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