New York, USA

EDI Rules Format

The EDIValidator component uses validation rules in order to correctly parse, validate and load EDI data.  There is one rule file, for example, for every implementation guide.    For example, 820, 837, 834, 850, 997, 999 etc

The validation rule file format governs the structure of a specific implementation guide.  It contains all the segments, elements, composite segments, code lists, formats, summary elements, rules, accepted element values and most importantly the structure of the EDI loops and segments.

EDI Rules Creator Studio enables the creation of validation rules via a simple user interface.  It is highly recommended that developers use this tool to create and edit all validation rules. 

A validation rules file has the following sections that appear in the following order

FILE DATA

Contains any custom data.  This data is not used in the validation of EDI files.  Developers can place metadata in this section.

<CustomName>=<Value>

DateCreated=12/12/2003
EDIFileType=X12
EDIVersion=837
Version=5010
Creator=John Smith
Description=270 Eligibility, Coverage or Benefit Inquiry

ELEMENT DEFINITIONS

Contains all the elements numbers and their definitions.  Definitions include element number, type, min and max lengths, and an optional description

<ElementNumber>=<Type, MinimumLength, MaximumLength, [Description]>

26=ID,2,3
28=NO,1,9
66=ID,1,2
67=AN,2,80
93=AN,1,60
96=NO,1,10
97=NO,1,6
98=ID,2,3
101=ID,2,2
102=AN,10,10
103=ID,2,2
104=AN,10,10
105=ID,2,2
106=AN,15,15
107=AN,15,15
108=DT,6,6
109=TM,4,4
110=ID,1,1
111=ID,5,5
112=NO,9,9
113=ID,1,1
114=ID,1,1,Description
115=ID,1,1

For example the following is interpreted as element number 143 of type string with a minimum length of 1 and a maximum length of 3
143=AN,1,3

Possible Element Types include

A
 Alphabetic Characters
AN
 String
ID
 Identifiers
NO
 Numeric (Integers)
PN
 Positive Integers
NN
 Negative Integers
R
 Decimal ( for currency)
DT
 Dates
TM
 Times

COMPOSITE ELEMENT DEFINITIONS

Contains all the definitions for composite segments.  Composite elements are elements that contain other elements

<CompositeElementName>=<ElementNumber, [Usage]>,[CompositeElementName]>

C003=[235,O][234,O][1339,O][1339,O][1339,O][1339,O][352,O]
C004=[1328,O][1328,O][1328,O][1328,O]
C022=[1270,O][1271,O][1250,O][1251,O][782,O][380,O][799,O][1271,O][1073,O]

Usage can be Required (M), Optional (O) and Not Used (N). By default elements are Optional.

SEGMENT DEFINITIONS

Contains definitions for all segments used in the EDI file

<SegmentName>=<ElementNumber, [Usage]>

AMT=[522][782][478]
BHT=[1005,M][353,M][127][373,M][337,M][640]
DMG=[1250][1251][1068][1067][1109][1066][26][659][380]+P0102,
DTP=[374,M][1250,M][1251,M]
EQ=[1365][C003][1207][1336][C004]
GE=[97,M][28,M]
GS=[479,M][142,M][124,M][373,M][337,M][28,M][455,M][480,M]
HI=[C022][C022][C022][C022][C022][C022][C022][C022][C022][C022][C022][C022]

General segments can contain regular elements and composite elements. 

Some segments that you can see above are;

  1. The HI Segment contains only composite elements (C022).
  2. Segment GS contains 8 elements that are all Required (M)

Element Usage can be Required (M), Optional (O) and Not Used (N). By default elements are Optional.

SEGMENT SELF RULES

Contains rules that apply to the usage of elements within a segment based on the value(s) of elements in the same segment

<SegmentName>~<ElementOrdinalNumber>~<[Operator]><Element Values>~<RequiredElementsList>~<NotUsedElementList>

NM1~1~2~3,4~5,6
Meaning:  In segment NM1, if element 1 has a value EQUAL to 2 then element 3 and 4 are required and element 4 and 5 are not used.

NM1~1~[NE]2,8~3,4~5,6
Meaning: In segment NM1, if element 1 has a value NOT EQUAL to 2 or 8 then element 3 and 4 are required and element 5 and 6 are not used.

NM1~1~[GT]2,8~3,4~5,6
Meaning:  In segment NM1, if element 1 has a value GREATER THAN  2 and 8 then element 3 and 4 are required and element 4 and 5 are not used.

NM1~1~[LT]2,8~3,4~5,6
Meaning:  In segment NM1, if element 1 has a value LESS THAN  2 and 8 then element 3 and 4 are required and element 5 and 6 are not used.

The possible operators are

EQ
 Equals (default)
NE
 Not Equals
LT
 Less Than
LE
 Less Than Or Equal To
GT
 Greater Than
GE
 Greater Than

COMPOSITE SEGMENT SELF RULES

This section is the same as section SEGMENT SELF RULES however it is for composite element self rules

CODELISTS

EDI element data can be validated against code lists.  For example zip codes, ICD 10 codes etc.

<ListName>=[<Filename>*<Delimiter>]

States=[States.txt*,]
POSCodes=[POSCodes.txt*,]
ZipCodes=[ZipCodes.txt*,]

Above are three code lists; States, POSCodes and ZipCodes.  Because they are surrounded by brackets ([]) they are external code lists.  They must be located in the same directory as the EDI rules file.  Each state will be on one line.

Example

NY,New York
CA,California

<ListName>=<Code>^<Value>,[<ListName>]

List1=A^Apple, B^Bat, C^Cat

This is a code list named List1. This is an internal code list.  This means that its codes and description are in-lined in the EDI rules file itself

FORMATS

Contains named regular expressions used to validate the contents of EDI elements.  If data elements don’t conform to specified formats an error will be raised

<FormatName>=<RegularExpression>

EIN=^\d{9}$
EIN2=^\d{2}-\d{7}$
SOCIALSECURITY1=^\d{9}$
SOCIALSECURITY2=^\d{3}-\d{2}-\d{4}$
ZipCode=^\d{5}([\-]\d{4})?$
MilitaryTimeFormat=^([0-1][0-9]|[2][0-3])([0-5][0-9])$

The format names can be referred to in the ELEMENT FORMATS section

EDI FILE STRUCTURE

Contains a tree-like structure of the EDI file in terms of loops and segments

{<LoopName>:<RepeatCount|>1><[SegmentName [*MaskNumber], Usage]>[{<LoopName>}]}

{INTERCHANGE HEADER:1[ISA,M]{FUNCTIONAL GROUP:1[GS,M]{ST HEADER:>1[ST,M][BHT,M]{1000A:1[NM1*1,M][PER*2,M,2]}{1000B:1[NM1*2,M]}{2000A:>1[HL*1,M][PRV*1][CUR]{2010AA:1[NM1*4,M][N3,M][N4*2,M][REF,M][REF,O,2][PER*2,O,2]}{2010AB:1[NM1*11][N3,M][N4*2,M]}{2010AC:1[NM1*2][N3,M][N4*2,M][REF][REF]}{2000B:>1[HL*2,M][SBR*1,M][PAT*1,X]{2010BA:1[NM1*3,M][N3][N4*2,M][DMG*3][REF][REF][PER*3]}{2010BB:1[NM1*2,M][N3][N4*2,M][REF,O,3][REF,O,2]}{2300:100[CLM*1,X][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][PWK*1,O,10][CN1][AMT*1][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][K3,O,10][NTE*1][CR1*2][CR2*1][CRC*1,O,3][CRC*1,O,3][CRC*2][CRC*3][HI*1,M][HI*2][HI*1,O,2][HCP*1]{2310A:2[NM1*4][REF,O,3]}{2310B:1[NM1*4][PRV*1][REF,O,4]}{2310C:1[NM1*12][N3,M][N4*2,M][REF,O,3][PER*3]}{2310D:1[NM1*4][REF,O,4]}{2310E:1[NM1*11][N3,M][N4*2,M]}{2310F:1[NM1*13][N3,M][N4*2,M]}{2320:10[SBR*4][CAS*1,O,5][AMT*1][AMT*1][AMT*1][OI*1,M][MOA]{2330A:1[NM1*3,M][N3][N4*2,M][REF]}{2330B:1[NM1*2,M][N3][N4*2,M][DTP][REF,O,2][REF][REF][REF][REF]}{2330C:2[NM1*11][REF,M,3]}{2330D:1[NM1*11][REF,M,3]}{2330E:1[NM1*11][REF,M,3]}{2330F:1[NM1*11][REF,M,3]}{2330G:1[NM1*11][REF,M,2]}}{2400:50[LX*1,M][SV1*1,M][SV5*1][PWK*1,O,10][PWK*2][CR1*2][CR3*1][CRC*1,O,3][CRC*2][CRC*4][DTP,M][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][DTP][QTY][QTY][MEA,O,5][CN1*1][REF][REF][REF,O,5][REF][REF][REF][REF][REF][REF,O,5][AMT*1][AMT*1][K3,O,10][NTE*1][NTE][PS1*1][HCP*2]{2410:1[LIN*1][CTP*1][REF]}{2420A:1[NM1*4][PRV*1][REF,O,20]}{2420B:1[NM1*9][REF,O,20]}{2420C:1[NM1*12][N3,M][N4*2,M][REF,O,3]}{2420D:1[NM1*4][REF,O,20]}{2420E:1[NM1*4][N3][N4*2,M][REF,O,20][PER*2]}{2420F:2[NM1*4][REF,O,20]}{2420G:1[NM1*11][N3,M][N4*2,M]}{2420H:1[NM1*13][N3,M][N4*2,M]}{2430:15[SVD*1][CAS*1,O,5][DTP,M][AMT]}{2440:>1[LQ*1][FRM*1,O,99]}}}{2000C:>1[HL*2,X][PAT*2,M]{2010CA:1[NM1*5,M][N3,M][N4*2,M][DMG*3,M][REF][PER*3]}{2300:100[CLM*1,X][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][PWK*1,O,10][CN1][AMT*1][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][K3,O,10][NTE*1][CR1*2][CR2*1][CRC*1,O,3][CRC*1,O,3][CRC*2][CRC*3][HI*1,M][HI*2][HI*1,O,2][HCP*1]{2310A:2[NM1*4][REF,O,3]}{2310B:1[NM1*4][PRV*1][REF,O,4]}{2310C:1[NM1*12][N3,M][N4*2,M][REF,O,3][PER*3]}{2310D:1[NM1*4][REF,O,4]}{2310E:1[NM1*11][N3,M][N4*2,M]}{2310F:1[NM1*13][N3,M][N4*2,M]}{2320:10[SBR*4][CAS*1,O,5][AMT*1][AMT*1][AMT*1][OI*1,M][MOA]{2330A:1[NM1*3,M][N3][N4*2,M][REF]}{2330B:1[NM1*2,M][N3][N4*2,M][DTP][REF,O,2][REF][REF][REF][REF]}{2330C:2[NM1*11][REF,M,3]}{2330D:1[NM1*11][REF,M,3]}{2330E:1[NM1*11][REF,M,3]}{2330F:1[NM1*11][REF,M,3]}{2330G:1[NM1*11][REF,M,2]}}{2400:50[LX*1,M][SV1*1,M][SV5*1][PWK,O,10][PWK*2][CR1*2][CR3*1][CRC*1,O,3][CRC*2][CRC*4,O,2][DTP,M][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][DTP][QTY][QTY][MEA,O,5][CN1*1][REF][REF][REF,O,5][REF][REF][REF][REF][REF][REF,O,5][AMT*1][AMT*1][K3,O,10][NTE*1][NTE][PS1*1][HCP*2]{2410:1[LIN*1][CTP*1][REF]}{2420A:1[NM1*4][PRV*1][REF,O,20]}{2420B:1[NM1*9][REF,O,20]}{2420C:1[NM1*12][N3,M][N4*2,M][REF,O,3]}{2420D:1[NM1*4][REF,O,20]}{2420E:1[NM1*4][N3][N4*2,M][REF,O,20][PER*2]}{2420F:2[NM1*4][REF,O,20]}{2420G:1[NM1*11][N3,M][N4*2,M]}{2420H:1[NM1*13][N3,M][N4*2,M]}{2430:15[SVD*1][CAS*1,O,5][DTP,M][AMT]}{2440:>1[LQ*1][FRM*1,O,99]}}}}}}{END ST HEADER LOOP:1[+SE,M]}}{END GS LOOP:1[+GE,M]}}{END ISA LOOP:1[+IEA,M]}}

Each segment that appears in the structure has an implicit ordinal value beginning with 1.  For example segment ISA has an ordinal value of 1, segment GS has an ordinal value of 2, ST has an ordinal value of 3 and BHT has an ordinal value of 4.  This ordinal value is what uniquely identifies each segment in the structure.

ELEMENT CODES

Contains the code values accepted by elements in the EDI file.  If an element has an accepted value(s) list and data in the element is not in that list then an error will be generated

<ElementNumber>=<ElementPosition>,<AcceptedValue, AcceptedValue…>

101=1:1,00,03
103=1:3,00,01
105=1:5,01,14,20,27,28,29,30,33,ZZ*1:7,01,14,20,27,28,29,30,33,ZZ
111=1:12,00501
113=1:14,0,1
101=1:1,00,03

From above, element 101 when used in the first segment (Ordinal value=1) and is the first element, has accepted values of 00 and 03

Example

128=5:1,87*15:1,0B,1A,1B,1C,1D,1G,1H,1J,B3,BQ,EI,FH.

When element 128 appears in the fifth segment (Ordinal Value=5) at element position 1 its accepted value is 87.  When element 128 appears in the fifteenth  segment (Ordinal Value=15) at element position 1 its accepted values are 0B,1A,1B,1C,1D,1G,1H,1J,B3,BQ,EI,FH.

ELEMENT DESCRIPTIONS

Contains the descriptions for elements in the EDI file

<ElementNumber>=<ElementPosition>,<Description>

98=11:1,Entity Identifier Code 1
66=11:8,Identification Code test

From above, element 98 when used in the 11th segment (Ordinal value=11) and is the first element (1), has description ‘Entity Identifier Code 1‘

Elements can have different descriptions based on what position they are located

This helps users to quickly know which element an error or warning occurs in

ELEMENT FORMATS

Used to specify element formats

<ElementNumber>=<ElementPosition>,<ElementOrdinalNumber>,<ElementValue>,CodeListName, CodeListName

108=1:9,0,0,DateYYMMDD
373=2:4,0,0,DateCCYYMMDD

Example
67=12:9,8,24,EIN,EIN2*12:9,8,34,SOCIALSECURITY1,SOCIALSECURITY2*18:9,8,24,EIN,EIN2

Meaning: When element 67 appears in the 12th segment at element position 9, when the 8th element’s value is 24 then element 67’s format is EIN or EIN2 (from the FORMATS section).  When element 67 appears in the 12th segment at element position 9, when the 8th elements values is 34 then element 67’s format is SOCIALSECURITY or SOCIALSECURITY2 (from the FORMATS section).  When element 67 appears in the 18th segment at element position 9, when the 8th elements values is 24 then element 67’s format is EIN or EIN2 (from the FORMATS section).

SUMMARY

Contains the summary elements.  Summary (balance) elements are elements whose values contain the sum of other elements

<ElementPosition>=<ElementPosition>

40:2=135:2
220:2=319:2

Segment with ordinal number of 40, element 2 must contain the sum of segment 139 element 2 values.  It does not matter how many times segment 139 repeats, segment 40 element 2 will contain the total sum of each repetition of segment 139 element 2.
We can also see that the segment positions on the left hand side of the equal sign are of lower segment ordinal numbers than the ones on the right hand side of the equal sign.  This means that elements can only contain the sum of elements below it.

Summary values can also be used to count the number of repetitions of a segment rather than just a total sum of an element’s value.  For example:

40:2=135

This means that a segment with ordinal number of 40, element 2 must contain the number of repetitions of the a segment with ordinal 135.  This is used when the need to count how many loops exist where is total number is displayed in an element of a higher loop, in this case segment 40 element 2.

An arithmetic operator can be place in front of an element to signify whether the its total sum or total difference should be used in the summary total 

12:23=+23:2,-45:4

Summary values can also have conditions 

25:5=26:3|26:1’EQ’PR,

This means only sum when segment 26 element 1 = ‘PR’

ELEMENT EQUALITY

Element equality conditions are used to specify that two element values must be equal.  Element equality conditions are usually used to check if EDI transaction numbers are the same at the beginning and ending of an EDI file.

<ElementPosition>=<ElementPosition>

1:13=45:2
2:6=44:2
3:2=43:2

 RULES

This section contain EDI validation rules.  RDPScript EDI Language is used to create validation rules. 
 

ELEMENT COUNTERS

Element counters are elements in certain segments that keep count of the current repetition of the loop that it is in.  A great example of this is the LX segment in an 837 transaction.

<ElementNumber>=<ElementPosition>

554=138:1

Meaning: When element 554 is used in segment position 138 for element 1 then it should contain the current repetition count.

ELEMENT CODE DESCRIPTION

Contains the description of each value an element can have.  This section is is rarely used

LOOP DESCRIPTIONS

Contains the descriptions of the loop used in the EDI file

<LoopName>=<Description>

INTERCHANGE HEADER=Beginning of the EDI Interchange
FUNCTIONAL GROUP=Beginning of the Functional Group Interchange
ST HEADER=Header Loop
2000A=INFORMATION SOURCE LEVEL
2100A= PAYER NAME
2000B=INFORMATION RECEIVER LEVEL
2100B=INFORMATION RECEIVER NAME
2000C=SERVICE PROVIDER LEVEL
2100C=PROVIDER NAME
2000D= SUBSCRIBER LEVEL
2100D=SUBSCRIBER NAME

SEGMENT DESCRIPTIONS

Contains the descriptions of the segment used in the EDI file based on their ordinal numbers

<SegmentName>=<Description>

ST=3, Transaction Set Header
BHT=4, Beginning of Hierarchical Transaction

Complete EDI Rule Files

FILE DATA
Version=004010
Description=837 Health Care Claims
ELEMENT DEFINITIONS
19=AN,2,30,City Name
26=ID,2,3,Country Code
28=NO,1,9,Group Control Number
66=ID,1,2,Identification Code Qualifier
67=AN,2,80,Identification Code
81=R,1,10,Weight
93=AN,1,60,Name
96=NO,1,10,Number of Included Segments
97=NO,1,6,Number of Transaction Sets Included
98=ID,2,3,Entity Identifier Code
100=ID,3,3,Currency Code
101=ID,2,2,Authorization Information Qualifier
102=AN,10,10,Author Information
103=ID,2,2,Security Information Qualifier
104=AN,10,10,Security Information
105=ID,2,2,Interchange ID Qualifier
106=AN,15,15,Interchange Sender ID
107=AN,15,15,Interchange Receiver ID
108=DT,6,6,Interchange Date
109=TM,4,4,Interchange Time
110=ID,1,1
111=ID,5,5,Interchange Control Version Number
112=NO,9,9,Interchange Control Number
113=ID,1,1,Acknowledgment Requested
114=ID,1,1,Interchange Usage Indicator
115=ID,1,1,Component Element Separator
116=ID,3,15,Postal Code
118=NO,1,9,Rate
124=AN,2,15,Application Receiver Code
127=AN,1,50,Reference Identification
128=ID,2,3,Reference Identification Qualifier
142=AN,2,15,Application Sender Code
143=ID,3,3,Transaction Set Identifier Code
156=ID,2,2,State or Province Code
165=ID,1,1,Repetition Separator
166=AN,1,55,Address Information
212=R,1,17,Unit Price
234=AN,1,48,Product/Service ID
235=ID,2,2,Product/Service ID Qualifier
236=ID,3,3,Price Identifier Code
309=ID,1,2,Location Qualifier
310=AN,1,30,Location Identifier
329=AN,4,9,Transaction Set Control Number
332=R,1,6,Percent Decimal Format
337=TM,4,8,Time
338=R,1,6,Terms Discount Percent
350=AN,1,20,Assigned Identification
352=AN,1,80,Description
353=ID,2,2,Transaction Set Purpose Code
355=ID,2,2,Unit or Basis for Measurement Code
363=ID,3,3,Note Reference Code
364=AN,1,256,Communication Number
365=ID,2,2,Communication Number Qualifier
366=ID,2,2,Contact Function Code
373=DT,8,8,Date
374=ID,3,3,Date/Time Qualifier
380=R,1,15,Quantity
449=AN,1,80,Fixed Format Information
455=ID,1,2,Responsible Agency Code
478=ID,1,1,Credit/Debit Flag Code
479=ID,2,2,Functional Identifier Code
480=AN,1,12,Version / Release / Industry Identifier Code
522=ID,1,3,Amount Qualifier Code
554=NO,1,6,Assigned Number
584=ID,2,2,Employment Status Code
594=ID,1,1,Frequency Code
609=NO,1,9,Count
615=ID,1,2
616=NO,1,3
628=AN,1,12
640=ID,2,2,Transaction Type Code
659=ID,1,2
673=ID,2,2
678=ID,1,2
679=ID,1,1
687=ID,2,2,Class of Trade Code
706=ID,2,2,Entity Relationship Code
734=AN,1,12,Hierarchical Parent ID Number
735=ID,1,2,Hierarchical Level Code
736=ID,1,1,Hierarchical Child Code
737=ID,2,2,Measurement Reference ID Code
738=ID,1,3,Measurement Qualifier
739=R,1,20,Measurement Value
755=ID,2,2,Report Type Code
756=ID,1,2,Report Transmission Code
757=NO,1,2,Report Copies Needed
782=R,1,18,Monetary Amount
799=AN,1,30,Version Identifier
901=ID,2,2,Reject Reason Code
921=ID,2,2
923=ID,1,1,Prognosis Code
954=R,1,10,Percent
1005=ID,4,4,Hierarchical Structure Code
1028=AN,1,38,Claim Submitter Identifier
1029=ID,1,2,Claim Status Code
1032=ID,1,2,Claim Filing Indicator Code
1033=ID,1,2,Claim Adj Group Code
1034=ID,1,5,Claim Adj Reason Code
1035=AN,1,60,Name Last or Organization Name
1036=AN,1,35,Name First
1037=AN,1,25,Name Middle
1038=AN,1,10,Name Prefix
1039=AN,1,10,Name Suffix
1065=ID,1,1,Entity Type Qualifier
1066=ID,1,2,Citizenship Status Code
1067=ID,1,1,Marital Status Code
1068=ID,1,1,Gender Code
1069=ID,2,2,Individual Relationship Code
1073=ID,1,1,Yes/No Condition or Response Code
1109=ID,1,1
1136=ID,2,2,Code Category
1138=ID,1,1,Payer Responsibility Sequence Number Code
1143=ID,1,1,Coordination of Benefits Code
1166=ID,2,2,Contract Type Code
1167=R,1,6
1220=ID,1,1,Student Status Code
1221=AN,1,3,Provider Code
1250=ID,2,3,DateTime Period Format Qualifier
1251=AN,1,35,Date Time Period
1270=ID,1,3,Code List Qual Code
1271=AN,1,30,Industry Code
1316=ID,1,1,Ambulance Trans Code
1317=ID,1,1,Ambulance Reason Code
1321=ID,2,2,CertificateCond Code
1325=ID,1,1,Claim Frequency Type Code
1327=ID,1,1,Copay Status Code
1328=NO,1,2,Diagnosis Code Pointer
1331=AN,1,2,Facility Code Value
1332=ID,1,2,Facility Code Qualifier
1334=ID,1,1,Health Care Professional Shortage Area Code
1335=ID,1,1,Insulin Dependent Code
1336=ID,1,3,Insurance Type Code
1337=ID,1,1,Level of Care Code
1338=ID,1,3,Level of Service Code
1339=AN,2,2,Procedure Modifier
1340=ID,1,2,Multiple Procedure Code
1341=AN,1,2,National or Local Assigned Review Value
1342=ID,1,1,Nature of Cond Code
1343=ID,1,2,Non-Institutional Claim Type Code
1348=ID,1,1
1349=ID,1,1
1350=ID,1,1
1351=ID,1,1,Patient Signature Source Code
1359=ID,1,1,Provider Accept Assignment Code
1360=ID,1,1,Provider Agreement Code
1362=ID,2,3,Related Causes Code
1363=ID,1,1,Release of Information Code
1364=ID,1,2,Review Code
1365=ID,1,2,Service Type Code
1366=ID,2,3,Special Program Code
1367=ID,2,3,Subluxation Level Code
1382=ID,1,1
1383=ID,2,2,Claim Submission Reason Code
1384=ID,1,1,Patient Location Code
1470=NO,1,9
1473=ID,2,2,Pricing Methodology
1514=ID,1,2,Delay Reason Code
1525=ID,1,2,Request Category Code
1526=ID,1,2,Policy Compliance Code
1527=ID,1,2,Exception Code
1705=AN,1,35,Implementation Convention Reference
1715=ID,1,3,Country Subdivision Code
11111112=NO,1,9
11111116=NO,1,5
COMPOSITE ELEMENT DEFINITIONS
C001=[355,O],@
C003=[235,O][234,O][1339,O][1339,O][1339,O][1339,O][352,O],@@.....,@@#####,@@.....
C004=[1328,O][1328,O][1328,O][1328,O],@...
C022=[1270,O][1271,O][1250,O][1251,O][782,O][380,O][799,O],@@#####,#######
C023=[1331,O][1332,O][1325,O],@#@,@@@
C024=[1362,O][1362,O][1362,O][156,O][26,O],@....,@.#..
C056=[1109,O][1270,O][1271,O],...
SEGMENT DEFINITIONS
AMT=[522][782][478],@@#
BHT=[1005,M][353,M][127,M][373,M][337,M][640,M]
CAS=[1033][1034][782][380][1034][782][380][1034][782][380][1034][782][380][1034][782][380][1034][782][380]+C0605C0705C0908C1008C1211C1311C1514C1614C1817C1917L050607L080910L111213L141516L171819,@@@................
CLM=[1028][782][1032][1343][C023][1073][1359][1073][1363][1351][C024][1366][1073][1338][1073][1360][1029][1073][1383][1514],@@##@*2@@@@..*2.#######.
CN1=[1166,M][782][332][127][338][799],@.....
CR1=[355][81][1316][1317][355][380][166][166][352][352]+P0102P0506,..@@@@##..,..#@@@##..
CR2=[609][380][1367][1367][355][380][380][1342][1073][352][352][1073]+P0102P0506C0403,#######@#..#
CR3=[1332][355][380][1335][352],@@@##
CR5=[1332][380][1348][1348][352][380][380][380][352][380][380][1349][1350][1350][1350][380][1382][1348]+R1011,@@#######..@...###
CR7=[921][1470][1470],@@@
CRC=[1136][1073][1321][1321][1321][1321][1321],@@@....,@@@####,@@@..##,@@@.###
CTP=[687][236][212][380][C001],###@@*1
CUR=[98,M][100,M]
DMG=[1250][1251][1068][1067][C056][1066][26][659][380][1270][1271]+P0102P1011C1105,@@@..*1.###..,.....*1.###..,@@@##*1######
DTP=[374,M][1250,M][1251,M]
FRM=[350][1073][127][373][332]+R02030405,@....
GE=[97,M][28,M]
GS=[479,M][142,M][124,M][373,M][337,M][28,M][455,M][480,M]
HCP=[1473][782][782][127][118][127][782][234][235][234][355][380][901][1526][1527]+P0910P1112R0113,@@.....#####...,@@.....#.......
HI=[C022][C022][C022][C022][C022][C022][C022][C022][C022][C022][C022][C022],@*1.*1.*1.*1.*1.*1.*1.*1.*1.*1.*1.*1,@*1.*1#*1#*1#*1#*1#*1#*1#*1#*1#*1#*1
HL=[628][734][735][736],@#@@,@@@@
HSD=[673][380][355][1167][615][616][678][679]+P0102C0605,........
IEA=[11111116,M][11111112,M]
ISA=[101,M][102,M][103,M][104,M][105,M][106,M][105,M][107,M][108,M][109,M][165,M][111,M][112,M][113,M][114,M][115,M]
K3=[449,M]
LIN,1=[350][235][234],#@@
LQ=[1270][1271]+C0102,@@
LX=[554],@
MEA=[737,M][738,M][739,M]
MOA=[954][782][127][127][127][127][127][782][782]
N3=[166,M][166]
N4=[19,M][156][116][26][309][310][1715]+C0605C0704E0207,@......,@...##.
NM1=[98,M][1065,M][1035][1036][1037][1038][1039][66][67]+P0809,@@@..##@@,@@@####@@,@@@..#.@@,@@@..#...,@@@..#.##,@@@..##..,@@.####..,@@@@.#...,@@#####..,@@#####@@,@@#######,@@@####..,@@.######
NTE=[363][352],@@
OI=[1032][1383][1073][1351][1360][1363],##@.#@
PAT=[1069][1384][584][1220][1250][1251][355][81][1073]+P0506P0708,####.....,@###.....
PER=[366][93][365][364][365][364][365][364]+P0304P0506P0708,@@@@....,@.@@....,@.@@..##
PRV=[1221][128][127],@@@
PS1=[127][782][156],@@#
PWK=[755,M][756][757][98][66][67]+P0506,@@##..,@@####
QTY=[673,M][380,M]
REF=[128,M][127,M]
SBR=[1138,M][1069][127][93][1336][1143][1073][584][1032],@....###.,@@..@###.,@@@...###,@@...###.
SE=[96,M][329,M]
ST=[143,M][329,M][1705,M]
SV1=[C003][782][355][380][1331][1365][C004][782][1073][1340][1073][1073][1364][1341][1327][1334][127][116][782][1337][1360]+P0304,@*1@@@.#@*1#.#..##.######
SV5=[C003][355][380][782][782][594][923],@*2@@@@@#
SVD=[67][782][C003][234][380][554],@@@*3#@.
SEGMENT SELF RULES
NM1~2~[EQ]1~4~0
NM1~2~[EQ]2~2~4,5
PWK~2~[EQ]BM,EL,EM,FX,FT~5,6~0
COMPOSITE ELEMENT SELF RULES
C024~1~[EQ]AA~4~0
C024~2~[EQ]AA~4~0
CODELISTS
States=[States.txt*,]
POSCodes=[POSCodes.txt*,]
ZipCodes=[ZipCodes.txt*,]
ClaimAdjustmentReasonCode=[ClaimAdjustmentReasonCode.txt*~]
FORMATS
EIN=^\d{9}$
EIN2=^\d{2}-\d{7}$
SOCIALSECURITY1=^\d{9}$
SOCIALSECURITY2=^\d{3}-\d{2}-\d{4}$
ZipCode=^\d{5}([\-]\d{4})?$
MilitaryTimeFormat=^([0-1][0-9]|[2][0-3])([0-5][0-9])$
DateYYMMDD=^((\d{2}((0[13578]|1[02])(0[1-9]|[12]\d|3[01])|(0[13456789]|1[012])(0[1-9]|[12]\d|30)|02(0[1-9]|1\d|2[0-8])))|([02468][048]|[13579][26])0229)$
DateCCYYMMDD=^(((\d{4}((0[13578]|1[02])(0[1-9]|[12]\d|3[01])|(0[13456789]|1[012])(0[1-9]|[12]\d|30)|02(0[1-9]|1\d|2[0-8])))|((\d{2}[02468][048]|\d{2}[13579][26]))0229)){0,8}$
EDI FILE STRUCTURE
{INTERCHANGE HEADER:1[ISA,M]{FUNCTIONAL GROUP:>1[GS,M]{ST HEADER:>1[ST,M][BHT,M]{1000A:1[NM1*1,M][PER*2,M,2]}{1000B:1[NM1*2,M]}{2000A:>1[HL*1,M][PRV*1][CUR]{2010AA:1[NM1*4,M][N3,M][N4*2,M][REF,M][REF,O,2][PER*2,O,2]}{2010AB:1[NM1*11][N3,M][N4*2,M]}{2010AC:1[NM1*2][N3,M][N4*2,M][REF][REF]}{2000B:>1[HL*2,M][SBR*1,M][PAT*1,X]{2010BA:1[NM1*4,M][N3][N4*2][DMG*3][REF][REF][PER*3]}{2010BB:1[NM1*2,M][N3][N4*2][REF,O,3][REF,O,2]}{2300:100[CLM*1,X][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][PWK*1,O,10][CN1][AMT*1][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][K3,O,10][NTE*1][CR1*2][CR2*1][CRC*1,O,3][CRC*1,O,3][CRC*2][CRC*3][HI*1,M][HI*2][HI*1,O,2][HCP*1]{2310A:2[NM1*4][REF,O,3]}{2310B:1[NM1*4][PRV*1][REF,O,4]}{2310C:1[NM1*12][N3,M][N4*2,M][REF,O,3][PER*3]}{2310D:1[NM1*4][REF,O,4]}{2310E:1[NM1*11][N3,M][N4*2,M]}{2310F:1[NM1*13][N3,M][N4*2,M]}{2320:10[SBR*4][CAS*1,O,5][AMT*1][AMT*1][AMT*1][OI*1,M][MOA]{2330A:1[NM1*3,M][N3][N4*2][REF]}{2330B:1[NM1*2,M][N3][N4*2][DTP][REF,O,2][REF][REF][REF][REF]}{2330C:2[NM1*11][REF,M,3]}{2330D:1[NM1*11][REF,M,3]}{2330E:1[NM1*11][REF,M,3]}{2330F:1[NM1*11][REF,M,3]}{2330G:1[NM1*11][REF,M,2]}}{2400:50[LX*1,M][SV1*1,M][SV5*1][PWK*1,O,10][PWK*2][CR1*2][CR3*1][CRC*1,O,3][CRC*2][CRC*4][DTP,M][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][DTP][QTY][QTY][MEA,O,5][CN1*1][REF][REF][REF,O,5][REF][REF][REF][REF][REF][REF,O,5][AMT*1][AMT*1][K3,O,10][NTE*1][NTE][PS1*1][HCP*2]{2410:1[LIN*1][CTP*1][REF]}{2420A:1[NM1*4][PRV*1][REF,O,20]}{2420B:1[NM1*9][REF,O,20]}{2420C:1[NM1*12][N3,M][N4*2,M][REF,O,3]}{2420D:1[NM1*4][REF,O,20]}{2420E:1[NM1*4][N3][N4*2][REF,O,20][PER*2]}{2420F:2[NM1*4][REF,O,20]}{2420G:1[NM1*11][N3,M][N4*2,M]}{2420H:1[NM1*13][N3,M][N4*2,M]}{2430:15[SVD*1][CAS*1,O,5][DTP,M][AMT]}{2440:>1[LQ*1][FRM*1,O,99]}}}{2000C:>1[HL*2,X][PAT*2,M]{2010CA:1[NM1*5,M][N3,M][N4*2,M][DMG*3,M][REF][REF][PER*3]}{2300:100[CLM*1,X][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][PWK*1,O,10][CN1][AMT*1][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][K3,O,10][NTE*1][CR1*2][CR2*1][CRC*1,O,3][CRC*1,O,3][CRC*2][CRC*3][HI*1,M][HI*2][HI*1,O,2][HCP*1]{2310A:2[NM1*4][REF,O,3]}{2310B:1[NM1*4][PRV*1][REF,O,4]}{2310C:1[NM1*12][N3,M][N4*2,M][REF,O,3][PER*3]}{2310D:1[NM1*4][REF,O,4]}{2310E:1[NM1*11][N3,M][N4*2,M]}{2310F:1[NM1*13][N3,M][N4*2,M]}{2320:10[SBR*4][CAS*1,O,5][AMT*1][AMT*1][AMT*1][OI*1,M][MOA]{2330A:1[NM1*3,M][N3][N4*2][REF]}{2330B:1[NM1*2,M][N3][N4*2][DTP][REF,O,2][REF][REF][REF][REF]}{2330C:2[NM1*11][REF,M,3]}{2330D:1[NM1*11][REF,M,3]}{2330E:1[NM1*11][REF,M,3]}{2330F:1[NM1*11][REF,M,3]}{2330G:1[NM1*11][REF,M,2]}}{2400:50[LX*1,M][SV1*1,M][SV5*1][PWK,O,10][PWK*2][CR1*2][CR3*1][CRC*1,O,3][CRC*2][CRC*4,O,2][DTP,M][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][DTP][QTY][QTY][MEA,O,5][CN1*1][REF][REF][REF,O,5][REF][REF][REF][REF][REF][REF,O,5][AMT*1][AMT*1][K3,O,10][NTE*1][NTE][PS1*1][HCP*2]{2410:1[LIN*1][CTP*1][REF]}{2420A:1[NM1*4][PRV*1][REF,O,20]}{2420B:1[NM1*9][REF,O,20]}{2420C:1[NM1*12][N3,M][N4*2,M][REF,O,3]}{2420D:1[NM1*4][REF,O,20]}{2420E:1[NM1*4][N3][N4*2][REF,O,20][PER*2]}{2420F:2[NM1*4][REF,O,20]}{2420G:1[NM1*11][N3,M][N4*2,M]}{2420H:1[NM1*13][N3,M][N4*2,M]}{2430:15[SVD*1][CAS*1,O,5][DTP,M][AMT]}{2440:>1[LQ*1][FRM*1,O,99]}}}}}}{END ST HEADER LOOP:1[+SE,M]}}{END GS LOOP:1[+GE,M]}}{END ISA LOOP:1[+IEA,M]}}
ELEMENT CODES
101=1:1,00,03
103=1:3,00,01
105=1:5,01,14,20,27,28,29,30,33,ZZ*1:7,01,14,20,27,28,29,30,33,ZZ
111=1:12,00501
113=1:14,0,1
114=1:15,P,T
479=2:1,HC
455=2:7,X
480=2:8,005010X222A1
143=3:1,837
1705=3:3,005010X222A1
1005=4:1,0019
353=4:2,00,18
640=4:6,31,CH,RP
98=5:1,41*7:1,40*10:1,85*11:1,85*17:1,87*20:1,PE*28:1,IL*35:1,PR*86:1,DN,P3*88:1,82*91:1,77*96:1,DQ*98:1,PW*101:1,45*111:1,IL*115:1,PR*124:1,DN,P3*126:1,82*128:1,77*130:1,DQ*132:1,85*177:1,82*180:1,QB*182:1,77*186:1,DQ*188:1,DK*193:1,DN,P3*195:1,PW*198:1,45*209:1,QC*262:1,DN,P3*264:1,82*267:1,77*272:1,DQ*274:1,PW*277:1,45*287:1,IL*291:1,PR*300:1,DN,P3*302:1,82*304:1,77*306:1,DQ*308:1,85*353:1,82*356:1,QB*358:1,77*362:1,DQ*364:1,DK*369:1,DN,P3*371:1,PW*374:1,45
1065=5:2,1,2*7:2,2*11:2,1,2*17:2,1,2*20:2,2*28:2,1,2*35:2,2*86:2,1*88:2,1,2*91:2,2*96:2,1*98:2,2*101:2,2*111:2,1,2*115:2,2*124:2,1*126:2,1,2*128:2,2*130:2,1*132:2,1,2*177:2,1,2*180:2,1,2*182:2,2*186:2,1*188:2,1*193:2,1*195:2,2*198:2,2*209:2,1*262:2,1*264:2,1,2*267:2,2*272:2,1*274:2,2*277:2,2*287:2,1,2*291:2,2*300:2,1*302:2,1,2*304:2,2*306:2,1*308:2,1,2*353:2,1,2*356:2,1,2*358:2,2*362:2,1*364:2,1*369:2,1*371:2,2*374:2,2
66=5:8,46*7:8,46*11:8,XX*20:8,PI,XV*28:8,II,MI*35:8,PI,XV*86:8,XX*88:8,XX*91:8,XX*96:8,XX*111:8,II,MI*115:8,PI,XV*177:8,XX*180:8,XX*182:8,XX*186:8,XX*188:8,XX*193:8,XX*233:5,AC*262:8,XX*264:8,XX*267:8,XX*272:8,XX*287:8,II,MI*291:8,PI,XV*353:8,XX*356:8,XX*358:8,XX*362:8,XX*364:8,XX*369:8,XX
366=6:1,IC*16:1,IC*34:1,IC*95:1,IC*192:1,IC*215:1,IC*271:1,IC*368:1,IC
365=6:3,EM,FX,TE*6:5,EM,EX,FX,TE*6:7,EM,EX,FX,TE*16:3,EM,FX,TE*16:5,EM,EX,FX,TE*16:7,EM,EX,FX,TE*34:3,TE*34:5,EX*95:3,TE*95:5,EX*192:3,EM,FX,TE*192:5,EM,EX,FX,TE*192:7,EM,EX,FX,TE*215:3,TE*215:5,EX*271:3,TE*271:5,EX*368:3,EM,FX,TE*368:5,EM,EX,FX,TE*368:7,EM,EX,FX,TE
735=8:3,20*25:3,22*207:3,23
736=8:4,1*25:4,0,1*207:4,0
1221=9:1,BI*89:1,PE*178:1,PE*265:1,PE*354:1,PE
128=9:2,PXC*14:1,EI,SY*15:1,0B,1G*23:1,2U,FY,NF*24:1,EI*32:1,SY*33:1,Y4*38:1,2U,EI,FY,NF*39:1,G2,LU*60:1,4N*61:1,F5*62:1,EW*63:1,9F*64:1,G1*65:1,F8*66:1,X4*67:1,9A*68:1,9C*69:1,LX*70:1,D9*71:1,EA*72:1,P4*73:1,1J*87:1,0B,1G,G2*89:2,PXC*90:1,0B,1G,G2,LU*94:1,0B,G2,LU*97:1,0B,1G,G2,LU*114:1,SY*119:1,2U,EI,FY,NF*120:1,G1*121:1,9F*122:1,T4*123:1,F8*125:1,0B,1G,G2*127:1,0B,IG,G2,LU*129:1,0B,G2,LU*131:1,0B,1G,G2,LU*133:1,G2,LU*158:1,9B*159:1,9D*160:1,G1*161:1,6R*162:1,EW*163:1,X4*164:1,F4*165:1,BT*166:1,9F*176:1,VY,XZ*178:2,PXC*179:1,0B,1G,G2,LU*181:1,0B,1G,G2*185:1,G2,LU*187:1,0B,1G,G2,LU*191:1,0B,1G,G2*194:1,0B,1G,G2*213:1,Y4*214:1,1W,SY*236:1,4N*237:1,F5*238:1,EW*239:1,9F*240:1,G1*241:1,F8*242:1,X4*243:1,9A*244:1,9C*245:1,LX*246:1,D9*247:1,EA*248:1,P4*249:1,1J*263:1,0B,1G,G2*265:2,PXC*266:1,0B,1G*270:1,0B,1A,1B,1C,1D,1G,1H,G2,LU,N5,TJ,X4,X5*273:1,0B,1G,G2,LU*290:1,SY*295:1,2U,EI,FY,NF*296:1,G1*297:1,9F*298:1,T4*299:1,F8*301:1,0B,1G,G2*303:1,0B,IG,G2,LU*305:1,0B,G2,LU*307:1,0B,1G,G2,LU*309:1,G2,LU*334:1,9B*335:1,9D*336:1,G1*337:1,6R*338:1,EW*339:1,X4*340:1,F4*341:1,BT*342:1,9F*352:1,VY,XZ*354:2,PXC*355:1,0B,1G,G2,LU*357:1,0B,1G,G2*361:1,G2,LU*363:1,0B,1G,G2,LU*367:1,0B,1G,G2*370:1,0B,1G,G2
156=13:2,[States]*19:2,[States]*30:2,[States]*37:2,[States]*40:11:4,[States]*93:2,[States]*113:2,[States]*184:2,[States]*190:2,[States]*211:2,[States]*216:11:4,[States]*269:2,[States]*289:2,[States]*360:2,[States]*366:2,[States]
1138=26:1,A,B,C,D,E,F,G,H,P,S,T,U*104:1,A,B,C,D,E,F,G,H,P,S,T,U*280:1,A,B,C,D,E,F,G,H,P,S,T,U
1069=26:2,18*104:2,01,18,19,20,21,39,40,53,G8*208:1,01,19,20,21,39,40,53,G8*280:2,01,18,19,20,21,39,40,53,G8
1336=26:5,12,13,14,15,16,41,42,43,47*104:5,12,13,14,15,16,41,42,43,47*280:5,12,13,14,15,16,41,42,43,47
1032=26:9,11,12,13,14,15,16,17,AM,BL,CH,CI,DS,FI,HM,LM,MA,MB,MC,OF,TV,VA,WC,ZZ*104:9,11,12,13,14,15,16,17,AM,BL,CH,CI,DS,FI,HM,LM,MA,MB,MC,OF,TV,VA,WC,ZZ*280:9,11,12,13,14,15,16,17,AM,BL,CH,CI,DS,FI,HM,LM,MA,MB,MC,OF,TV,VA,WC,ZZ
1250=27:5,D8*31:1,D8*41:2,D8*42:2,D8*43:2,D8*44:2,D8*45:2,D8*46:2,D8*47:2,D8*48:2,D8*49:2,D8,RD8*50:2,D8*51:2,D8*52:2,D8*53:2,D8*54:2,D8*55:2,D8*56:2,D8*118:2,D8*144:2,D8,RD8*145:2,D8*146:2,D8*147:2,D8*148:2,D8*149:2,D8*150:2,D8*151:2,D8*152:2,D8*153:2,D8*203:2,D8*208:5,D8*212:1,D8*217:2,D8*218:2,D8*219:2,D8*220:2,D8*221:2,D8*222:2,D8*223:2,D8*224:2,D8*225:2,D8,RD8*226:2,D8*227:2,D8*228:2,D8*229:2,D8*230:2,D8*231:2,D8*232:2,D8*294:2,D8*320:2,D8,RD8*321:2,D8*322:2,D8*323:2,D8*324:2,D8*325:2,D8*326:2,D8*327:2,D8*328:2,D8*329:2,D8*379:2,D8
355=27:7,01*76:1,LB*76:5,DH*135:3,MJ,UN*136:2,DA*139:1,LB*139:5,DH*140:2,MO*173:11,MJ,UN*175:5:1,F2,GR,ME,ML,UN*208:7,01*252:1,LB*252:5,DH*311:3,MJ,UN*312:2,DA*315:1,LB*315:5,DH*316:2,MO*349:11,MJ,UN*351:5:1,F2,GR,ME,ML,UN
1073=27:9,Y*40:6,N,Y*40:8,N,W,Y*77:12,N,Y*78:2,N,Y*79:2,N,Y*80:2,Y*81:2,N,Y*109:3,N,W,Y*135:9,Y*135:11,Y*135:12,Y*141:2,N,Y*142:2,N,Y*143:2,N,Y*206:2,N,W,Y*208:9,Y*216:6,N,Y*216:8,N,W,Y*253:12,N,Y*254:2,N,Y*255:2,N,Y*256:2,Y*257:2,N,Y*285:3,N,W,Y*311:9,Y*311:11,Y*311:12,Y*317:2,N,Y*318:2,N,Y*319:2,N,Y*382:2,N,W,Y
1068=31:3,F,M,U*212:3,F,M,U
1331=40:5:1,[POSCodes]*135:5,[POSCodes]*216:5:1,[POSCodes]*311:5,[POSCodes]
1332=40:5:2,B*140:1,I,R,S*216:5:2,B*316:1,I,R,S
1359=40:7,A,B,C*216:7,A,B,C
1363=40:9,I,Y*109:6,I,Y*216:9,I,Y*285:6,I,Y
1351=40:10,P*109:4,P*216:10,P*285:4,P
1362=40:11:1,AA,EM,OA*40:11:2,AA,EM,OA*216:11:1,AA,EM,OA*216:11:2,AA,EM,OA
1366=40:12,02,03,05,09*216:12,02,03,05,09
1514=40:20,1,2,3,4,5,6,7,8,9,10,11,15*216:20,1,2,3,4,5,6,7,8,9,10,11,15
374=41:1,431*42:1,454*43:1,304*44:1,453*45:1,439*46:1,484*47:1,455*48:1,471*49:1,314,360,361*50:1,297*51:1,296*52:1,435*53:1,096*54:1,090,091*55:1,444*56:1,050*118:1,573*144:1,472*145:1,471*146:1,607*147:1,463*148:1,461*149:1,304*150:1,738,739*151:1,011*152:1,455*153:1,454*203:1,573*217:1,431*218:1,454*219:1,304*220:1,453*221:1,439*222:1,484*223:1,455*224:1,471*225:1,314,360,361*226:1,297*227:1,296*228:1,435*229:1,096*230:1,090,091*231:1,444*232:1,050*294:1,573*320:1,472*321:1,471*322:1,607*323:1,463*324:1,461*325:1,304*326:1,738,739*327:1,011*328:1,455*329:1,454*379:1,573
755=57:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,R,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP*137:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,IR,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP*138:1,CT*233:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,R,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP*313:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,IR,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP*314:1,CT
756=57:2,AA,BM,EL,EM,FT,FX*137:2,AA,BM,EL,FT*138:2,AB,AD,AF,AG,NS*233:2,AA,BM,EL,EM,FT,FX*314:2,AB,AD,AF,AG,NS
1166=58:1,01,02,03,04,05,06,09*157:1,01,02,03,04,05,06,09*234:1,01,02,03,04,05,06,09*333:1,01,02,03,04,05,06,09
522=59:1,F5*106:1,D*107:1,A8*108:1,EAF*167:1,T*168:1,F4*204:1,EAF*235:1,F5*282:1,D*283:1,A8*284:1,EAF*343:1,T*344:1,F4*380:1,EAF
127=60:2,1,2,3,4,5,6,7*61:2,Y,N*122:2,Y*236:2,1,2,3,4,5,6,7*237:2,Y,N*298:2,Y
363=75:1,ADD,CER,DCP,DGN,TPO*170:1,ADD,DCP*171:1,TPO*251:1,ADD,CER,DCP,DGN,TPO*346:1,ADD,DCP*347:1,TPO
1317=76:4,A,B,C,D,E*139:4,A,B,C,D,E*252:4,A,B,C,D,E*315:4,A,B,C,D,E
1342=77:8,A,C,D,E,F,G,M*253:8,A,C,D,E,F,G,M
1136=78:1,07*79:1,E1,E2,E3*80:1,75*81:1,ZZ*141:1,07*142:1,70*143:1,09*254:1,07*255:1,E1,E2,E3*256:1,75*257:1,ZZ*317:1,07*318:1,70*319:1,09
1321=78:3,01,04,05,06,07,08,09,12*78:4,01,04,05,06,07,08,09,12*78:5,01,04,05,06,07,08,09,12*78:6,01,04,05,06,07,08,09,12*78:7,01,04,05,06,07,08,09,12*79:3,L1,L2,L3,L4,L5*79:4,L1,L2,L3,L4,L5*79:5,L1,L2,L3,L4,L5*79:6,L1,L2,L3,L4,L5*79:7,L1,L2,L3,L4,L5*80:3,IH*81:3,AV,NU,S2,ST*81:4,AV,NU,S2,ST*81:5,AV,NU,S2,ST*141:3,01,04,05,06,07,08,09,12*141:4,01,04,05,06,07,08,09,12*141:5,01,04,05,06,07,08,09,12*141:6,01,04,05,06,07,08,09,12*141:7,01,04,05,06,07,08,09,12*142:3,65*143:3,38,ZV*143:4,38,ZV*254:3,01,04,05,06,07,08,09,12*254:4,01,04,05,06,07,08,09,12*254:5,01,04,05,06,07,08,09,12*254:6,01,04,05,06,07,08,09,12*254:7,01,04,05,06,07,08,09,12*255:3,L1,L2,L3,L4,L5*255:4,L1,L2,L3,L4,L5*255:5,L1,L2,L3,L4,L5*255:6,L1,L2,L3,L4,L5*255:7,L1,L2,L3,L4,L5*256:3,IH*257:3,AV,NU,S2,ST*257:4,AV,NU,S2,ST*257:5,AV,NU,S2,ST*317:3,01,04,05,06,07,08,09,60*317:4,01,04,05,06,07,08,09,60*317:5,01,04,05,06,07,08,09,60*317:6,01,04,05,06,07,08,09,60*317:7,01,04,05,06,07,08,09,60*318:3,65*319:3,ZV*319:4,ZV
1270=82:1:1,ABK,BK*82:2:1,ABF,BF*82:3:1,ABF,BF*82:4:1,ABF,BF*82:5:1,ABF,BF*82:6:1,ABF,BF*82:7:1,ABF,BF*82:8:1,ABF,BF*82:9:1,ABF,BF*82:10:1,ABF,BF*82:11:1,ABF,BF*82:12:1,ABF,BF*83:1:1,BP*83:2:1,BO*84:1:1,BG*84:2:1,BG*84:3:1,BG*84:4:1,BG*84:5:1,BG*84:6:1,BG*84:7:1,BG*84:8:1,BG*84:9:1,BG*84:10:1,BG*84:11:1,BG*84:12:1,BG*205:1,AS,UT*258:1:1,ABK,BK*258:2:1,ABF,BF*258:3:1,ABF,BF*258:4:1,ABF,BF*258:5:1,ABF,BF*258:6:1,ABF,BF*258:7:1,ABF,BF*258:8:1,ABF,BF*258:9:1,ABF,BF*258:10:1,ABF,BF*258:11:1,ABF,BF*258:12:1,ABF,BF*259:1:1,BP*259:2:1,BO*260:1:1,BG*260:2:1,BG*260:3:1,BG*260:4:1,BG*260:5:1,BG*260:6:1,BG*260:7:1,BG*260:8:1,BG*260:9:1,BG*260:10:1,BG*260:11:1,BG*260:12:1,BG*381:1,AS,UT
1473=85:1,00,01,02,03,04,05,07,08,09,10,11,12,13,14*173:1,00,01,02,03,04,05,06,07,08,09,10,11,12,13,14*261:1,00,01,02,03,04,05,07,08,09,10,11,12,13,14*349:1,00,01,02,03,04,05,06,07,08,09,10,11,12,13,14
901=85:13,T1,T2,T3,T4,T5,T6*173:13,T1,T2,T3,T4,T5,T6*261:13,T1,T2,T3,T4,T5,T6*349:13,T1,T2,T3,T4,T5,T6
1526=85:14,1,2,3,4,5*173:14,1,2,3,4,5*261:14,1,2,3,4,5*349:14,1,2,3,4,5
1527=85:15,1,2,3,4,5,6*173:15,1,2,3,4,5,6*261:15,1,2,3,4,5,6*349:15,1,2,3,4,5,6
1033=105:1,CO,CR,OA,PI,PR*202:1,CO,CR,OA,PI,PR*281:1,CO,CR,OA,PI,PR*378:1,CO,CR,OA,PI,PR
235=135:1:1,ER,HC,IV,WK*136:1:1,HC*173:9,ER,HC,IV,WK*174:2,N4,EN,EO,HI,ON,UK,UP*201:3:1,ER,HC,IV,WK*311:1:1,ER,HC,IV,WK*312:1:1,HC*349:9,ER,HC,IV,WK*350:2,N4,EN,EO,HI,ON,UK,UP*377:3:1,ER,HC,IV,WK
1327=135:15,0*311:15,0
594=136:6,1,4,6*312:6,1,4,6
673=154:1,PT*155:1,FL*330:1,PT*331:1,FL
737=156:1,OG,TR*332:1,OG,TR
738=156:2,HT,R1,R2,R3,R4*332:2,HT,R1,R2,R3,R4
ELEMENT FORMATS
108=1:9,0,0,DateYYMMDD
373=2:4,0,0,DateCCYYMMDD
1251=31:2,0,,DateCCYYMMDD*41:3,0,,DateCCYYMMDD*42:3,0,,DateCCYYMMDD*43:3,0,,DateCCYYMMDD*44:3,0,,DateCCYYMMDD*45:3,0,,DateCCYYMMDD*46:3,0,,DateCCYYMMDD*47:3,0,,DateCCYYMMDD*48:3,0,,DateCCYYMMDD*49:3,0,,DateCCYYMMDD*50:3,0,,DateCCYYMMDD*51:3,0,,DateCCYYMMDD*52:3,0,,DateCCYYMMDD*53:3,0,,DateCCYYMMDD*54:3,0,,DateCCYYMMDD*55:3,0,,DateCCYYMMDD*56:3,0,,DateCCYYMMDD*217:3,0,,DateCCYYMMDD*218:3,0,,DateCCYYMMDD*219:3,0,,DateCCYYMMDD*220:3,0,,DateCCYYMMDD*221:3,0,,DateCCYYMMDD*222:3,0,,DateCCYYMMDD*223:3,0,,DateCCYYMMDD*224:3,0,,DateCCYYMMDD*225:3,0,,DateCCYYMMDD*226:3,0,,DateCCYYMMDD*227:3,0,,DateCCYYMMDD*228:3,0,,DateCCYYMMDD*229:3,0,,DateCCYYMMDD*230:3,0,,DateCCYYMMDD*231:3,0,,DateCCYYMMDD*232:3,0,,DateCCYYMMDD
SUMMARY
40:2=135:2
220:2=319:2
ELEMENT EQUALITY
1:13=385:2
2:6=384:2
3:2=383:2
RULES
27=26:2'EQ'18!USAGE!0!1
31=26:2'EQ'18!USAGE!2!0
40=26:2'EQ'18!USAGE!2!1
104=26:1'EQ'S!USAGE!2!0
146=140:1'EQ'R,S!USAGE!2!0
207=26:2'NE'18!USAGE!2!1
321=315:1'EQ'R,S!USAGE!2!0
+SegPos[135:5] = if (SegPos[135:5] == SegPos[40:5:1]) then Error[ElementHasWrongValue,"SV105 must be different from 2300 CLM05-01"] end
ELEMENT COUNTERS
554=134:1
554=309:1
ELEMENT CODE DESCRIPTION
LOOP DESCRIPTIONS
INTERCHANGE HEADER=Beginning of the EDI Interchange
FUNCTIONAL GROUP=Beginning of Functional Group
ST HEADER=Header Loop
1000A=SUBMITTER NAME
1000B=RECEIVER NAME
2000A=BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL
2010AA=BILLING PROVIDER NAME
2010AB=PAY-TO ADDRESS NAME
2010AC=PAY-TO PLAN NAME
2000B=SUBSCRIBER HIERARCHICAL LEVEL
2010BA=SUBSCRIBER NAME
2010BB=PAYER NAME
2300=CLAIM INFORMATION
2310A=REFERRING PROVIDER NAME
2310B=RENDERING PROVIDER NAME
2310C=SERVICE FACILITY LOCATION
2310D=SUPERVISING PROVIDER NAME
2310E=AMBULANCE PICK-UP LOCATION
2310F=AMBULANCE DROP-OFF LOCATION
2320=OTHER SUBSCRIBER INFORMATION
2330A=OTHER SUBSCRIBER NAME
2330B=OTHER PAYER NAME
2330C=OTHER PAYER REFERRING PROVIDER
2330D=OTHER PAYER RENDERING PROVIDER
2330E=OTHER PAYER SERVICE FACILITY LOCATION
2330F=OTHER PAYER SUPERVISING PROVIDER
2330G=OTHER PAYER BILLING PROVIDER
2400=SERVICE LINE
2410=DRUG IDENTIFICATION
2420A=RENDERING PROVIDER NAME
2420B=PURCHASED SERVICE PROVIDER NAME
2420C=SERVICE FACILITY LOCATION
2420D=SUPERVISING PROVIDER NAME
2420E=ORDERING PROVIDER NAME
2420F=REFERRING PROVIDER NAME
2420G=AMBULANCE PICK-UP LOCATION
2420H=AMBULANCE DROP-OFF LOCATION
2430=LINE ADJUDICATION INFORMATION
2440=FORM IDENTIFICATION CODE
2000C=PATIENT HIERARCHICAL LEVEL
2010CA=PATIENT NAME
2300=CLAIM INFORMATION
2310A=REFERRING PROVIDER NAME
2310B=RENDERING PROVIDER NAME
2310C=SERVICE FACILITY LOCATION
2310D=SUPERVISING PROVIDER NAME
2310E=AMBULANCE PICK-UP LOCATION
2310F=AMBULANCE DROP-OFF LOCATION
2320=OTHER SUBSCRIBER INFORMATION
2330A=OTHER SUBSCRIBER NAME
2330B=OTHER PAYER NAME
2330C=OTHER PAYER REFERRING PROVIDER
2330D=OTHER PAYER RENDERING PROVIDER
2330E=OTHER PAYER SERVICE FACILITY LOCATION
2330F=OTHER PAYER SUPERVISING PROVIDER
2330G=OTHER PAYER BILLING PROVIDER
2400=SERVICE LINE
2410=DRUG IDENTIFICATION
2420A=RENDERING PROVIDER NAME
2420B=PURCHASED SERVICE PROVIDER NAME
2420C=SERVICE FACILITY LOCATION
2420D=SUPERVISING PROVIDER NAME
2420E=ORDERING PROVIDER NAME
2420F=REFERRING PROVIDER NAME
2420G=AMBULANCE PICK-UP LOCATION
2420H=AMBULANCE DROP-OFF LOCATION
2430=LINE ADJUDICATION INFORMATION
2440=FORM IDENTIFICATION CODE
END ST HEADER LOOP=END OF THE ST HEADER
END GS LOOP=END OF FUNCTIONAL GROUP
END ISA LOOP=END OF TRANSACTION
SEGMENT DESCRIPTIONS
ISA=1,Interchange Control Header
GS=2,Functional Group Header
ST=3,Transaction Set Header
BHT=4,Beginning of Hierarchical Transaction
NM1=5,Submitter Name
PER=6,Submitter EDI Contact Information
NM1=7,Receiver Name
HL=8,Billing/Pay-to Provider Hierarchical Level
PRV=9,Billing/Pay-to Provider Specialty Information
CUR=10,Foreign Currency Information
NM1=11,Billing Provider Name
N3=12,Billing Provider Address
N4=13,Billing Provider City/State/ZIP Code
REF=14,Billing Provider Tax Identification
REF=15,Billing Provider UPIN/License Information
PER=16,Billing Provider Contact Information
NM1=17,Pay-to Provider Name
N3=18,Pay-to Provider Address
N4=19,Pay-to Provider City/State/ZIP Code
NM1=20,Pay-To Plan Name
N3=21,Pay-to Plan Address
N4=22,Pay-To Plan City
REF=23,Pay-to Plan Secondary Identification
REF=24,Pay-To Plan Tax Identification Number
HL=25,Subscriber Hierarchical Level
SBR=26,Subscriber Information
PAT=27,Patient Information
NM1=28,Subscriber Name
N3=29,Subscriber Address
N4=30,Subscriber City/State/ZIP Code
DMG=31,Subscriber Demographic Information
REF=32,Subscriber Secondary Identification
REF=33,Property and Casualty Claim Number
PER=34,Property and Casualty Subscriber Contact Information
NM1=35,Payer Name
N3=36,Payer Address
N4=37,Payer City/State/ZIP Code
REF=38,Payer Secondary Identification
REF=39,Billing Provider Secondary Identification
CLM=40,Claim Information
DTP=41,Onset of Current Illness or Symptom
DTP=42,Initial Treatment
DTP=43,Date Last Seen
DTP=44,Acute Manifestation
DTP=45,Accident Date
DTP=46,Last Menstrual Period
DTP=47,Last X-ray
DTP=48,Hearing and Vision Prescription Date
DTP=49,Disability Dates
DTP=50,Last Worked
DTP=51,Authorized Return to Work
DTP=52,Admission
DTP=53,Discharge
DTP=54,Assumed and Relinquished Care Dates
DTP=55,Property and Casualty Date of First Contact
DTP=56,Repricer Received Date
PWK=57,Claim Supplemental Information
CN1=58,Contract Information
AMT=59,Patient Amount Paid
REF=60,Service Authorization Exception Code
REF=61,Mandatory Medicare (Section 4081) Crossover Indicator
REF=62,Mammography Certification Number
REF=63, Referral Number
REF=64,Prior Authorization
REF=65,Payer Claim Control Number
REF=66,Clinical Laboratory Improvement Amendment (CLIA) Number
REF=67,Repriced Claim Number
REF=68,Adjusted Repriced Claim Number
REF=69,Investigational Device Exemption Number
REF=70,Claim Identification Number for Clearing Houses and Other Transmission Intermediaries
REF=71,Medical Record Number
REF=72,Demonstration Project Identifier
REF=73,Care Plan Oversight
K3=74,File Information
NTE=75,Claim Note
CR1=76,Ambulance Transport Information
CR2=77,Spinal Manipulation Service Information
CRC=78,Ambulance Certification
CRC=79,Patient Condition Information: Vision
CRC=80,Homebound Indicator
CRC=81,EPSDT Referral
HI=82,Health Care Diagnosis Code
HI=83,Anesthesia Related Procedure
HI=84,Condition Information
HCP=85,Claim Pricing/Repricing Information
NM1=86,Referring Provider Name
REF=87,Referring Provider Secondary Identification
NM1=88,Rendering Provider Name
PRV=89,Rendering Provider Specialty Information
REF=90,Rendering Provider Secondary Identification
NM1=91,Service Facility Location Name
N3=92,Service Facility Location Address
N4=93,Service Facility Location City/State/ZIP
REF=94,Service Facility Location Secondary Identification
PER=95,Service Facility Contact Information
NM1=96,Supervising Provider Name
REF=97,Supervising Provider Secondary Identification
NM1=98,AMBULANCE PICK-UP LOCATION
N3=99,Ambulance Pick-up Location Address
N4=100,Ambulance Pick-up Location City
NM1=101,AMBULANCE DROP-OFF LOCATION
N3=102,Ambulance Drop-off Location Address
N4=103,Ambulance Drop-off Location City
SBR=104,Other Subscriber Information
CAS=105,Claim Level Adjustments
AMT=106,Coordination of Benefits (COB) Payer Paid Amount
AMT=107,Coordination of Benefits (COB) Total Non-Covered
AMT=108,Remaining Patient Liability
OI=109,Other Insurance Coverage Information
MOA=110,Medicare Outpatient Adjudication Information
NM1=111,Other Subscriber Name
N3=112,Other Subscriber Address
N4=113,Other Subscriber City/State/ZIP Code
REF=114,Other Subscriber Secondary Identification
NM1=115,Other Payer Name
N3=116,Other Payer Address
N4=117,Other Payer City
DTP=118,Claim Check or Remittance Date
REF=119,Other Payer Secondary Identifier
REF=120,Other Payer Prior Authorization
REF=121,Other Payer Referral Number
REF=122,Other Payer Claim Adjustment Indicator
REF=123,Other Payer Claim Control Number
NM1=124,Other Payer Referring Provider
REF=125,Other Payer Referring Provider Identification
NM1=126,Other Payer Rendering Provider
REF=127,Other Payer Rendering Provider Secondary Identification
NM1=128,Other Payer Service Facility Location
REF=129,Other Payer Service Facility Location Identification
NM1=130,Other Payer Supervising Provider
REF=131,Other Payer Supervising Provider Identification
NM1=132,Other Payer Billing Provider
REF=133,Other Payer Billing Provider Secondary Identification
LX=134,Service Line
SV1=135,Professional Service
SV5=136,Durable Medical Equipment Service
PWK=137,Line Supplemental Information
PWK=138,DMERC CMN Indicator
CR1=139,Ambulance Transport Information
CR3=140,Durable Medical Equipment Certification
CRC=141,Ambulance Certification
CRC=142,Hospice Employee Indicator
CRC=143,Condition Indicator/Durable Medical Equipment
DTP=144,Date - Service Date
DTP=145,Prescription Date
DTP=146,Certification Revision/Recertification Date
DTP=147,Date - Begin Therapy Date
DTP=148,Date - Last Certification Date
DTP=149,Date - Date Last Seen
DTP=150,Date - Test
DTP=151,Date - Shipped
DTP=152,Date - Last X-ray
DTP=153,Date - Initial Treatment
QTY=154,Ambulance Patient Count
QTY=155,Obstetric Anesthesia Additional Units
MEA=156,Test Result
CN1=157,Contract Information
REF=158,Repriced Line Item Reference Number
REF=159,Adjusted Repriced Line Item Reference Number
REF=160,Prior Authorization
REF=161,Line Item Control Number
REF=162,Mammography Certification Number
REF=163,Clinical Laboratory Improvement Amendment (CLIA) Identification
REF=164,Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
REF=165,Immunization Batch Number
REF=166,Referral Number
AMT=167,Sales Tax Amount
AMT=168,Postage Claimed Amount
K3=169,File Information
NTE=170,Line Note
NTE=171,Third Party Organization Notes
PS1=172,Purchased Service Information
HCP=173,Line Pricing/Repricing Information
LIN=174,Drug Identification
CTP=175,Drug Pricing
REF=176,Prescription Number
NM1=177,Rendering Provider Name
PRV=178,Rendering Provider Specialty Information
REF=179,Rendering Provider Secondary Identification
NM1=180,Purchased Service Provider Name
REF=181,Purchased Service Provider Secondary Identification
NM1=182,Service Facility Location
N3=183,Service Facility Location Address
N4=184,Service Facility Location City/State/ZIP
REF=185,Service Facility Location Secondary Identification
NM1=186,Supervising Provider Name
REF=187,Supervising Provider Secondary Identification
NM1=188,Ordering Provider Name
N3=189,Ordering Provider Address
N4=190,Ordering Provider City/State/ZIP Code
REF=191,Ordering Provider Secondary Identification
PER=192,Ordering Provider Contact Information
NM1=193,Referring Provider Name
REF=194,Other Payer Prior Authorization or Referral Number
NM1=195,Ambulance Pick-up Location
N3=196,Ambulance Pick-up Location Address
N4=197,Ambulance Pick-up Location City
NM1=198,Ambulance Pick-up Location
N3=199,Ambulance Pick-up Location Address
N4=200,Ambulance Pick-up Location City
SVD=201,Line Adjudication Information
CAS=202,Line Adjustment
DTP=203,Line Check or Remittance Date
AMT=204,Remaining Patient Liability
LQ=205,Form Identification Code
FRM=206,Supporting Documentation
HL=207,Patient Hierarchical Level
PAT=208,Patient Information
NM1=209,Patient Name
N3=210,Patient Address
N4=211,Patient City/State/ZIP Code
DMG=212,Patient Demographic Information
REF=213,Property and Casualty Claim Number
REF=214,Property and Casualty Patient Identifier
PER=215,Property and Casualty Patient Contact Information
CLM=216,Claim Information
DTP=217,Onset of Current Illness or Symptom
DTP=218,Initial Treatment
DTP=219,Date Last Seen
DTP=220,Acute Manifestation
DTP=221,Accident Date
DTP=222,Last Menstrual Period
DTP=223,Last X-ray
DTP=224,Hearing and Vision Prescription Date
DTP=225,Disability Dates
DTP=226,Last Worked
DTP=227,Authorized Return to Work
DTP=228,Admission
DTP=229,Discharge
DTP=230,Assumed and Relinquished Care Dates
DTP=231,Property and Casualty Date of First Contact
DTP=232,Repricer Received Date
PWK=233,Claim Supplemental Information
CN1=234,Contract Information
AMT=235,Patient Amount Paid
REF=236,Service Authorization Exception Code
REF=237,Mandatory Medicare (Section 4081) Crossover Indicator
REF=238,Mammography Certification Number
REF=239, Referral Number
REF=240,Prior Authorization
REF=241,Payer Claim Control Number
REF=242,Clinical Laboratory Improvement Amendment (CLIA) Number
REF=243,Repriced Claim Number
REF=244,Adjusted Repriced Claim Number
REF=245,Investigational Device Exemption Number
REF=246,Claim Identification Number for Clearing Houses and Other Transmission Intermediaries
REF=247,Medical Record Number
REF=248,Demonstration Project Identifier
REF=249,Care Plan Oversight
K3=250,File Information
NTE=251,Claim Note
CR1=252,Ambulance Transport Information
CR2=253,Spinal Manipulation Service Information
CRC=254,Ambulance Certification
CRC=255,Patient Condition Information: Vision
CRC=256,Homebound Indicator
CRC=257,EPSDT Referral
HI=258,Health Care Diagnosis Code
HI=259,Anesthesia Related Procedure
HI=260,Condition Information
HCP=261,Claim Pricing/Repricing Information
NM1=262,Referring Provider Name
REF=263,Referring Provider Secondary Identification
NM1=264,Rendering Provider Name
PRV=265,Rendering Provider Specialty Information
REF=266,Rendering Provider Secondary Identification
NM1=267,Service Facility Location Name
N3=268,Service Facility Location Address
N4=269,Service Facility Location City/State/ZIP
REF=270,Service Facility Location Secondary Identification
PER=271,Service Facility Contact Information
NM1=272,Supervising Provider Name
REF=273,Supervising Provider Secondary Identification
NM1=274,AMBULANCE PICK-UP LOCATION
N3=275,Ambulance Pick-up Location Address
N4=276,Ambulance Pick-up Location City
NM1=277,AMBULANCE DROP-OFF LOCATION
N3=278,Ambulance Drop-off Location Address
N4=279,Ambulance Drop-off Location City
SBR=280,Other Subscriber Information
CAS=281,Claim Level Adjustments
AMT=282,Coordination of Benefits (COB) Payer Paid Amount
AMT=283,Coordination of Benefits (COB) Total Non-Covered
AMT=284,Remaining Patient Liability
OI=285,Other Insurance Coverage Information
MOA=286,Medicare Outpatient Adjudication Information
NM1=287,Other Subscriber Name
N3=288,Other Subscriber Address
N4=289,Other Subscriber City/State/ZIP Code
REF=290,Other Subscriber Secondary Identification
NM1=291,Other Payer Name
N3=292,Other Payer Address
N4=293,Other Payer City
DTP=294,Claim Check or Remittance Date
REF=295,Other Payer Secondary Identifier
REF=296,Other Payer Prior Authorization
REF=297,Other Payer Referral Number
REF=298,Other Payer Claim Adjustment Indicator
REF=299,Other Payer Claim Control Number
NM1=300,Other Payer Referring Provider
REF=301,Other Payer Referring Provider Identification
NM1=302,Other Payer Rendering Provider
REF=303,Other Payer Rendering Provider Secondary Identification
NM1=304,Other Payer Service Facility Location
REF=305,Other Payer Service Facility Location Identification
NM1=306,Other Payer Supervising Provider
REF=307,Other Payer Supervising Provider Identification
NM1=308,Other Payer Billing Provider
REF=309,Other Payer Billing Provider Secondary Identification
LX=310,Service Line
SV1=311,Professional Service
SV5=312,Durable Medical Equipment Service
PWK=313,Line Supplemental Information
PWK=314,DMERC CMN Indicator
CR1=315,Ambulance Transport Information
CR3=316,Durable Medical Equipment Certification
CRC=317,Ambulance Certification
CRC=318,Hospice Employee Indicator
CRC=319,Condition Indicator/Durable Medical Equipment
DTP=320,Date - Service Date
DTP=321,Prescription Date
DTP=322,Certification Revision/Recertification Date
DTP=323,Date - Begin Therapy Date
DTP=324,Date - Last Certification Date
DTP=325,Date - Date Last Seen
DTP=326,Date - Test
DTP=327,Date - Shipped
DTP=328,Date - Last X-ray
DTP=329,Date - Initial Treatment
QTY=330,Ambulance Patient Count
QTY=331,Obstetric Anesthesia Additional Units
MEA=332,Test Result
CN1=333,Contract Information
REF=334,Repriced Line Item Reference Number
REF=335,Adjusted Repriced Line Item Reference Number
REF=336,Prior Authorization
REF=337,Line Item Control Number
REF=338,Mammography Certification Number
REF=339,Clinical Laboratory Improvement Amendment (CLIA) Identification
REF=340,Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
REF=341,Immunization Batch Number
REF=342,Referral Number
AMT=343,Sales Tax Amount
AMT=344,Postage Claimed Amount
K3=345,File Information
NTE=346,Line Note
NTE=347,Third Party Organization Notes
PS1=348,Purchased Service Information
HCP=349,Line Pricing/Repricing Information
LIN=350,Drug Identification
CTP=351,Drug Pricing
REF=352,Prescription Number
NM1=353,Rendering Provider Name
PRV=354,Rendering Provider Specialty Information
REF=355,Rendering Provider Secondary Identification
NM1=356,Purchased Service Provider Name
REF=357,Purchased Service Provider Secondary Identification
NM1=358,Service Facility Location
N3=359,Service Facility Location Address
N4=360,Service Facility Location City/State/ZIP
REF=361,Service Facility Location Secondary Identification
NM1=362,Supervising Provider Name
REF=363,Supervising Provider Secondary Identification
NM1=364,Ordering Provider Name
N3=365,Ordering Provider Address
N4=366,Ordering Provider City/State/ZIP Code
REF=367,Ordering Provider Secondary Identification
PER=368,Ordering Provider Contact Information
NM1=369,Referring Provider Name
REF=370,Other Payer Prior Authorization or Referral Number
NM1=371,Ambulance Pick-up Location
N3=372,Ambulance Pick-up Location Address
N4=373,Ambulance Pick-up Location City
NM1=374,Ambulance Pick-up Location
N3=375,Ambulance Pick-up Location Address
N4=376,Ambulance Pick-up Location City
SVD=377,Line Adjudication Information
CAS=378,Line Adjustment
DTP=379,Line Check or Remittance Date
AMT=380,Remaining Patient Liability
LQ=381,Form Identification Code
FRM=382,Supporting Documentation
SE=383,Transaction Set Trailer
GE=384,Functional Group Trailer
IEA=385,Interchange Control Trailer