Entity Type Qualifier svl_prov_typ_cd F6 06 x 1 26 26

Non-Person Entity 1 L
NM103 1035 O AN 1/35 R [ ]* Supervising Provider Last Name svl_prov_lnm F6 07 x 35 27 61
NM104 1036 O AN 1/25 R [ ]* Supervising Provider First Name svl_prov_fnm F6 08 x 12 62 73
NM105 1037 O AN 1/25 S [ ]* Supervising Provider Middle Name svl_prov_mi F6 09 x 1 74 74
NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Supervising Provider Name Suffix svl_prov_suffix F6 10 x 10 75 84
EIN 24 E
SSN 34 S
NPI XX
map data.
svl_prov_npi F6 11 x 15 85 99 If 'XX' in NM108, Map to F6-11

527 REF O S-5 REF* Supervising Provider Secondary Assumption is that only 1 of each qualifier

Max Cd
Medicaid Number 1D
UPIN 1G
Champus Number 1H
Medicaid Number
UPIN
Commercial Number
Champus Number
Employer's ID svl_sec_id See REF02 for positions If REF 01 = 'EI' and NM108 equals '24' or
'34', map to F7-07
'34', map to F7-07
LOOP 2420E S-1 ORDERING PROVIDER INFORMATION This Loop defines information in the F6
Packett.This F6 Packet contains F6, F7, and
F7 and F8.
529 NM1 O S-1 NM1* Ordering Provider Name Information

NM101 98 M ID 2/3 R DK* Name Qualifier svl_prov_nm_qual_f6 F6 05 x 2 24 25 If F7 and/or F8 are created from information
Ordering Provider DK in this Loop, Map this field to the F7-05
and/or F8-05

Person 1

Max Cd
NM103 1035 O AN 1/35 R [ ]* Last Name or Organization Name svl_prov_lnm F6 07 x 35 27 61
NM104 1036 O AN 1/25 R [ ]* Ordering Provider First Name svl_prov_fnm F6 08 x 12 62 73
NM105 1037 O AN 1/25 S [ ]* Ordering Provider Middle Name svl_prov_mi F6 09 x 1 74 74

NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Ordering Provider Name Suffix svl_prov_suffix F6 10 x 10 75 84
EIN 24 E
SSN 34 S
NPI XX
NM109 67 X AN 2/80 S [ ]~ Ordering Provider ID If NM108 = '24' and the third position of
map data.

533 N3 O R-1 N3* Ordering Provider Address Information
N301 166 M AN 1/55 R [ ]* Ordering Provider Address 1 svl_prov_addr_1 F8 07 x 30 86 115
N302 166 O AN 1/55 S [ ]~ Ordering Provider Address 2 svl_prov_addr_2 F8 08 x 30 116 145

534 N4 O R-1 N4* Ordering Provider City State and Zip
N401 19 O AN 2/30 R [ ]* Ordering Provider City svl_prov_city F8 09 x 20 146 165
N402 156 O ID 2/2 R [ ]* Ordering Provider State / Province Code svl_prov_st F8 10 x 2 166 167
N403 116 O ID 3/15 R [ ]* Ordering Provider Zip Code svl_prov_zip F8 11 x 9 168 176
N404 26 O ID 2/3 S [ ]~ Ordering Provider Country Code svl_prov_cntry_cd F8 12 x 3 177 179
536 REF O S-5 REF* Ordering Provider Secondary Identification Assumption is that only 1 of each qualifier
Numbers will be used. If 2 of the same qualifer come

Max Cd
Medicaid Number 1D
UPIN 1G
Champus Number 1H
Medicaid Number
UPIN
Commercial Number
Champus Number
'34' map to F7-07
'34' map to F7-07
svl_prov_npi F6 11 x 15 85 99 If F6-13 is not present, then map to F6-13
538 PER O S-2 PER* Ordering Provider Contact Informtion Assumption is that only 1 of each qualifier
will be used.
PER01 366 M ID 2/2 R IC* Contact Function Code IC NOT MAPPED
PER02 93 O AN 1/60 R [ ]* Contact Name svl_prov_contact_nm F6 17 x 35 139 173
PER03 365 X ID 2/2 R [Sel Code]* Communication Number Qualifier If 2 of the same qualifer come in, overwrite
Electronic Mail EM the previous.
Facsimile FX NOT MAPPED
Telephone TE
PER04 364 X AN 1/80 R [ ]* Communication Number If not 'EM', 'FX', 'TE', do not map
Ordering Provider Email svl_prov_email F7 18 x 40 126 165 IF PER03 = 'EM', Map to F7-18
Ordering Provider FAX svl_prov_fax F7 17 x 10 116 125 IF PER03 = 'FX', Map to F7-17
Ordering Provider Telephone svl_prov_contact_no F6 18 9 10 174 183 IF PER03 = 'TE', Map to F6-18

Max Cd
Phone Extension EX
Electronic Mail EM
Facsimile FX
Telephone TE
PER06 364 X AN 1/80 S [ ]* Communication Number If not 'EX,' 'EM', 'FX', 'TE', do not map
Orderning Provider Telephone Extention svl_prov_tel_ext F7 16 x 5 111 115 IF PER05 = 'EX', Map to F7-16
Orderning Provider Email svl_prov_email F7 18 x 40 126 165 IF PER05 = 'EM', Map to F7-18
Orderning Provider FAX svl_prov_fax F7 17 x 10 116 125 IF PER05 = 'FX', Map to F7-17
Orderning Provider Telephone svl_prov_contact_no F6 18 9 10 174 183 IF PER05 = 'TE', Map to F6-18
Phone Extension
Electronic Mail EX
Facsimile EM
Telephone FX
TE
PER08 364 X AN 1/80 S [ ]~ Communication Number If not 'EX,' 'EM', 'FX', 'TE', do not map
Orderning Provider Telephone Extention svl_prov_tel_ext F7 16 x 5 111 115 IF PER07 = 'EX', Map to F7-16
Orderning Provider Email svl_prov_email F7 18 x 40 126 165 IF PER07 = 'EM', Map to F7-18
Orderning Provider FAX svl_prov_fax F7 17 x 10 116 125 IF PER07 = 'FX', Map to F7-17
Orderning Provider Telephone svl_prov_contact_no F6 18 9 10 174 183 IF PER07 = 'TE', Map to F6-18
LOOP 2420F S-2 REFERRING/PCP PROVIDER This Loop defines information in the F6
F7 and F8.
542 NM1 O S-1 NM1* Refering/PCP Provider Name Information
NM101 98 M ID 2/3 R [Sel Code]* Name Qualifier DN svl_prov_nm_qual_f6 F6 05 x 2 24 25 If F7 and/or F8 are created from information
P3 in this Loop, Map this field to the F7-05 and/
or F8-05

Person 1 L
NM103 1035 O AN 1/35 R [ ]* Referring/PCP Provider Last Name svl_prov_lnm F6 07 x 35 27 61
NM104 1036 O AN 1/25 R [ ]* Referring/PCP Provider First Name svl_prov_fnm F6 08 x 12 62 73
NM105 1037 O AN 1/25 S [ ]* Referring/PCP Provider Middle Name svl_prov_mi F6 09 x 1 74 74

NM106 N/U *
NM107 1039 O AN 1/10 S [ ]* Referring/PCP Provider Name Suffix svl_prov_suffix F6 10 x 10 75 84

Max Cd
EIN 24 E
SSN 34 S
NPI XX
NM109 67 X AN 2/80 S [ ]~ Referring/PCP Provider Identifier If NM108 = '24' and the third position of
map data.

544 PRV O R-1 Referring/PCP Provider Specialty
Information
PRV01 1221 M ID 1/3 R RF* Provider Code RF
PRV02 128 M ID 2/3 R ZZ* Mutually Defined Provider Taxonomy Code ZZ NOT MAPPED
PRV03 127 M AN 1/30 R [ ]~ Provider Taxonomy Code svl_prov_taxomy_cd F6 16 x 11 128 138 See Code Table for Source
547 REF O S-5 REF* Referring/PCP Provider Secondary Assumption is that only 1 of each qualifier
Medicaid Number 1D
UPIN 1G
Champus Number 1H
Employer's ID EI svl_sec_id_qual See REF01 for positions If NM108 equals '24' or '34', Map 'EI 'to F7-06
svl_prov_tin_qual F6 12 x 1 100 100 If NM108 equals 'XX', map 'E' to F6-12

Social Security Number SY svl_sec_id_qual See REF01 for positions If NM108 equals '24' or '34', map 'SY' to F7-
06
svl_prov_tin_qual F6 12 x 1 100 100 If NM108 equals 'XX', map 'S' to F6-12

Max Cd

Medicaid Number
UPIN
Commercial Number
Champus Number
'34' map to F7-07
'34' map to F7-07
LOOP 2420G S-4 OTHER PAYER PRIOR Map only if NM101 value = PR
AUTHORIZATION OR REFERRAL
NUMBER
550 NM1 O S-1 NM1* Other Payer Name Information
NM101 98 M ID 2/3 R PR* Name Qualifier
Other Payer PR
NM102 1065 M ID 1/1 R 2* Entity Type Qualifier NOT MAPPED
Non-Person Entity 2
NM103 1035 O AN 1/35 R [ ]* Other Payer Last Name svl_othr_pyr_nm KP 07 x 35 59 93
NM104-107 N/ ****
U
NM108 66 X ID 1/2 R [Sel Code]* Identification Code Qualifier PI svl_othr_pyr_id_qual_kr KR 05 x 2 27 28
XV
NM109 67 X AN 2/80 R [ ]~ Other Payer Identifier svl_othr_pyr_id_no_kr KR 06 x 30 29 58 If Loop 2420G is present and NM108 = 'PI',
Then map payer id positions 1-5 left justified
to KR-06
552 REF O S-2 REF* Other Payer Referral / Prior Authorization

Numbers
REF O 1 of 2
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier 9F NOT MAPPED
G1
REF02 127 X AN 1/30 R [ ]~ Referral Number svl_othr_pyr_ref_no KR 07 x 30 59 88 If REF01= '9F', map to KR-07
Prior Authorization Number svl_othr_pyr_prior_auth_no KR 08 x 30 89 118 If REF01= 'G1', map to KR-08

REF O 2 of 2
REF01 128 M ID 2/3 R [Sel Code]* Reference Number Qualifier 9F NOT MAPPED
G1

Max Cd
REF02 127 X AN 1/30 R [ ]~ Referral Number svl_othr_pyr_ref_no KR 09 x 30 119 148 If REF01= '9F', map to KR-09
Prior Authorization Number svl_othr_pyr_prior_auth_no KR 10 x 30 149 178 If REF01= 'G1', map to KR-10
LOOP 2430 S-25 LINE ADJUDICATION INFORMATION
554 SVD O S-1 SVD* Service Line Adjudication Information
SVD01 67 M AN 2/80 R [ ]* Payer Identifier svl_othr_pyr_id_no_ks KS 05 x 15 27 41 Primary Payer ID in NM109 2330 Loop when
SBR01 = P in 2000 B Loop
Map first 5 bytes.
SVD02 782 M R 1/18 R [ ]* Service Line Paid Amount svl_othr_pyr_pd_amt KS 06 9v99 08 42 49 Define as 'Real'
SVD03 C003 O R Composite Medical Procedure
SVD03-1 235 M ID 2/2 R [Sel Code]: Product or Service ID Qualifier svl_othr_pyr_proc_qual KS 07 x 02 50 51 See Code Table for values
SVD03-2 234 M AN 1/48 R [ ]: Procedure Code svl_othr_pyr_proc_cd KS 08 x 05 52 56

SVD03-3 1339 O AN 2/2 S [ ]: Procedure Modifier 1 svl_othr_pyr_proc_mod_1 KS 09 x 02 57 58
SVD03-7 352 O AN 1/80 S [ ]* Procedure Code Description svl_othr_pyr_proc_cd_desc KS 13 x 80 65 144
SVD04 N/U *
SVD05 380 O AN 1/15 R [ ]* Paid Service Unit Count svl_othr_pyr_pd_units KS 14 9v9 15 145 159 Convert from Data Type Real to Implied
Decimel (9V9)
SVD06 554 O N0 1/6 S [ ]~ Bundled Line Number svl_othr_pyr_bun_line_no KS 15 x 20 160 179
558 CAS O S-99 CAS* Line Adjustment
CAS01 1033 M ID 1/2 R [Sel Code]* Claim Adjustment Group Code svl_cas_grp_cd KT 05 x 2 27 28 When new CAS Segment occurs, create new
KT Record increasing the Sub-Sequence
Number by 1
sub_seq_no KT 03 9 2 05 06 Increment by one for each KT Record within

this Segment
CAS02 1034 M ID 1/5 R [ ]* Adjustment Reason Code svl_cas_cd KT 06 x 5 29 33 See Code Table for Source
CAS03 782 M R 1/18 R [ ]* Adjustment Amount svl_cas_amt KT 07 9v99 8 34 41 Define as 'Real'
CAS04 380 O R 1/15 S [ ]* Adjustment Quantity svl_cas_qty KT 08 x 14 42 55
CAS05 1034 X ID 1/5 S [ ]* Adjustment Reason Code svl_cas_cd KT 09 x 5 56 60 See Code Table for Source
CAS06 782 X R 1/18 S [ ]* Adjustment Amount svl_cas_amt KT 10 9v99 8 61 68 Define as 'Real'
CAS07 380 X R 1/15 S [ ]* Adjustment Quantity svl_cas_qty KT 11 x 14 69 82

Max Cd
CAS19 380 X R 1/15 S [ ]~ Adjustment Quantity svl_cas_qty KT 23 x 14 177 190
566 DTP O S-1 DTP* Line Adjudication Date
DTP03 1251 M AN 1/35 R [ ]~ Date Time Period svl_othr_pyr_adj_pd_dt KS 16 x 8 180 187
Line Adjudication Date
LOOP 2440 S-5 FORM IDENTIFICATION CODE
568 LQ O S-1 LQ* Form Identification Code
LQ01 1270 O ID 1/3 R [Sel Code]* Form Identification Code svl_form_id_qual GY 05 x 2 28 29 See Code Table for values
LQ02 1271 X AN 1/30 R [ ]~ Form Identifier svl_form_id GY 06 x 30 30 59

570 FRM M R-99 FRM* Supporting Documentation Repeat Form Information for each repeat
of FRM
FRM01 350 M AN 1/20 R [ ]* Question Number/Letter svl_ques_no GY 07 x 20 60 79
FRM02 1073 X ID 1/1 S [Sel Code]* Question Response svl_ques_cd GY 08 x 1 80 80 See Code Table for values
FRM03 127 X AN 1/30 S [ ]* Question Response svl_ques_txt GY 09 x 30 81 110
FRM04 373 X DT 8/8 S [ ]* Question Response svl_ques_dt GY 10 x 8 111 118
FRM05 332 X R 1/6 S [ ]~ Question Response svl_ques_pcnt GY 11 x 6 119 124
TRAILER R-1
B30 SE M R-1 SE* TRANSACTION SET TRAILER Generated by Translator
SE01 96 M N0 1/10 R [ ]* Transaction Segment Count NOT MAPPED
SE02 329 M AN 4/9 R [ ]~ Transaction Set Control Number NOT MAPPED
B10 GE M R-1 GE* FUNCTIONAL GROUP TRAILER
GE01 97 M N0 1/6 R [ ]* Number Of Transactions Sets Included NOT MAPPED
GE02 28 M N0 1/9 R [ ]~ Group Control Number NOT MAPPED
B7 IEA M R-1 IEA* INTERCHANGE CONTROL TRAILER
IEA01 116 M N0 1/5 R [ ]* Number Of Included Functional Groups NOT MAPPED
IEA02 112 M N0 9/9 R [ ]~ Interchange Control Number NOT MAPPED

Repriced TPO
LOOP 2010AB CURRENT LOGIC NEW LOGIC to be added to current

2010AB NM109 67 Pay-To Provider Tax Id BR 11 9 9 140 148 If NM108 = '24' or '34' move NM109 to BR-11 if the value is “999999999” in NM109 and the value is “24” in
NM108, then do not map either value to PCDS
NM108 66 Pay -To Provider NPI BR 12 x 10 149 158 If NM108 = 'XX', move NM109 to BR-12 if the value is “999999999” in NM109 and the value is “24” in
2010AB N301 166 Pay-To Provider Address 1 BC 04 x 30 18 47 If 'XX' do not map. *Note: do mot map if N301 not present
2010AB N401 19 Pay- To Provider City Name BC 06 x 20 78 97 If 'XXX' do not map. We do not map the BC record IB
2010AB N403 116 Pay-To Provider Zip Code BC 08 x 9 100 108 Strip non-numeric characters and concatenate before mapping If '99999' do not map We do not map the BC record IB
to BC-08.
LOOP 2010BA CURRENT LOGIC NEW LOGIC to be added to current
2010BA NM103 1035 Subscriber Last Name D0 11 x 20 103 122 Always Map If 'XX' do not map.
DB 07 x 35 120 154 Always Map If 'XX' do not map.
C0 04 x 20 22 41 If SBR02 ='18', Map to C0-04 If 'XX' do not map.
CB 04 x 35 25 59 If SBR02 = '18', Map to CB-04 If 'XX' do not map.
2010BA NM104 1036 Subscriber First Name D0 12 x 10 123 132 Always Map If 'XX' do not map.
C0 05 x 10 42 51 If SBR02 = '18', Map to C0-05 If 'XX' do not map.
CB 05 x 12 60 71 If SBR02 = '18', Map to CB-05 If 'XX' do not map.
N301 166 Subscriber Address 1 D1 04 x 30 22 51 Always Map If 'XX' do not map.
C0 11 x 18 67 84 Only if SBR02='18' If 'XX' do not map.
CB 06 x 30 72 101 Only if SBR02='18' If 'XX' do not map.
2010BA N401 19 Subscriber City Name D1 06 x 20 82 101 Always Map If 'XXX' do not map.
C0 13 x 15 103 117 Only if SBR02='18' If 'XXX' do not map.
CB 08 x 20 132 151 Only if SBR02='18' If 'XXX' do not map.
2010BA N402 156 Subscriber State/Prov Code D1 07 x 2 102 103 Always Map If 'XX' do not map.
C0 14 x 2 118 119 If 'XX' do not map.
2010BA N403 116 Subscriber Zip Code D1 08 x 9 104 112 Strip non-numeric characters and concatenate before mapping If '99999' do not map.
to D1-08
C0 15 X 9 120 128 If '99999' do not map.
2010BA DMG02 1251 Subscriber Birth Date D0 19 9 8 140 147 Always Map If '17760704' do not map.
C0 08 X 8 54 61 Always Map If '17760704' do not map.
LOOP 2010BB CURRENT LOGIC NEW LOGIC to be added to current
2010BB NM103 1035 Payer Last/Org Name D0 08 x 17 49 65 Always Map If 'XX' do not map.
D2 10 x 30 116 145 Always Map If 'XX' do not map.
LOOP 2010BC CURRENT LOGIC NEW LOGIC to be added to current
2010BC NM103 1035 Resp Party Last/Org Name C2 05 x 20 23 42 If 'XX' do not map.
CC 04 x 35 25 59 If 'XX' do not map.
2010BC N301 166 Resp Party Address 1 C2 08 x 18 54 71 If 'XX' do not map.
CC 06 x 30 72 101 If 'XX' do not map.
2010BC N401 19 Resp Party City Name C2 10 x 15 90 104 If 'XXX' do not map.
CC 08 x 20 132 151 If 'XXX' do not map.
2010BC N403 116 Resp Party Zip Code C2 12 x 9 107 115 Strip non-numeric characters and concatenate before mapping If '99999' do not map.
to C2-12
LOOP 2010CA CURRENT LOGIC NEW LOGIC to be added to current
132 09/27/2022
Repriced TPO
2010CA N301 166 Patient Address 1 C0 11 x 18 67 84 If 'XX' do not map.

CB 06 x 30 72 101 If 'XX' do not map.
2010CA N401 19 Patient City Name C0 13 x 15 103 117 If 'XXX' do not map.
CB 08 x 20 132 151 If 'XXX' do not map.
2010CA N402 156 Patient State/Prov Code C0 14 x 2 118 119 If 'XX' do not map.
2010CA N403 116 Patient Zip Code C0 15 x 9 120 128 Strip non-numeric characters and concatenate before mapping If '99999' do not map.
to C0-15.
2010CA DMG02 1251 Patient Birth Date C0 08 9 8 54 61 If '17760704' do not map.
LOOP 2310A CURRENT LOGIC NEW LOGIC to be added to current
2310A NM103 1035 Referring/PCP Provider Last Name E6 07 x 35 27 61 If 'XX' do not map.
2310A NM103 1035 Referring/PCP Provider Last Name E6 07 x 35 27 61 If 'XX' do not map.
2310A NM108 66 Identification Code Qualifier E6 12 x 1 100 100 Map only if NM108 = 24 or 34 if the value is “999999999” in NM109 and the value is “24” in
EIN NM108, then do not map either value to PCDS
SSN
NPI
2310A NM109 67 Referring/PCP Provider Identifier If NM108 = '24' and the third position of NM109 = '_', strip the if the value is “999999999” in NM109 and the value is “24” in
'_' and concatinate the number prior to mapping to E6-13, else NM108, then do not map either value to PCDS
just map data.
E6 11 x 15 85 99 If 'XX' in NM108, Map to E6-11 If '999999999' do not map NM108 or NM109.

LOOP 2310B CURRENT LOGIC NEW LOGIC to be added to current
2310B NM103 1035 Last Name or Organization Name E6 07 x 35 27 61 If Submitter ID = '332211999' or '332211888' and if NM103 = If 'XX' do not map.
'None', then Do Not Map.
If data already present, re-initialize field with spaces and map
with data from this element.
2310B NM108 66 Identification Code Qualifier E6 12 x 1 100 100 Map only if NM108 = 24 or 34 Would not recognize as a default. NO CHANGES Per Kelly
EIN If data already present, re-initialize field with spaces and map
SSN with data from this element.
NPI
2310B NM109 67 Rendering Provider ID If NM108 = '24' and the third position of NM109 = '_', strip the Would not recognize as a default. NO CHANGES per Kelly
'_' and concatinate the number prior to mapping to E6-13, else
just map data.
E6 13 x 9 101 109 If 24 or 34 in NM108 Map to E6-13 Would not recognize as a default. NO CHANGES Per Kelly
E6 11 x 15 85 99 If 'XX' in NM108 Map to E6-11 Would not recognize as a default. NO CHANGES Per Kelly
LOOP 2310C CURRENT LOGIC NEW LOGIC to be added to current

2310C NM103 1035 Name Last or Organization Name E6 07 x 35 27 61 If 'XX' do not map.
LOOP 2310D CURRENT LOGIC NEW LOGIC to be added to current
2310D N301 166 Laboratory or Facility Address Line 1 E8 07 x 30 86 115 If data already present, re-initialize field with spaces and map If 'XX' do not map.
2310D N401 19 Laboratory or Facility City Name E8 09 x 20 146 165 If data already present, re-initialize field with spaces and map If 'XXX' do not map.
133 09/27/2022
Repriced TPO
2310D N402 156 Laboratory or Facility State/Province E8 10 x 2 166 167 If data already present, re-initialize field with spaces and map If 'XX' do not map.
Name with data from this element.
2310D N403 116 Laboratory or Facility Zip Code E8 11 x 9 168 176 If data already present, re-initialize field with spaces and map If ''99999' do not map.
Strip non-numeric characters and concatenate before mapping
to E8-11.
LOOP 2310E CURRENT LOGIC NEW LOGIC to be added to current

2310E NM103 1035 Supervising Provider Last Name E6 07 x 35 27 61 If 'XX' do not map.
2310E NM104 1036 Supervising Provider First Name E6 08 x 12 62 73 If 'XX' do not map.
LOOP 2320 CURRENT LOGIC NEW LOGIC to be added to current
2320 DMG02 1251 Subscriber Birth Date D0 19 9 8 140 147 If '17760704' do not map.
2330A NM103 1035 Other Subscriber Last Name D0 11 x 20 103 122 Always Map If 'XX' do not map.
DB 08 X 155 166 If 'XX' do not map.
2330A NM108 66 Identification Number Qualifier D0 23 x 2 165 166 Always Map Would not recognize as a default. NO CHANGES
2330A NM109 67 Other Subscriber Primary Identifier D0 07 x 17 32 48 Always Map If '999999999' do not map NM108 or NM109.
DB 06 X 95 119 If '999999999' do not map NM108 or NM109.
2330A N401 19 Other Insured City Name D1 06 x 20 82 101 If 'XXX' do not map.
2330A N403 116 Other Insured Zip Code D1 08 x 9 104 112 Strip non-numeric characters and concatenate before mapping If '99999' do not map.
to D1-08.
LOOP 2330B CURRENT LOGIC NEW LOGIC to be added to current
2330B Other Payer Last/Org Name D0 08 x 17 49 65 If 'XX' do not map.
2330B DB 04 x 35 25 59 If '00000' do not map.
2420A NM103 1035 Last Name or Organization Name F6 07 x 35 27 61 If 'XX' do not map.
2420A NM109 67 Rendering Provider ID If NM108 = '24' and the third position of NM109 = '_', strip the if the value is “999999999” in NM109 and the value is “24” in
'_' and concatinate the number prior to mapping to E6-13, else NM108, then do not map either value to PCDS
just map data.
F6 13 x 9 101 109 If '24' or '34' in NM108 , Map to F6-13 if the value is “999999999” in NM109 and the value is “24” in
F6 11 x 15 85 99 If 'XX' in NM108 , Map to F6-11 if the value is “999999999” in NM109 and the value is “24” in
LOOP 2420C CURRENT LOGIC NEW LOGIC to be added to current
2420C N301 166 Laboratory or Facility Address Line 1 F8 07 x 30 86 115 If 'XX' do not map.
2420C N401 19 Laboratory or Facility City Name F8 09 x 20 146 165 If 'XXX' do not map.
2420C N403 116 Laboratory or Facility Zip Code F8 11 x 9 168 176 If '99999' do not map.
LOOP 2420E CURRENT LOGIC NEW LOGIC to be added to current
2420E NM103 1035 Last Name or Organization Name F6 07 x 35 27 61 If 'XX' do not map.
2420E NM104 1036 Ordering Provider First Name F6 08 x 12 62 73 If 'XX' do not map.
2420E N301 166 Ordering Provider Address 1 F8 07 x 30 86 115 If 'XX' do not map.
2420E N401 19 Ordering Provider City F8 09 x 20 146 165 If 'XXX' do not map.
2420E N403 116 Ordering Provider Zip Code F8 11 x 9 168 176 If '99999' do not map.
LOOP 2420F CURRENT LOGIC NEW LOGIC to be added to current
134 09/27/2022
Repriced TPO
2420F NM103 1035 Referring/PCP Provider Last Name F6 07 x 35 27 61 If 'XX' do not map.
2420F NM104 1036 Referring/PCP Provider First Name F6 08 x 12 62 73 If 'XX' do not map.
135 09/27/2022

Ansi Loop Logic-2010

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Ansi Loop Logic-2010

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Rendering Provider Name or ID Information

PayerID Payers that require Rendering Provider Name , ID or Address information

87815 Acordia National

22248 Amerihealth Mercy Health Plan

59298 Employer Mutual

62155 PHP TennCare

33002 Universal Care-TN

90060 First Guard Health

X12N PCDS Description

2000B SBR09 Claim Filing Indicator Code

2010BB REF01 Payer Secondary ID Qualifier

2000C PAT09 Pregnancy Indicator

42 42 Ambulance - Air or Water

2300 CLM06 Provider Signature Indicator

Y A Yes, benefits are assigned

AA A Auto Accident Related

EM Y Employment Related (E0-17)

2300 CLM20 Delay Reason Code

2300 PWK02 Attachment Transmission Type Code

2300 CRC02 Vision Certification Condition Indicator

2305 HSD07 Home Health Calendar Pattern Code

2305 HSD08 Home Health Delivery Time Pattern Code

2310B NM101 Provider Name Qualifiers

2310E NM101 Provider Name Qualifiers

2320 SBR05 Insurance Type Code

2320 DMG03 Other Subscriber Gender Code

2320 OI06 Release of Information Code

2330A REF01 Other Subscriber Secondary ID Qualifier

2400 SV101-1 Procedure Code Qualifier

2400 SV106 Type of Service Code

L L Renal Supplies in the Home

2400 CR208 Nature of Condition Code

2400 CRC03-7 Ambulance Condition Code

2400 CN101 Contract Type Code

2410 CTP05-1 Drug Pricing Unit Code Qualifier

2420B NM101 Purchased Service Provider Name Qualifier

2420C NM108 Tax Identification Number Qualifier

2420G NM108 Other Payer Prior Authorization ID Qualifier

2430 SVD03-1 Procedure Code Qualifier

2440 LQ01 Form Identifier Qualifier

May 24, 2006

September 26, 2006

October 11, 2006

November 29, 2006

Janurary 15, 2007

Janurary 31, 2007

March 23, 2007

April 27, 2007

July 11, 2007

October 18, 2007

October 26, 2007

December 17, 2007

January 10, 2008

January 15, 2008

January 31, 2008

Feburary 15, 2008

November 18, 2004

November 29, 2004

2400/CR511 Line# 1210: MTT#04110437943 & MTT# 04123043243

March 25, 2005

June 22, 2005

February 21, 2006

September 12, 2006