837 Health Care Claim:
Professional
HIPAA/V5010X222A1/837: 837 Health Care Claim: Professional
Status: Final
Company:
Publication:
Blue Cross of Northeastern PA
1/12/2012
3/3/2011
Health Care Claim : Professional - 837
Table of Contents
837
Health Care Claim : Professional ............................................................................................................ 1
ISA Interchange Control Header ............................................................................................................... 4
GS
Functional Group Header .................................................................................................................. 6
ST
Transaction Set Header .................................................................................................................... 7
BHT Beginning of Hierarchical Transaction .................................................................................................. 8
NM1 Submitter Name .............................................................................................................................. 9
PER Submitter EDI Contact Information ..................................................................................................... 10
NM1 Receiver Name .............................................................................................................................. 12
HL
Billing Provider Hierarchical Level ...................................................................................................... 13
PRV Billing Provider Specialty Information.................................................................................................. 14
NM1 Billing Provider Name ..................................................................................................................... 15
N3
Billing Provider Address .................................................................................................................. 17
N4
Billing Provider City, State, ZIP Code................................................................................................... 18
REF Billing Provider Tax Identification ....................................................................................................... 19
PER Billing Provider Contact Information ................................................................................................... 20
NM1 Pay-to Address Name ...................................................................................................................... 22
N3
Pay-To Address - ADDRESS ............................................................................................................. 23
N4
Pay-to Address City, State, ZIP Code ................................................................................................... 24
HL
Subscriber Hierarchical Level ............................................................................................................ 25
SBR Subscriber Information .................................................................................................................... 26
PAT Patient Information ......................................................................................................................... 28
NM1 Subscriber Name ........................................................................................................................... 29
N3
Subscriber Address ........................................................................................................................ 30
N4
Subscriber City, State, ZIP Code ........................................................................................................ 31
DMG Subscriber Demographic Information .................................................................................................. 32
NM1 Payer Name .................................................................................................................................. 33
N3
Payer Address............................................................................................................................... 34
N4
Payer City, State, ZIP Code ............................................................................................................... 35
HL
Patient Hierarchical Level ................................................................................................................. 36
PAT Patient Information ......................................................................................................................... 37
NM1 Patient Name ................................................................................................................................ 38
N3
Patient Address ............................................................................................................................. 39
N4
Patient City, State, ZIP Code ............................................................................................................. 40
DMG Patient Demographic Information ....................................................................................................... 41
CLM Claim Information........................................................................................................................... 42
PWK Claim Supplemental Information ........................................................................................................ 45
AMT Patient Amount Paid ....................................................................................................................... 47
REF Referral Number ............................................................................................................................ 48
REF Prior Authorization ......................................................................................................................... 49
REF Payer Claim Control Number ............................................................................................................. 50
NTE Claim Note ................................................................................................................................... 51
CR1 Ambulance Transport Information ...................................................................................................... 52
HI
Health Care Diagnosis Code ............................................................................................................. 53
HI
Anesthesia Related Procedure ........................................................................................................... 58
NM1 Referring Provider Name .................................................................................................................. 59
NM1 Rendering Provider Name ................................................................................................................ 61
PRV Rendering Provider Specialty Information ............................................................................................ 63
NM1 Service Facility Location Name .......................................................................................................... 64
N3
Service Facility Location Address ...................................................................................................... 65
N4
Service Facility Location City, State, ZIP Code ....................................................................................... 66
NM1 Ambulance Pick-up Location............................................................................................................. 67
N3
Ambulance Pick-up Location Address ................................................................................................. 68
N4
Ambulance Pick-up Location City, State, Zip Code .................................................................................. 69
NM1 Ambulance Drop-off Location ............................................................................................................ 70
N3
Ambulance Drop-off Location Address ................................................................................................ 71
N4
Ambulance Drop-off Location City, State, Zip Code ................................................................................. 72
SBR Other Subscriber Information ............................................................................................................ 73
CAS Claim Level Adjustments ................................................................................................................. 75
AMT Coordination of Benefits (COB) Payer Paid Amount ................................................................................ 78
5010X837PA1.ecs
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Health Care Claim : Professional - 837
AMT
AMT
OI
MOA
NM1
N3
N4
REF
NM1
N3
N4
REF
LX
SV1
SV5
PWK
DTP
REF
NTE
SVD
CAS
DTP
AMT
SE
GE
IEA
Coordination of Benefits (COB) Total Non-covered Amount ...................................................................... 79
Remaining Patient Liability ............................................................................................................... 80
Other Insurance Coverage Information ................................................................................................ 81
Outpatient Adjudication Information ................................................................................................... 82
Other Subscriber Name ................................................................................................................... 84
Other Subscriber Address ................................................................................................................ 85
Other Subscriber City, State, ZIP Code................................................................................................. 86
Other Subscriber Secondary Identification............................................................................................ 87
Other Payer Name .......................................................................................................................... 88
Other Payer Address ....................................................................................................................... 89
Other Payer City, State, ZIP Code ....................................................................................................... 90
Other Payer Claim Control Number ..................................................................................................... 91
Service Line Number ....................................................................................................................... 92
Professional Service ....................................................................................................................... 93
Durable Medical Equipment Service .................................................................................................... 97
Line Supplemental Information .......................................................................................................... 98
Date - Service Date ....................................................................................................................... 100
Line Item Control Number .............................................................................................................. 101
Line Note ................................................................................................................................... 102
Line Adjudication Information ......................................................................................................... 103
Line Adjustment .......................................................................................................................... 106
Line Check or Remittance Date ........................................................................................................ 109
Remaining Patient Liability ............................................................................................................. 110
Transaction Set Trailer .................................................................................................................. 111
Functional Group Trailer ................................................................................................................ 112
Interchange Control Trailer ............................................................................................................. 113
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For internal use only
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Health Care Claim : Professional - 837
837
Health Care Claim: Professional
Functional Group=HC
Not Defined:
Pos
Id
ISA
GS
Segment Name
Interchange Control Header
Functional Group Header
Req
M
M
Max Use
1
1
Repeat
Notes
Usage
Required
Required
Id
ST
BHT
Segment Name
Transaction Set Header
Beginning of Hierarchical
Transaction
Req
M
M
Max Use
1
1
Repeat
Notes
Usage
Required
Required
1
Submitter Name
Submitter EDI Contact
Information
O
O
1
2
N1/0200L
N1/0200
Receiver Name
O
1
Segment Name
Req
Max Use
M
1
Required
O
1
Situational
O
O
O
1
1
1
O
1
Required
O
2
Situational
O
O
O
1
1
1
Subscriber Hierarchical Level
Subscriber Information
Patient Information
M
O
O
1
1
1
Subscriber Name
Subscriber Address
Subscriber City, State, ZIP
Code
Subscriber Demographic
Information
O
O
O
1
1
1
O
1
Heading:
Pos
0050
0100
LOOP ID - 1000A
0200
NM1
0450
PER
LOOP ID - 1000B
0200
NM1
1
Required
Required
N1/0200L
N1/0200
Required
Notes
Usage
Detail:
Pos
Id
LOOP ID - 2000A
0010
HL
0030
PRV
Billing Provider Hierarchical
Level
Billing Provider Specialty
Information
LOOP ID - 2010AA
0150
NM1
Billing Provider Name
0250
N3
Billing Provider Address
0300
N4
Billing Provider City, State, ZIP
Code
0350
REF
Billing Provider Tax
Identification
0400
PER
Billing Provider Contact
Information
LOOP ID - 2010AB
0150
NM1
Pay-to Address Name
0250
N3
Pay-To Address - ADDRESS
0300
N4
Pay-to Address City, State, ZIP
Code
LOOP ID - 2000B
0010
HL
0050
SBR
0070
PAT
LOOP ID - 2010BA
0150
NM1
0250
N3
0300
N4
0320
DMG
5010X837PA1.ecs
Repeat
>1
1
1
N2/0150L
N2/0150
N2/0250
N2/0150L
N2/0150
Required
Required
Required
Situational
Required
Required
>1
Required
Required
Situational
1
1
N2/0150L
N2/0150
Required
Situational
Situational
Situational
For internal use only
3/3/2011
Health Care Claim : Professional - 837
LOOP ID - 2010BB
0150
NM1
Payer Name
0250
N3
Payer Address
0300
N4
Payer City, State, ZIP Code
LOOP ID - 2000C
0010
HL
0070
PAT
LOOP ID - 2010CA
0150
NM1
0250
N3
0300
N4
0320
DMG
LOOP ID - 2300
1300
CLM
1550
PWK
1750
AMT
1800
REF
1800
REF
1800
REF
1900
NTE
1950
CR1
2310
HI
2310
HI
LOOP ID - 2310A
2500
NM1
LOOP ID - 2310B
2500
NM1
2550
PRV
LOOP ID - 2310C
2500
NM1
2650
N3
2700
N4
LOOP ID - 2310E
2500
NM1
2650
N3
2700
N4
LOOP ID - 2310F
2500
NM1
2650
N3
2700
N4
LOOP ID - 2320
2900
SBR
2950
CAS
3000
AMT
5010X837PA1.ecs
1
O
O
O
1
1
1
Patient Hierarchical Level
Patient Information
O
O
1
1
Patient Name
Patient Address
Patient City, State, ZIP Code
Patient Demographic
Information
O
O
O
O
1
1
1
1
Claim Information
Claim Supplemental Information
Patient Amount Paid
Referral Number
Prior Authorization
Payer Claim Control Number
Claim Note
Ambulance Transport
Information
Health Care Diagnosis Code
Anesthesia Related Procedure
O
O
O
O
O
O
O
O
1
10
1
1
1
1
1
1
O
O
1
1
Referring Provider Name
O
1
Rendering Provider Name
Rendering Provider Specialty
Information
O
O
1
1
Service Facility Location Name
Service Facility Location
Address
Service Facility Location City,
State, ZIP Code
O
O
1
1
O
1
Ambulance Pick-up Location
Ambulance Pick-up Location
Address
Ambulance Pick-up Location
City, State, Zip Code
O
O
1
1
O
1
Ambulance Drop-off Location
Ambulance Drop-off Location
Address
Ambulance Drop-off Location
City, State, Zip Code
O
O
1
1
O
1
Other Subscriber Information
Claim Level Adjustments
Coordination of Benefits (COB)
Payer Paid Amount
O
O
O
1
5
1
N2/0150L
N2/0150
Required
Situational
Situational
>1
Situational
Required
1
N2/0150L
N2/0150
Required
Required
Required
Required
100
N2/1800
N2/1950
Required
Situational
2
1
1
N2/2500L
N2/2500
N2/2500L
N2/2500
N2/2500L
N2/2500
Situational
Situational
Situational
Situational
Required
Required
1
N2/2500L
N2/2500
Situational
Required
Required
1
N2/2500L
N2/2500
Situational
Required
Required
10
2
Required
Situational
Situational
Situational
Situational
Situational
Situational
Situational
N2/2900L
N2/2900
Situational
Situational
Situational
For internal use only
3/3/2011
Health Care Claim : Professional - 837
3000
AMT
3000
3100
AMT
OI
3200
MOA
LOOP ID - 2330A
3250
NM1
3320
N3
3400
N4
3550
REF
LOOP ID - 2330B
3250
NM1
3320
N3
3400
N4
3550
REF
LOOP ID - 2400
3650
LX
3700
SV1
4000
SV5
4200
PWK
4550
DTP
4700
REF
4850
NTE
LOOP ID - 2430
5400
SVD
5450
CAS
5500
DTP
5505
AMT
5550
SE
Coordination of Benefits (COB)
Total Non-covered Amount
Remaining Patient Liability
Other Insurance Coverage
Information
Outpatient Adjudication
Information
O
1
Situational
O
O
1
1
Situational
Required
O
1
Situational
Other Subscriber Name
Other Subscriber Address
Other Subscriber City, State,
ZIP Code
Other Subscriber Secondary
Identification
O
O
O
1
1
1
O
1
Other Payer Name
Other Payer Address
Other Payer City, State, ZIP
Code
Other Payer Claim Control
Number
O
O
O
1
1
1
O
1
Service Line Number
Professional Service
Durable Medical Equipment
Service
Line Supplemental Information
Date - Service Date
Line Item Control Number
Line Note
O
O
O
1
1
1
O
O
O
O
10
1
1
1
Line Adjudication Information
Line Adjustment
Line Check or Remittance Date
Remaining Patient Liability
Transaction Set Trailer
O
O
O
O
M
1
5
1
1
1
1
N2/3250L
N2/3250
Required
Situational
Situational
Situational
1
N2/3250L
N2/3250
Required
Situational
Situational
Situational
50
N2/3650L
N2/3650
Required
Required
Situational
Situational
Required
Situational
Situational
15
N2/5400L
N2/5400
Situational
Situational
Required
Situational
Required
Not Defined:
Pos
Id
Segment Name
Req
Max Use
Repeat
Notes
Usage
Functional Group Trailer
M
1
Required
GE
IEA
Interchange Control Trailer
M
1
Required
1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is
billing provider, subscriber, patient, claim level, and claim service line level. Billing providers who sort claims using this hierarchy will
use the 837 more efficiently because information that applies to all lower levels in the hierarchy will not have to be repeated within the
transaction.
2. This standard is also recommended for the submission of similar data within a pre-paid managed care context. Referred to as
capitated encounters, this data usually does not result in a payment, though it is possible to submit a “mixed” claim that includes both
pre-paid and request for payment services. This standard will allow for the submission of data from providers of health care products
and services to a Managed Care Organization or other payer. This standard may also be used by payers to share data with plan
sponsors, employers, regulatory entities and Community Health Information Networks.
3. This standard can, also, be used as a transaction set in support of the coordination of benefits claims process. Additional looped
segments can be used within both the claim and service line levels to transfer each payer’s adjudication information to subsequent
payers.
5010X837PA1.ecs
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Health Care Claim : Professional - 837
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 16
Interchange Control Header
ISA
User Option (Usage): Required
Element Summary:
Ref
ISA01
Id
I01
Element Name
Authorization Information Qualifier
Code
00
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Name
No Authorization Information Present (No Meaningful Information in I02)
ISA02
I02
Authorization Information
M
AN
10/10
Required
ISA03
I03
Security Information Qualifier
M
ID
2/2
Required
Code
00
Name
No Security Information Present (No Meaningful Information in I04)
ISA04
I04
Security Information
M
AN
10/10
Required
ISA05
I05
Interchange ID Qualifier
M
ID
2/2
Required
AN
15/15
Required
This ID qualifies the Sender in ISA06.
Code
30
ISA06
I06
Name
U.S. Federal Tax Identification Number
Interchange Sender ID
M
If a Group, please include the Federal tax id of the Group. If a Solo Practitioner or Facility, please
include either the Solo tax id or the Facility tax id. Trading Partners may enter the trading partner
tax id.
ISA07
I05
Interchange ID Qualifier
M
ID
2/2
Required
M
AN
15/15
Required
M
DT
6/6
Required
M
TM
4/4
Required
1/1
Required
5/5
Required
This ID qualifies the Receiver in ISA08.
Code
30
ISA08
I07
Name
U.S. Federal Tax Identification Number
Interchange Receiver ID
Please use 232413324.
ISA09
I08
Interchange Date
The date format is YYMMDD.
ISA10
I09
Interchange Time
The time format is HHMM.
ISA11
I65
Repetition Separator
M
The preferred Repetition Separator is ( > ).
ISA12
I11
Interchange Control Version Number
Code
00501
5010X837PA1.ecs
M
ID
Name
Standards Approved for Publication by ASC X12 Procedures Review Board through
October 2003
4
For internal use only
3/3/2011
ISA13
Health Care Claim : Professional - 837
I12
Interchange Control Number
M
N0
9/9
Required
The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
Must be a positive unsigned number and must be identical to the value in IEA02.
ISA14
I13
Acknowledgment Requested
M
ID
1/1
Required
1/1
Required
1/1
Required
See Section B.1.1.5.1 for interchange acknowledgment information.
Code
1
ISA15
I14
Interchange Usage Indicator
Code
P
ISA16
I15
Name
Interchange Acknowledgment Requested (TA1)
M
ID
Name
Production Data
Component Element Separator
M
The preferred element separator is colon ( : ).
TR3 Notes:
1. All positions within each of the data elements must be filled.
2. For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must be a positive
unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
3. The first element separator defines the element separator to be used through the entire interchange.
4. The ISA segment terminator defines the segment terminator used throughout the entire interchange.
5. Spaces in the example interchanges are represented by “.” for clarity.
TR3 Example:
ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*RECEIVERS.ID...*030101*1253*^*00501*000000905*1*T*:~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 8
Functional Group Header
GS
User Option (Usage): Required
Element Summary:
Ref
GS01
Id
479
Element Name
Functional Identifier Code
Req
M
Type
ID
Min/Max
2/2
Usage
Required
This is the 2-character Functional Identifier Code assigned to each transaction set by X12. The specific
code for a transaction set defined by this implementation guide is presented in section 1.2, Version
Information.
Code
HC
GS02
142
Name
Health Care Claim (837)
Application Sender's Code
M
AN
2/15
Required
Use this code to identify the unit sending the information.
Please use the Group Federal Tax id or if a Solo practitioner or Facility, the Solo or Facility tax id.
Trading Partners should enter the trading partner tax id.
GS03
124
Application Receiver's Code
M
AN
2/15
Required
M
DT
8/8
Required
M
TM
4/8
Required
1/9
Required
Use this code to identify the unit receiving the information.
Please enter 232413324.
GS04
373
Date
Use this date for the functional group creation date.
GS05
337
Time
Use this time for the creation time. The recommended format is HHMM.
GS06
28
Group Control Number
M
N0
For implementations compliant with this guide, GS06 must be unique within a single transmission (that is,
within a single ISA to IEA enveloping structure). The authors recommend that GS06 be unique within all
transmissions over a period of time to be determined by the sender.
GS07
455
Responsible Agency Code
Code
X
GS08
480
M
ID
1/2
Required
M
AN
1/12
Required
Name
Accredited Standards Committee X12
Version / Release / Industry Identifier Code
This is the unique Version/Release/Industry Identifier Code assigned to an implementation by X12N. The
specific code for a transaction set defined by this implementation guide is presented in section 1.2, Version
Information.
Code
Name
005010X222A Standards Approved for Publication by ASC X12 Procedures Review Board through
1
October 2003
TR3 Example:
GS*XX*SENDER CODE*RECEIVERCODE*19991231*0802*1*X*005010X222A1~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Pos: 0050
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 3
Transaction Set Header
ST
User Option (Usage): Required
Element Summary:
Ref
ST01
Id
143
Element Name
Transaction Set Identifier Code
Code
837
ST02
329
Req
M
Type
ID
Min/Max
3/3
Usage
Required
M
AN
4/9
Required
Name
Health Care Claim
Transaction Set Control Number
The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique
within a specific interchange (ISA-IEA), but can repeat in other interchanges.
ST03
1705
Implementation Convention Reference
O
AN
1/35
Required
This element must be populated with the guide identifier named in Section 1.2.
This field contains the same value as GS08. Some translator products strip off the ISA and GS segments
prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure
that the appropriate application mapping is utilized at translation time.
TR3 Example:
ST*837*987654*005010X222A1~
5010X837PA1.ecs
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For internal use only
3/3/2011
Health Care Claim : Professional - 837
Beginning of Hierarchical
Transaction
BHT
Pos: 0100
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 6
User Option (Usage): Required
Element Summary:
Ref
BHT01
Id
1005
Element Name
Hierarchical Structure Code
Code
0019
BHT02
353
Req
M
Type
ID
Min/Max
4/4
Usage
Required
ID
2/2
Required
Name
Information Source, Subscriber, Dependent
Transaction Set Purpose Code
M
BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE
envelope. The terms “original” and “reissue” refer to the electronic transmission status of the 837 batch, not
the billing status.
Code
00
BHT03
127
Name
Original
Reference Identification
O
AN
1/50
Required
The inventory file number of the transmission assigned by the submitter’s system. This number operates
as a batch control number.
This field is limited to 30 characters.
BHT04
373
Date
O
DT
8/8
Required
This is the date that the original submitter created the claim or encounter file from their business
application system.
BHT05
337
Time
O
TM
4/8
Required
This is the time that the original submitter created the claim or encounter file from their business
application system.
BHT06
640
Transaction Type Code
Code
31
CH
O
ID
2/2
Required
Name
Subrogation Demand
Chargeable
TR3 Notes:
1. The second example denotes the case where the entire transaction set contains ENCOUNTERS.
TR3 Example:
BHT*0019*00*0123*20040618*0932*CH~
BHT*0019*00*44445*20040213*0345*RP~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Pos: 0200
Max: 1
Heading - Optional
Loop: 1000A
Elements: 7
Submitter Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
41
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Submitter
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when NM102 = 1 (person) and the person has a first name. If not required by
this implementation guide, do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when NM102 = 1 (person) and the middle name or initial of the person is
needed to identify the individual. If not required by this implementation guide, do not send.
NM108
66
Identification Code Qualifier
Code
46
NM109
67
X
ID
1/2
Required
2/80
Required
Name
Electronic Transmitter Identification Number (ETIN)
Identification Code
X
AN
TR3 Notes:
1. The submitter is the entity responsible for the creation and formatting of this transaction.
TR3 Example:
NM1*41*2*ABC SUBMITTER*****46*999999999~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Submitter EDI Contact
Information
PER
Pos: 0450
Max: 2
Heading - Optional
Loop: 1000A
Elements: 8
User Option (Usage): Required
Element Summary:
Ref
PER01
Id
366
Element Name
Contact Function Code
Code
IC
PER02
93
Req
M
Type
ID
Min/Max
2/2
Usage
Required
O
AN
1/60
Situational
Name
Information Contact
Name
Situational Rule: Required when the contact name is different than the name contained in the Submitter
Name (NM1) segment of this loop
AND
it is the first iteration of the Submitter EDI Contact Information (PER) segment. If not required by this
implementation guide, do not send.
PER03
365
Communication Number Qualifier
Code
EM
FX
TE
X
ID
2/2
Required
Name
Electronic Mail
Facsimile
Telephone
PER04
364
Communication Number
X
AN
1/256
Required
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
Code
EM
EX
FX
TE
PER06
364
Name
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
X
AN
1/256
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
Code
EM
EX
FX
TE
PER08
364
Name
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
X
AN
1/256
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
5010X837PA1.ecs
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this implementation guide, do not send.
TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries using the North
American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number
using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone
number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long
distance access numbers, such as “1”, in the telephone number. Telephone extensions, when applicable, must be submitted in the
next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric
extension. Do not include data that indicates an extension, such as “ext” or “x-”.
2. The contact information in this segment identifies the person in the submitter organization who deals with data transmission
issues. If data transmission problems arise, this is the person to contact in the submitter organization.
3. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including
extensions.
TR3 Example:
PER*C*JOHN SMITH*TE*5555551234*EX*123~
5010X837PA1.ecs
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Pos: 0200
Max: 1
Heading - Optional
Loop: 1000B
Elements: 5
Receiver Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
40
NM102
1065
NM103
1035
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
X
AN
1/60
Required
X
ID
1/2
Required
2/80
Required
Name
Receiver
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
Name Last or Organization Name
Please enter First Priority.
NM108
66
Identification Code Qualifier
Code
46
NM109
67
Name
Electronic Transmitter Identification Number (ETIN)
Identification Code
X
AN
TR3 Example:
NM1*40*2*XYZ RECEIVER*****46*11122333~
5010X837PA1.ecs
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Billing Provider Hierarchical
Level
HL
Pos: 0010
Max: 1
Detail - Mandatory
Loop: 2000A
Elements: 3
User Option (Usage): Required
Element Summary:
Ref
HL01
Id
628
Element Name
Hierarchical ID Number
Req
M
Type
AN
Min/Max
1/12
Usage
Required
The first HL01 within each ST-SE envelope must begin with “1”, and be incremented by one each time an
HL is used in the transaction. Only numeric values are allowed in HL01.
HL03
735
Hierarchical Level Code
Code
20
HL04
736
ID
1/2
Required
O
ID
1/1
Required
Name
Information Source
Hierarchical Child Code
Code
1
M
Name
Additional Subordinate HL Data Segment in This Hierarchical Structure.
TR3 Example:
HL*1**20*1~
5010X837PA1.ecs
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Billing Provider Specialty
Information
PRV
Pos: 0030
Max: 1
Detail - Optional
Loop: 2000A
Elements: 3
User Option (Usage): Situational
Element Summary:
Ref
PRV01
Id
1221
Element Name
Provider Code
Code
BI
PRV02
128
127
Type
ID
Min/Max
1/3
Usage
Required
X
ID
2/3
Required
X
AN
1/50
Required
Name
Billing
Reference Identification Qualifier
Code
PXC
PRV03
Req
M
Name
Health Care Provider Taxonomy Code
Reference Identification
ExternalCodeList
Name: 682
Description: Health Care Provider Taxonomy
Situational Rule:
Required when the payer’s adjudication is known to be impacted by the provider taxonomy code. If not required by this
implementation guide, do not send.
TR3 Example:
PRV*BI*PXC*207Q00000X~
All claims require the taxonomy code in Loop 2000A, PRV03.
5010X837PA1.ecs
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Pos: 0150
Max: 1
Detail - Optional
Loop:
Elements: 8
2010AA
Billing Provider Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
85
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Billing Provider
Entity Type Qualifier
Code
1
2
Req
M
Name
Person
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when NM102 = 1 (person) and the person has a first name. If not required by
this implementation guide, do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when NM102 = 1 (person) and the middle name or initial of the person is
needed to identify the individual. If not required by this implementation guide, do not send.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Situational Rule: Required when NM102 = 1 (person) and the name suffix of the person is needed to
identify the individual. If not required by this implementation guide, do not send.
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Situational Rule: Required for providers in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an
NPI.
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National
Provider Identifier (NPI) implementation date when the provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an
NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.
Code
XX
NM109
67
Name
Centers for Medicare and Medicaid Services National Provider Identifier
Identification Code
X
AN
2/80
Situational
Situational Rule: Required for providers in the United States or its
territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National
Provider Identifier (NPI) implementation date when the provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an
5010X837PA1.ecs
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NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
TR3 Notes:
1. Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health
care provider’s NPI or its subpart’s NPI is reported in NM109. When a health care provider organization has determined that it needs
to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider
MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be
the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider
Subpart Presentation.
2. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be
reported in the REF segment of Loop ID-2010BB.
3. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment
of this loop.
4. The Billing Provider may be an individual only when the health care provider performing services is an independent,
unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes.
That individual’s NPI is reported in NM109, and the individual’s Tax Identification Number must be reported in the REF segment of
this loop. The individual’s NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who
are Not Eligible for Enumeration).
5. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example,
personal care services, carpenters, etc); the Billing Provider should be the legal entity. However, willing trading partners may agree
upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF
(Tax Identification Number) segment of this loop.
TR3 Example:
NM1*85*2*ABC Group Practice*****XX*1234567890~
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Pos: 0250
Max: 1
Detail - Optional
Loop:
Elements: 1
2010AA
Billing Provider Address
N3
User Option (Usage): Required
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
Must be a street address. Cannot submit a Post Office box or Lock Box address.
TR3 Notes:
1. The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To
Address Loop (Loop ID-2010AB), if necessary.
TR3 Example:
N3*123 MAIN STREET~
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Billing Provider City, State, ZIP
Code
N4
Pos: 0300
Max: 1
Detail - Optional
Loop:
Elements: 5
2010AA
User Option (Usage): Required
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Required
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Required
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Required
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Required
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
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For internal use only
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Pos: 0350
Max: 1
Detail - Optional
Loop:
Elements: 2
2010AA
Billing Provider Tax
Identification
REF
User Option (Usage): Required
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
As of the mandated implementation date for the NPI, the only valid values for Health Care Providers are EI
and SY. Non-Health Care Providers may use any of the listed values for REF01.
Code
EI
SY
REF02
127
Name
Employer's Identification Number
Social Security Number
Reference Identification
X
AN
1/50
Required
TR3 Notes:
1. This is the tax identification number (TIN) of the entity to be paid for the submitted services.
TR3 Example:
REF*EI*123456789~
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Pos: 0400
Max: 2
Detail - Optional
Loop:
Elements: 8
2010AA
Billing Provider Contact
Information
PER
User Option (Usage): Situational
Element Summary:
Ref
PER01
Id
366
Element Name
Contact Function Code
Code
IC
PER02
93
Req
M
Type
ID
Min/Max
2/2
Usage
Required
O
AN
1/60
Situational
Name
Information Contact
Name
Situational Rule: Required in the first iteration of the Billing Provider Contact Information segment. If not
required by this implementation guide, do not send.
PER03
365
Communication Number Qualifier
Code
EM
FX
TE
X
ID
2/2
Required
Name
Electronic Mail
Facsimile
Telephone
PER04
364
Communication Number
X
AN
1/256
Required
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
Code
EM
EX
FX
TE
PER06
364
Name
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
X
AN
1/256
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
Code
EM
EX
FX
TE
PER08
364
Name
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
X
AN
1/256
Situational
Situational Rule: Required when this information is deemed necessary by the submitter. If not required by
this implementation guide, do not send.
Situational Rule:
5010X837PA1.ecs
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Health Care Claim : Professional - 837
Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this
implementation guide, do not send.
TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries using the North
American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number
using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone
number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long
distance access numbers, such as “1”, in the telephone number. Telephone extensions, when applicable, must be submitted in the
next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric
extension. Do not include data that indicates an extension, such as “ext” or “x-”.
2. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including
extensions.
TR3 Example:
PER*IC*JOHN SMITH*TE*5555551234*EX*123~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Pos: 0150
Max: 1
Detail - Optional
Loop:
Elements: 2
2010AB
Pay-to Address Name
NM1
User Option (Usage): Situational
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
87
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Pay-to Provider
Entity Type Qualifier
Code
1
2
Req
M
Name
Person
Non-Person Entity
Situational Rule:
Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do
not send.
TR3 Notes:
1. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when
different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
TR3 Example:
NM1*87*2~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Pos: 0250
Max: 1
Detail - Optional
Loop:
Elements: 2
2010AB
Pay-To Address - ADDRESS
N3
User Option (Usage): Required
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
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For internal use only
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Pay-to Address City, State, ZIP
Code
N4
Pos: 0300
Max: 1
Detail - Optional
Loop:
Elements: 5
2010AB
User Option (Usage): Required
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
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For internal use only
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Subscriber Hierarchical Level
HL
Pos: 0010
Max: 1
Detail - Mandatory
Loop: 2000B
Elements: 4
User Option (Usage): Required
Element Summary:
Ref
HL01
Id
628
Element Name
Hierarchical ID Number
Req
M
Type
AN
Min/Max
1/12
Usage
Required
HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric
values are allowed in HL01.
HL02
734
Hierarchical Parent ID Number
O
AN
1/12
Required
HL03
735
Hierarchical Level Code
M
ID
1/2
Required
O
ID
1/1
Required
Code
22
HL04
736
Name
Subscriber
Hierarchical Child Code
The claim (Loop ID-2300) can be used when HL04 has no subordinate levels (HL04 = 0) or when HL04
has subordinate levels indicated (HL04 = 1).
In the first case (HL04 = 0), the subscriber is the patient and there are no dependent claims. The second
case (HL04 = 1) happens when claims for one or more dependents of the subscriber are being sent under
the same billing provider HL (for example, a spouse and son are both treated by the same provider). In that
case, the subscriber HL04 = 1 because there is at least one dependent to this subscriber. The dependent
HL (spouse) would then be sent followed by the Loop ID-2300 for the spouse. The next HL would be the
dependent HL for the son followed by the Loop ID-2300 for the son.
In order to send claims for the subscriber and one or more dependents, the Subscriber HL, with
Relationship Code SBR02=18 (Self), would be followed by the Subscriber’s Loop ID-2300 for the
Subscriber’s claims. Then the Subscriber HL would be repeated, followed by one or more Patient HL loops
for the dependents, with the proper Relationship Code in PAT01, each followed by their respective Loop
ID-2300 for each dependent’s claims.
TR3 Notes:
1. If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then
the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is
not used. (This is the requirement for member's whose alpha prefix is YZH.)
2. If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it
is not known to the sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are
required. (This is the requirement for members whose alpha prefix is either QFG, QFC, QFD, QFT, QFI, QFM, QFO, GSQ, AUV,
EBU, NNU, NTQ, NTJ, SNQ or SVQ.)
TR3 Example:
HL*2*1*22*1~
5010X837PA1.ecs
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For internal use only
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Health Care Claim : Professional - 837
Pos: 0050
Max: 1
Detail - Optional
Loop: 2000B
Elements: 5
Subscriber Information
SBR
User Option (Usage): Required
Element Summary:
Ref
SBR01
Id
1138
Element Name
Payer Responsibility Sequence Number Code
Req
M
Type
ID
Min/Max
1/1
Usage
Required
Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than
value “U”) may occur no more than once.
Code
A
B
C
D
E
F
G
H
P
S
T
U
SBR02
1069
Name
Payer Responsibility Four
Payer Responsibility Five
Payer Responsibility Six
Payer Responsibility Seven
Payer Responsibility Eight
Payer Responsibility Nine
Payer Responsibility Ten
Payer Responsibility Eleven
Primary
Secondary
Tertiary
Unknown
Individual Relationship Code
O
ID
2/2
Situational
Situational Rule: Required when the patient is the subscriber or is considered to be the subscriber. If not
required by this implementation guide, do not send.
Code
18
SBR03
127
Name
Self
Reference Identification
O
AN
1/50
Situational
Situational Rule: Required when the subscriber’s identification card for the destination payer (Loop ID2010BB) shows a group number. If not required by this implementation guide, do not send.
This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in
Loop ID-2010BA-NM109.
SBR04
93
Name
O
AN
1/60
Situational
Situational Rule: Required when SBR03 is not used and the group
name is available. If not required by this implementation guide, do not send.
SBR09
1032
Claim Filing Indicator Code
O
ID
1/2
Situational
Situational Rule: Required prior to mandated used of PlanID. Not used after PlanID is mandated. If not
required by this implementation guide, do not send.
Code
10
11
12
13
14
15
16
BL
CH
5010X837PA1.ecs
Name
Central Certification
Other Non-Federal Programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
Blue Cross/Blue Shield
Champus
26
For internal use only
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Health Care Claim : Professional - 837
CI
FI
HM
LM
MA
MB
MC
VA
ZZ
Commercial Insurance Co.
Federal Employees Program
Health Maintenance Organization
Liability Medical
Medicare Part A
Medicare Part B
Medicaid
Veterans Affairs Plan
Mutually Defined
TR3 Example:
SBR*P**GRP01020102******CI~
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Pos: 0070
Max: 1
Detail - Optional
Loop: 2000B
Elements: 3
Patient Information
PAT
User Option (Usage): Situational
Element Summary:
Ref
PAT05
Id
1250
Element Name
Date Time Period Format Qualifier
Req
X
Type
ID
Min/Max
2/3
Usage
Situational
Situational Rule: Required when patient is known to be deceased and the date of death is available to the
provider billing system. If not required by this implementation guide, do not send.
Code
D8
PAT07
355
Name
Date Expressed in Format CCYYMMDD
Unit or Basis for Measurement Code
X
ID
2/2
Situational
Situational Rule: Required when claims involve Medicare Durable
Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or
DME MAC 10.03. If not required by this implementation guide, do not send.
Code
01
PAT08
81
Name
Actual Pounds
Weight
X
R
1/10
Situational
Situational Rule: Required when claims involve Medicare Durable
Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or
DME MAC 10.03. If not required by this implementation guide, do not send.
Situational Rule:
Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met.
If not required by this implementation guide, do not send.
TR3 Example:
PAT*****D8*19970314~
PAT*******01*146~
5010X837PA1.ecs
28
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0150
Max: 1
Detail - Optional
Loop:
Elements: 8
2010BA
Subscriber Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
IL
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Insured or Subscriber
Entity Type Qualifier
Code
1
2
Req
M
Name
Person
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when NM102 = 1 (person) and the person has a first name. If not required by
this implementation guide, do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when NM102 = 1 (person) and the middle name or initial of the person is
needed to identify the individual. If not required by this implementation guide, do not send.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Situational Rule: Required when NM102 = 1 (person) and the name suffix of the person is needed to
identify the individual. If not required by this implementation guide, do not send.
Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Situational Rule: Required when NM102 = 1 (person). If not required by this implementation guide, do not
send.
Code
II
MI
NM109
67
Name
Standard Unique Health Identifier for each Individual in the United States
Member Identification Number
Identification Code
X
AN
2/80
Situational
Situational Rule: Required when NM102 = 1 (person). If not required by this implementation guide, do not
send.
TR3 Notes:
1. In worker’s compensation or other property and casualty claims, the “subscriber” may be a non-person entity (for example, the
employer). However, this varies by state.
TR3 Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
5010X837PA1.ecs
29
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0250
Max: 1
Detail - Optional
Loop:
Elements: 2
2010BA
Subscriber Address
N3
User Option (Usage): Situational
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
Situational Rule:
Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not
send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
30
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Subscriber City, State, ZIP Code
N4
Pos: 0300
Max: 1
Detail - Optional
Loop:
Elements: 5
2010BA
User Option (Usage): Situational
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Situational Rule:
Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not
send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
31
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0320
Max: 1
Detail - Optional
Loop:
Elements: 3
2010BA
Subscriber Demographic
Information
DMG
User Option (Usage): Situational
Element Summary:
Ref
DMG01
Id
1250
Element Name
Date Time Period Format Qualifier
Code
D8
Req
X
Type
ID
Min/Max
2/3
Usage
Required
Name
Date Expressed in Format CCYYMMDD
DMG02
1251
Date Time Period
X
AN
1/35
Required
DMG03
1068
Gender Code
O
ID
1/1
Required
Code
F
M
U
Name
Female
Male
Unknown
Situational Rule:
Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not
send.
TR3 Example:
DMG*D8*19690815*M~
5010X837PA1.ecs
32
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0150
Max: 1
Detail - Optional
Loop:
Elements: 5
2010BB
Payer Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
PR
NM102
1065
NM103
1035
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
X
AN
1/60
Required
X
ID
1/2
Required
Name
Payer
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
Name Last or Organization Name
Please send First Priority.
NM108
66
Identification Code Qualifier
On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV
must be sent. Prior to the mandated implementation date and prior to any phase-in period identified by
Federal regulation, PI must be sent. If a phase-in period is designated, PI must be sent unless:
1. Both the sender and receiver agree to use the National Plan ID,
2. The receiver has a National Plan ID, and
3. The sender has the capability to send the National Plan ID. If all of the above conditions are true, XV
must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can
be sent in the corresponding REF segment using qualifier 2U.
Code
PI
XV
NM109
67
Name
Payor Identification
Centers for Medicare and Medicaid Services PlanID
Identification Code
X
AN
2/80
Required
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services PlanID
TR3 Notes:
1. This is the destination payer.
2. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party
administrator.
TR3 Example:
NM1*PR*2*ABC INSURANCE CO*****PI*11122333~
5010X837PA1.ecs
33
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0250
Max: 1
Detail - Optional
Loop:
Elements: 2
2010BB
Payer Address
N3
User Option (Usage): Situational
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
O
AN
1/55
Situational
Please send 19 North Main Street.
N302
166
Address Information
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
Situational Rule:
Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location
(for example, a clearinghouse). If not required by this implementation guide, do not send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
34
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0300
Max: 1
Detail - Optional
Loop:
Elements: 5
2010BB
Payer City, State, ZIP Code
N4
User Option (Usage): Situational
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Required
Please send Wilkes-Barre
N402
156
State or Province Code
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
Please send PA.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
Please send 18711-0302.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
35
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0010
Max: 1
Detail - Optional
Loop: 2000C
Elements: 4
Patient Hierarchical Level
HL
User Option (Usage): Situational
Element Summary:
Ref
HL01
Id
628
Element Name
Hierarchical ID Number
HL02
734
HL03
735
Req
M
Type
AN
Min/Max
1/12
Usage
Required
Hierarchical Parent ID Number
O
AN
1/12
Required
Hierarchical Level Code
M
ID
1/2
Required
O
ID
1/1
Required
Code
23
HL04
736
Name
Dependent
Hierarchical Child Code
Code
0
Name
No Subordinate HL Segment in This Hierarchical Structure.
Situational Rule:
Required when the patient is a dependent of the subscriber identified in Loop ID-2000B and cannot be uniquely identified to the
payer without the subscriber’s identifier in the Subscriber Level. If not required by this implementation guide, do not send.
TR3 Notes:
1. There are no HLs subordinate to the Patient HL.
2. If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Identification Number, then the
patient is considered the subscriber and is to be identified in the Subscriber Level.
TR3 Example:
HL*3*2*23*0~
Please do not send this Loop for First Priority Health claims. This Loop should be sent for First Priority Life Insurance
Company claims only.
5010X837PA1.ecs
36
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0070
Max: 1
Detail - Optional
Loop: 2000C
Elements: 5
Patient Information
PAT
User Option (Usage): Required
Element Summary:
Ref
PAT01
Id
1069
Element Name
Individual Relationship Code
Req
O
Type
ID
Min/Max
2/2
Usage
Required
ID
2/3
Situational
Specifies the patient’s relationship to the person insured.
Code
01
19
20
21
39
40
53
G8
PAT05
1250
Name
Spouse
Child
Employee
Unknown
Organ Donor
Cadaver Donor
Life Partner
Other Relationship
Date Time Period Format Qualifier
X
Situational Rule: Required when patient is known to be deceased and the date of death is available to the
provider billing system. If not required by this implementation guide, do not send.
Code
D8
PAT06
1251
Name
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Situational Rule: Required when patient is known to be deceased and the date of death is available to the
provider billing system. If not required by this implementation guide, do not send.
PAT07
355
Unit or Basis for Measurement Code
X
ID
2/2
Situational
Situational Rule: Required when claims involve Medicare Durable
Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or
DME MAC 10.03.
If not required by this implementation guide, do not send.
Code
01
PAT08
81
Name
Actual Pounds
Weight
X
R
1/10
Situational
Situational Rule: Required when claims involve Medicare Durable
Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or
DME MAC 10.03. If not required by this implementation guide, do not send.
TR3 Example:
PAT*01~
5010X837PA1.ecs
37
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0150
Max: 1
Detail - Optional
Loop:
Elements: 6
2010CA
Patient Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
QC
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Patient
Entity Type Qualifier
Code
1
Req
M
Name
Person
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when NM102 = 1 (person) and the person has a first name. If not required by
this implementation guide, do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when the middle name or initial of the
person is needed to identify the individual. If not required by this implementation guide, do not send.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Situational Rule: Required when the name suffix is needed to identify the individual. If not required by this
implementation guide, do not send.
TR3 Example:
NM1*QC*1*DOE*SALLY*J~
5010X837PA1.ecs
38
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0250
Max: 1
Detail - Optional
Loop:
Elements: 2
2010CA
Patient Address
N3
User Option (Usage): Required
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
39
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0300
Max: 1
Detail - Optional
Loop:
Elements: 4
2010CA
Patient City, State, ZIP Code
N4
User Option (Usage): Required
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Required
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Required
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
40
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 0320
Max: 1
Detail - Optional
Loop:
Elements: 3
2010CA
Patient Demographic
Information
DMG
User Option (Usage): Required
Element Summary:
Ref
DMG01
Id
1250
Element Name
Date Time Period Format Qualifier
Code
D8
Req
X
Type
ID
Min/Max
2/3
Usage
Required
Name
Date Expressed in Format CCYYMMDD
DMG02
1251
Date Time Period
X
AN
1/35
Required
DMG03
1068
Gender Code
O
ID
1/1
Required
Code
F
M
U
Name
Female
Male
Unknown
TR3 Example:
DMG*D8*19690815*M~
5010X837PA1.ecs
41
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 1300
Max: 1
Detail - Optional
Loop: 2300
Elements: 10
Claim Information
CLM
User Option (Usage): Required
Element Summary:
Ref
CLM01
Id
1028
Element Name
Claim Submitter's Identifier
Req
M
Type
AN
Min/Max
1/38
Usage
Required
The number that the submitter transmits in this position is echoed back to the submitter in the 835 and
other transactions. This permits the submitter to use the value in this field as a key in the submitter’s
system to match the claim to the payment information returned in the 835 transaction. The two
recommended identifiers are either the Patient Account Number or the Claim Number in the billing
submitter’s patient management system. The developers of this implementation guide strongly recommend
that submitters use unique numbers for this field for each individual claim.
When Loop ID 2010AC is present, CLM01 represents the subrogated Medicaid agency’s ICN from their
original 835 CLP07 - Payer Claim Control Number. See section 1.4.1.4 of the front matter for a description
of post payment recovery claims for subrogated Medicaid agencies.
The maximum number of characters to be supported for this field is ‘20’. Characters beyond the maximum
are not required to be stored nor returned by any 837-receiving system.
CLM02
782
Monetary Amount
O
R
1/18
Required
The Total Claim Charge Amount must be greater than or equal to zero.
The total claim charge amount must balance to the sum of all service line charge amounts reported in the
Professional Service (SV1) segments for this claim.
CLM05
C023
Health Care Service Location Information
O
Comp
Required
CLM05 applies to all service lines unless it is over written at the line level.
CLM05-01
1331
Facility Code Value
M
AN
1/2
Required
This element identifies a place of service from code source 237 to identify the type of facility where
services were performed.
ExternalCodeList
Name: 237
Description: Place of Service Codes for Professional Claims
CLM05-02
1332
Facility Code Qualifier
Code
B
CLM05-03
1325
O
ID
1/2
Required
1/1
Required
Name
Place of Service Codes for Professional or Dental Services
Claim Frequency Type Code
O
ID
If codes '7' or '8' are populated in Loop 2300 (Payer Claim Control Number), then REF01=F8 and
REF02 are required.
ExternalCodeList
Name: 235
Description: Claim Frequency Type Code
CLM06
1073
Yes/No Condition or Response Code
Code
N
Y
CLM07
1359
O
ID
1/1
Required
O
ID
1/1
Required
Name
No
Yes
Provider Accept Assignment Code
Within this element the context of the word assignment is related to the relationship between the provider
and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to
5010X837PA1.ecs
42
For internal use only
3/3/2011
Health Care Claim : Professional - 837
the provider. The benefit assignment indicator is in CLM08.
Code
A
B
C
CLM08
1073
Name
Assigned
Assignment Accepted on Clinical Lab Services Only
Not Assigned
Yes/No Condition or Response Code
O
ID
1/1
Required
This element answers the question whether or not the insured has authorized the plan to remit payment
directly to the provider.
Code
N
W
Y
CLM09
1363
Name
No
Not Applicable
Yes
Release of Information Code
O
ID
1/1
Required
The Release of Information response is limited to the information carried in this claim.
Code
I
Y
CLM10
1351
Name
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated
by Federal Statutes
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related
to a Claim
Patient Signature Source Code
O
ID
1/1
Situational
Situational Rule: Required when a signature was executed on the patient’s behalf under state or federal
law. If not required by this implementation guide, do not send.
Code
P
CLM11
C024
Name
Signature generated by provider because the patient was not physically present for
services
Related Causes Information
O
Comp
Situational
Situational Rule: Required when the services provided are employment related or the result of an
accident. If not required by this implementation guide, do not send.
If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required.
CLM11-01
1362
Related-Causes Code
Code
AA
EM
OA
CLM11-02
1362
M
ID
2/3
Required
O
ID
2/3
Situational
Name
Auto Accident
Employment
Other Accident
Related-Causes Code
Situational Rule: Required when more than one related cause code applies. See CLM11-1 for valid
values. If not required by this implementation guide, do not send.
Code
AA
EM
OA
CLM11-04
156
Name
Auto Accident
Employment
Other Accident
State or Province Code
O
ID
2/2
Situational
Situational Rule: Required when CLM11-1 or CLM11-2 has a value of ‘AA’ to identify the state, province
or sub-country code in which the automobile accident occurred. If accident occurred in a country or
5010X837PA1.ecs
43
For internal use only
3/3/2011
Health Care Claim : Professional - 837
location that does not have states, provinces or sub-country codes named in Code Source 22, do not use.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
CLM11-05
26
Country Code
O
ID
2/3
Situational
Situational Rule: Required when CLM11-1 or CLM11-2 = AA and the accident occurred in a country other
than US or Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
CLM20
1514
Delay Reason Code
O
ID
1/2
Situational
Situational Rule: Required when the claim is submitted late (past contracted date of filing limitations). If
not required by this implementation guide, do not send.
Code
1
2
3
4
5
6
7
8
9
10
11
15
Name
Proof of Eligibility Unknown or Unavailable
Litigation
Authorization Delays
Delay in Certifying Provider
Delay in Supplying Billing Forms
Delay in Delivery of Custom-made Appliances
Third Party Processing Delay
Delay in Eligibility Determination
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation
Rules
Administration Delay in the Prior Approval Process
Other
Natural Disaster
TR3 Notes:
1. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to
a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISAIEA. Willing trading partners can agree to set limits higher.
2. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail
information can be given in either the subscriber or the dependent hierarchical level. Because of this the claim information is said to
“float.” Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the
dependent. In other words, the claim information, loop 2300, is placed following loop 2010BB in the Subscriber Hierarchical Level
(HL) when patient information is sent in loop 2010BA of the Subscriber HL. Claim information is placed in the Patient hierarchical
level when the patient information is sent in loop 2010CA of the Patient HL. When the patient is the subscriber or is considered to be
the subscriber, loops 2000C and 2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for
details.
TR3 Example:
CLM*A37YH556*500***11::1*Y*A*Y*I*P~
5010X837PA1.ecs
44
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Claim Supplemental Information
PWK
Pos: 1550
Max: 10
Detail - Optional
Loop: 2300
Elements: 4
User Option (Usage): Situational
Element Summary:
Ref
PWK01
Id
755
Element Name
Report Type Code
Code
03
04
05
06
07
08
09
10
11
13
15
21
77
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
5010X837PA1.ecs
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Name
Report Justifying Treatment Beyond Utilization Guidelines
Drugs Administered
Treatment Diagnosis
Initial Assessment
Functional Goals
Plan of Treatment
Progress Report
Continued Treatment
Chemical Analysis
Certified Test Report
Justification for Admission
Recovery Plan
Support Data for Verification
Allergies/Sensitivities Document
Autopsy Report
Ambulance Certification
Admission Summary
Prescription
Physician Order
Referral Form
Benchmark Testing Results
Baseline
Blanket Test Results
Chiropractic Justification
Consent Form(s)
Certification
Drug Profile Document
Dental Models
Durable Medical Equipment Prescription
Diagnostic Report
Discharge Monitoring Report
Discharge Summary
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Models
Nursing Notes
Operative Note
Oxygen Content Averaging Report
Orders and Treatments Document
45
For internal use only
3/3/2011
Health Care Claim : Professional - 837
OE
OX
OZ
P4
P5
PE
PN
PO
PQ
PY
PZ
RB
RR
RT
RX
SG
V5
XP
PWK02
756
Report Transmission Code
Code
AA
BM
EL
EM
FT
FX
PWK05
66
Objective Physical Examination (including vital signs) Document
Oxygen Therapy Certification
Support Data for Claim
Pathology Report
Patient Medical History Document
Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Renewable Oxygen Content Averaging Report
Symptoms Document
Death Notification
Photographs
O
ID
1/2
Required
X
ID
1/2
Situational
Name
Available on Request at Provider Site
By Mail
Electronically Only
E-Mail
File Transfer
By Fax
Identification Code Qualifier
Situational Rule: Required when PWK02 = “BM”, “EL”, “EM”, “FX” or “FT”. If not required by this
implementation guide, do not send.
Code
AC
PWK06
67
Name
Attachment Control Number
Identification Code
X
AN
2/80
Situational
Situational Rule: Required when PWK02 = “BM”, “EL”, “EM”, “FX” or “FT”. If not required by this
implementation guide, do not send.
PWK06 is used to identify the attached electronic documentation.
The number in PWK06 is carried in the TRN of the electronic attachment.
For the purpose of this implementation, the maximum field length is 50.
Situational Rule:
Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275)
rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the
TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider’s office and is
available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of
“AA” in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
TR3 Example:
PWK*OZ*BM***AC*DMN0012~
5010X837PA1.ecs
46
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 1750
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
Patient Amount Paid
AMT
User Option (Usage): Situational
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Code
F5
AMT02
782
Req
M
Type
ID
Min/Max
1/3
Usage
Required
M
R
1/18
Required
Name
Patient Amount Paid
Monetary Amount
Situational Rule:
Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
TR3 Notes:
1. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his/her representative(s).
TR3 Example:
AMT*F5*152.45~
5010X837PA1.ecs
47
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 1800
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
Referral Number
REF
User Option (Usage): Situational
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Code
9F
REF02
127
Req
M
Type
ID
Min/Max
2/3
Usage
Required
X
AN
1/50
Required
Name
Referral Number
Reference Identification
Situational Rule:
Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
AND a referral is involved. If not required by this implementation guide, do not send.
TR3 Notes:
1. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference
identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop
ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
TR3 Example:
REF*9F*12345~
5010X837PA1.ecs
48
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 1800
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
Prior Authorization
REF
User Option (Usage): Situational
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Code
G1
REF02
127
Req
M
Type
ID
Min/Max
2/3
Usage
Required
X
AN
1/50
Required
Name
Prior Authorization Number
Reference Identification
Situational Rule:
Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized.
If not required by this implementation guide, do not send.
TR3 Notes:
1. Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The
UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health
services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer
reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop
REF which holds that payer’s information.
2. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference
identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop
ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
TR3 Example:
REF*G1*13579~
5010X837PA1.ecs
49
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 1800
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
Payer Claim Control Number
REF
User Option (Usage): Situational
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Code
F8
REF02
127
Req
M
Type
ID
Min/Max
2/3
Usage
Required
X
AN
1/50
Required
Name
Original Reference Number
Reference Identification
Situational Rule:
Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If
not required by this implementation guide, do not send.
TR3 Notes:
1. This information is specific to the destination payer reported in Loop ID-2010BB.
TR3 Example:
REF*F8*R555588~
This is required when CLM05-3 is a '7' or '8'.
5010X837PA1.ecs
50
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 1900
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
Claim Note
NTE
User Option (Usage): Situational
Element Summary:
Ref
NTE01
Id
363
Element Name
Note Reference Code
Code
ADD
CER
DCP
DGN
TPO
NTE02
352
Req
O
Type
ID
Min/Max
3/3
Usage
Required
1/80
Required
Name
Additional Information
Certification Narrative
Goals, Rehabilitation Potential, or Discharge Plans
Diagnosis Description
Third Party Organization Notes
Description
M
AN
Situational Rule:
Required when in the opinion of the provider, the information is needed to substantiate the medical treatment and is not supported
elsewhere within the claim data set. If not required by this implementation guide, do not send.
TR3 Notes:
1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment
in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in
NTE01 in Loop ID-2300.
2. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use
narrative information with claims are encouraged to codify that information within the ASC X12 environment.
TR3 Example:
NTE*ADD*SURGERY WAS UNUSUALLY LONG BECAUSE [FILL IN REASON]~
5010X837PA1.ecs
51
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Ambulance Transport
Information
CR1
Pos: 1950
Max: 1
Detail - Optional
Loop: 2300
Elements: 7
User Option (Usage): Situational
Element Summary:
Ref
CR101
Id
355
Element Name
Unit or Basis for Measurement Code
Req
X
Type
ID
Min/Max
2/2
Usage
Situational
Situational Rule: Required when it is necessary to justify the medical necessity of the level of ambulance
services. If not required by this implementation guide, do not send.
Code
LB
CR102
81
Name
Pound
Weight
X
R
1/10
Situational
Situational Rule: Required when it is necessary to justify the medical necessity of the level of ambulance
services. If not required by this implementation guide, do not send.
CR104
1317
Ambulance Transport Reason Code
Code
A
B
C
D
E
CR105
355
380
ID
1/1
Required
Name
Patient was transported to nearest facility for care of symptoms, complaints, or both
Patient was transported for the benefit of a preferred physician
Patient was transported for the nearness of family members
Patient was transported for the care of a specialist or for availability of specialized
equipment
Patient Transferred to Rehabilitation Facility
Unit or Basis for Measurement Code
Code
DH
CR106
O
X
ID
2/2
Required
X
R
1/15
Required
Name
Miles
Quantity
0 (zero) is a valid value when ambulance services do not include a charge for mileage.
CR109
352
Description
O
AN
1/80
Situational
Situational Rule: Required when the service is a round trip. If not required by this implementation guide,
do not send.
CR110
352
Description
O
AN
1/80
Situational
Situational Rule: Required when needed to justify usage of stretcher. If not required by this
implementation guide, do not send.
Situational Rule:
Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send.
TR3 Notes:
1. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in
Loop ID-2400 with the same value in CR101.
TR3 Example:
CR1*LB*140*I*A*DH*12****UNCONSCIOUS~
5010X837PA1.ecs
52
For internal use only
3/3/2011
HI
Health Care Claim : Professional - 837
Pos: 2310
Max: 1
Detail - Optional
Loop: 2300
Elements: 12
Health Care Diagnosis Code
User Option (Usage): Required
Element Summary:
Ref
HI01
Id
C022
Element Name
Health Care Code Information
Req
M
Type
Comp
Min/Max
Usage
Required
The diagnosis listed in this element is assumed to be the principal diagnosis.
HI01-01
1270
Code List Qualifier Code
Code
BK
ABK
HI01-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal
Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal
Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI02
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnosis and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI02-01
1270
Code List Qualifier Code
Code
BF
ABF
HI02-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI03
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI03-01
1270
Code List Qualifier Code
Code
BF
5010X837PA1.ecs
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
53
For internal use only
3/3/2011
Health Care Claim : Professional - 837
ABF
HI03-02
1271
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI04
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI04-01
1270
Code List Qualifier Code
Code
BF
ABF
HI04-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI05
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI05-01
1270
Code List Qualifier Code
Code
BF
ABF
HI05-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI06
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI06-01
1270
Code List Qualifier Code
Code
5010X837PA1.ecs
M
ID
1/3
Required
Name
54
For internal use only
3/3/2011
Health Care Claim : Professional - 837
BF
ABF
HI06-02
1271
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI07
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI07-01
1270
Code List Qualifier Code
Code
BF
ABF
HI07-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI08
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI08-01
1270
Code List Qualifier Code
Code
BF
ABF
HI08-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI09
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI09-01
5010X837PA1.ecs
1270
Code List Qualifier Code
M
55
ID
1/3
Required
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Code
BF
ABF
HI09-02
1271
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI10
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI10-01
1270
Code List Qualifier Code
Code
BF
ABF
HI10-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI11
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI11-01
1270
Code List Qualifier Code
Code
BF
ABF
HI11-02
1271
M
ID
1/3
Required
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI12
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional diagnoses and the preceding HI
data elements have been used to report other diagnoses. If not required by this implementation guide, do
not send.
HI12-01
5010X837PA1.ecs
1270
Code List Qualifier Code
M
56
ID
1/3
Required
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Code
BF
ABF
HI12-02
1271
Name
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
TR3 Notes:
1. Do not transmit the decimal point for ICD codes. The decimal point is implied.
TR3 Example:
HI*BK:8901*BF:87200*BF:5559~
5010X837PA1.ecs
57
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Anesthesia Related Procedure
HI
Pos: 2310
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Element Summary:
Ref
HI01
Id
C022
Element Name
Health Care Code Information
HI01-01
1270
Code List Qualifier Code
Code
BP
HI01-02
1271
Req
M
Type
Comp
Min/Max
Usage
Required
M
ID
1/3
Required
Name
Health Care Financing Administration Common Procedural Coding System Principal
Procedure
Industry Code
M
AN
1/30
Required
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
HI02
C022
Health Care Code Information
O
Comp
Situational
Situational Rule: Required when it is necessary to report an additional procedure and the preceding HI
data elements have been used to report other procedures. If not required by this implementation guide, do
not send.
HI02-01
1270
Code List Qualifier Code
Code
BO
HI02-02
1271
M
ID
1/3
Required
Name
Health Care Financing Administration Common Procedural Coding System
Industry Code
M
AN
1/30
Required
If SVC101 in Loop 2400 contains procedure code 01999, then HI02-02 is required.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
Situational Rule:
Required on claims where anesthesiology services are being billed/reported if the provider knows the surgical code and knows the
adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send.
TR3 Example:
HI*BP:33414~
5010X837PA1.ecs
58
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 2500
Max: 1
Detail - Optional
Loop: 2310A
Elements: 8
Referring Provider Name
NM1
User Option (Usage): Situational
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
DN
P3
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Referring Provider
Primary Care Provider
Entity Type Qualifier
Code
1
Req
M
Name
Person
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when the person has a first name. If not required by this implementation guide,
do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when the middle name or initial of the
person is needed to identify the individual. If not required by this implementation guide, do not send.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Situational Rule: Required when the name suffix is needed to identify the individual. If not required by this
implementation guide, do not send.
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Situational Rule: Required for providers on or after the mandated HIPAA National Provider Identifier (NPI)
implementation date when the provider has received an NPI and the NPI is available to the submitter.
OR
Required for providers prior to the mandated HIPAA NPI implementation date when the provider has
received an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.
Code
XX
NM109
67
Name
Centers for Medicare and Medicaid Services National Provider Identifier
Identification Code
X
AN
2/80
Situational
Situational Rule: Required for providers on or after the mandated HIPAA National Provider Identifier (NPI)
implementation date when the provider has received an NPI and the NPI is available to the submitter.
OR
Required for providers prior to the mandated HIPAA NPI implementation date when the provider has
received an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
Situational Rule:
Required when this claim involves a referral. If not required by this implementation guide, do not send.
5010X837PA1.ecs
59
For internal use only
3/3/2011
Health Care Claim : Professional - 837
TR3 Notes:
1. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered
services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
2. When there is only one referral on the claim, use code “DN - Referring Provider”. When more than one referral exists and there is
a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the
rendering provider on this claim. Use code “P3 - Primary Care Provider” in the second iteration of the loop to indicate the initial
referral from the primary care provider or whatever provider wrote the initial referral for this patient’s episode of care being
billed/reported in this transaction.
3. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with
the same value in NM101.
TR3 Example:
NM1*DN*1*WELBY*MARCUS*W**JR*XX*444332222~
5010X837PA1.ecs
60
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 2500
Max: 1
Detail - Optional
Loop: 2310B
Elements: 8
Rendering Provider Name
NM1
User Option (Usage): Situational
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
82
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Rendering Provider
Entity Type Qualifier
Code
1
2
Req
M
Name
Person
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when NM102 = 1 (person) and the person has a first name. If not required by
this implementation guide, do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when NM102 = 1 (person) and the middle name or initial of the person is
needed to identify the individual. If not required by this implementation guide, do not send.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Situational Rule: Required when NM102 = 1 (person) and the name suffix of the person is needed to
identify the individual. If not required by this implementation guide, do not send.
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Situational Rule: Required for providers in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an
NPI.
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National
Provider Identifier (NPI) implementation date when the provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an
NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.
Code
XX
NM109
67
Name
Centers for Medicare and Medicaid Services National Provider Identifier
Identification Code
X
AN
2/80
Situational
Situational Rule: Required for providers in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an
NPI.
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National
Provider Identifier (NPI) implementation date when the provider has received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an
NPI and the submitter has the capability to send it.
5010X837PA1.ecs
61
For internal use only
3/3/2011
Health Care Claim : Professional - 837
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
Situational Rule:
Required when the Rendering Provider information is different than that carried in the Billing Provider Loop 2010AA. If not required
by this implementation guide, do not send.
TR3 Notes:
1. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or
other facility) who rendered the care. In the case where a substitute provider (locum tenans) was used, enter that provider’s
information here.
2. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with
the same value in NM101.
TR3 Example:
NM1*82*1*DOE*JANE*C***XX*12345678~
5010X837PA1.ecs
62
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Rendering Provider Specialty
Information
PRV
Pos: 2550
Max: 1
Detail - Optional
Loop: 2310B
Elements: 3
User Option (Usage): Situational
Element Summary:
Ref
PRV01
Id
1221
Element Name
Provider Code
Code
PE
PRV02
128
127
Type
ID
Min/Max
1/3
Usage
Required
X
ID
2/3
Required
X
AN
1/50
Required
Name
Performing
Reference Identification Qualifier
Code
PXC
PRV03
Req
M
Name
Health Care Provider Taxonomy Code
Reference Identification
ExternalCodeList
Name: 682
Description: Health Care Provider Taxonomy
Situational Rule:
Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do
not send.
TR3 Notes:
1. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a
PRV segment with the same value in PRV01.
TR3 Example:
PRV*PE*PXC*1223G0001X~
When the Rendering Provider is sent, this PRV is required.
5010X837PA1.ecs
63
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Service Facility Location Name
NM1
Pos: 2500
Max: 1
Detail - Optional
Loop: 2310C
Elements: 5
User Option (Usage): Situational
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
77
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Service Location
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Situational Rule: Required when the service location to be identified has an NPI and is not a component
or subpart of the Billing Provider entity.
If not required by this implementation guide, do not send.
Code
XX
NM109
67
Name
Centers for Medicare and Medicaid Services National Provider Identifier
Identification Code
X
AN
2/80
Situational
Situational Rule: Required when the service location to be identified has an NPI and is not a component
or subpart of the Billing Provider entity.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
Situational Rule:
Required when purchased services are being billed/reported on this claim. If not required by this implementation guide, do not send.
TR3 Notes:
1. When an organization health care provider’s NPI is provided to identify the Service Location, the organization health care provider
must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an
organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of
the Billing Provider. In that case, the subpart must be the Billing Provider.
2. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use
this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location.
3. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with
the same value in NM101.
TR3 Example:
NM1*77*2*ABC CLINIC*****XX*1234567891~
5010X837PA1.ecs
64
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Service Facility Location
Address
N3
Pos: 2650
Max: 1
Detail - Optional
Loop: 2310C
Elements: 2
User Option (Usage): Required
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
TR3 Notes:
1. If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered
(for example, “crossroad of State Road 34 and 45” or “Exit near Mile marker 265 on Interstate 80”.)
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
65
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Service Facility Location City,
State, ZIP Code
N4
Pos: 2700
Max: 1
Detail - Optional
Loop: 2310C
Elements: 5
User Option (Usage): Required
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when the address is outside the United States of America. If not required by
this implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
66
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 2500
Max: 1
Detail - Optional
Loop: 2310E
Elements: 2
Ambulance Pick-up Location
NM1
User Option (Usage): Situational
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
PW
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Pickup Address
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
Situational Rule:
Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not
send.
TR3 Notes:
1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with
the same value in NM101.
TR3 Example:
NM1*PW*2~
5010X837PA1.ecs
67
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Ambulance Pick-up Location
Address
N3
Pos: 2650
Max: 1
Detail - Optional
Loop: 2310E
Elements: 2
User Option (Usage): Required
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
TR3 Notes:
1. If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was
rendered (for example, “crossroad of State Road 34 and 45" or ”Exit near Mile marker 265 on Interstate 80".)
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
68
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Ambulance Pick-up Location
City, State, Zip Code
N4
Pos: 2700
Max: 1
Detail - Optional
Loop: 2310E
Elements: 5
User Option (Usage): Required
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
69
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Ambulance Drop-off Location
NM1
Pos: 2500
Max: 1
Detail - Optional
Loop: 2310F
Elements: 3
User Option (Usage): Situational
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
45
NM102
1065
NM103
1035
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
X
AN
1/60
Situational
Name
Drop-off Location
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
Name Last or Organization Name
Situational Rule: Required when drop-off location name is known. If not required by this implementation
guide, do not send.
Situational Rule:
Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not
send.
TR3 Notes:
1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with
the same value in NM101.
TR3 Example:
NM1*45*2~
5010X837PA1.ecs
70
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Ambulance Drop-off Location
Address
N3
Pos: 2650
Max: 1
Detail - Optional
Loop: 2310F
Elements: 2
User Option (Usage): Required
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
71
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Ambulance Drop-off Location
City, State, Zip Code
N4
Pos: 2700
Max: 1
Detail - Optional
Loop: 2310F
Elements: 5
User Option (Usage): Required
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
72
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Other Subscriber Information
SBR
Pos: 2900
Max: 1
Detail - Optional
Loop: 2320
Elements: 6
User Option (Usage): Situational
Element Summary:
Ref
SBR01
Id
1138
Element Name
Payer Responsibility Sequence Number Code
Req
M
Type
ID
Min/Max
1/1
Usage
Required
Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than
value “U”) may occur no more than once.
Code
A
B
C
D
E
F
G
H
P
S
T
U
SBR02
1069
Individual Relationship Code
Code
01
18
19
20
21
39
40
53
G8
SBR03
127
Name
Payer Responsibility Four
Payer Responsibility Five
Payer Responsibility Six
Payer Responsibility Seven
Payer Responsibility Eight
Payer Responsibility Nine
Payer Responsibility Ten
Payer Responsibility Eleven
Primary
Secondary
Tertiary
Unknown
O
ID
2/2
Required
O
AN
1/50
Situational
Name
Spouse
Self
Child
Employee
Unknown
Organ Donor
Cadaver Donor
Life Partner
Other Relationship
Reference Identification
Situational Rule: Required when the subscriber’s identification card for the non-destination payer
identified in Loop ID-2330B of this iteration of Loop ID-2320 shows a group number. If not required by this
implementation guide, do not send.
This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in
element NM109 of Loop ID-2330A for this iteration of Loop ID-2320.
SBR04
93
Name
O
AN
1/60
Situational
Situational Rule: Required when SBR03 is not used and the group
name is available. If not required by this implementation guide, do not send.
SBR05
1336
Insurance Type Code
O
ID
1/3
Situational
Situational Rule: Required when the payer identified in loop 2330B for this iteration of the 2320 loop is
Medicare and Medicare is not the primary payer (SBR01 is not P). If not required by this implementation
guide, do not send.
Code
12
5010X837PA1.ecs
Name
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health
73
For internal use only
3/3/2011
Health Care Claim : Professional - 837
13
14
15
16
41
42
43
47
SBR09
1032
Plan
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination
Period with an Employer's Group Health Plan
Medicare Secondary, No-fault Insurance including Auto is Primary
Medicare Secondary Worker's Compensation
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
Medicare Secondary Black Lung
Medicare Secondary Veteran's Administration
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan
(LGHP)
Medicare Secondary, Other Liability Insurance is Primary
Claim Filing Indicator Code
O
ID
1/2
Situational
Situational Rule: Required prior to mandated use of the HIPAA
National Plan ID. If not required by this implementation guide, do not send.
Code
11
12
13
14
15
16
17
AM
BL
CH
CI
DS
FI
HM
LM
MA
MB
MC
OF
TV
VA
WC
ZZ
Name
Other Non-Federal Programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
Dental Maintenance Organization
Automobile Medical
Blue Cross/Blue Shield
Champus
Commercial Insurance Co.
Disability
Federal Employees Program
Health Maintenance Organization
Liability Medical
Medicare Part A
Medicare Part B
Medicaid
Other Federal Program
Title V
Veterans Affairs Plan
Workers' Compensation Health Claim
Mutually Defined
Situational Rule:
Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide,
do not send.
TR3 Notes:
1. All information contained in the 2320 Loop applies only to the payer who is identified in the 2330B Loop of this iteration of the 2320
Loop. It is specific only to that payer. If information on additional payers is needed to be carried, repeat the 2320 Loop with its
respective 2330 Loops.
2. See Crosswalking COB Data Elements section for more information on handling COB in the 837.
TR3 Example:
SBR*S*01*GR0786******13~
5010X837PA1.ecs
74
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 2950
Max: 5
Detail - Optional
Loop: 2320
Elements: 19
Claim Level Adjustments
CAS
User Option (Usage): Situational
Element Summary:
Ref
CAS01
Id
1033
Element Name
Claim Adjustment Group Code
Code
CO
CR
OA
PI
PR
CAS02
1034
Req
M
Type
ID
Min/Max
1/2
Usage
Required
M
ID
1/5
Required
Name
Contractual Obligations
Correction and Reversals
Other adjustments
Payor Initiated Reductions
Patient Responsibility
Claim Adjustment Reason Code
See CODE SOURCE 139: Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS03
782
Monetary Amount
M
R
1/18
Required
CAS04
380
Quantity
O
R
1/15
Situational
Situational Rule: Required when the number of service units has been adjusted. If not required by this
implementation guide, do not send.
CAS05
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS06
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS05 is used. If not required by this implementation guide, do not
send.
CAS07
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS05 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS08
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS09
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS08 is used. If not required by this implementation guide, do not
send.
5010X837PA1.ecs
75
For internal use only
3/3/2011
CAS10
Health Care Claim : Professional - 837
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS08 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS11
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS12
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS11 is used. If not required by this implementation guide, do not
send.
CAS13
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS11 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS14
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS15
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS14 is used. If not required by this implementation guide, do not
send.
CAS16
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS14 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS17
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01.
If not required by this implementation guide, do not send.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS18
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS17 is used. If not required by this implementation guide, do not
send.
CAS19
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS17 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
Situational Rule:
Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment
information. If not required by this implementation guide, do not send.
TR3 Notes:
1. Submitters must use this CAS segment to report prior payers’ claim level adjustments that cause the amount paid to differ from
the amount originally charged.
2. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS
segment again.
5010X837PA1.ecs
76
For internal use only
3/3/2011
Health Care Claim : Professional - 837
3. Codes and associated amounts must come from either paper remittance advice or 835s (Remittance Advice) received on the
claim. Or, when this claim has not been adjudicated by the payer identified in Loop 2330B and the provider has the appropriate
supporting documentation, the provider may then complete this segment.
4. A single CAS segment contains six repetitions of the “adjustment trio” composed of adjustment reason code, adjustment amount,
and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment
Group Code (CAS01). The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero
adjustment, it is reported in the second adjustment trio CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
TR3 Example:
CAS*PR*1*7.93~
CAS*OA*93*15.06~
5010X837PA1.ecs
77
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Coordination of Benefits (COB)
Payer Paid Amount
AMT
Pos: 3000
Max: 1
Detail - Optional
Loop: 2320
Elements: 2
User Option (Usage): Situational
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Code
D
AMT02
782
Req
M
Type
ID
Min/Max
1/3
Usage
Required
M
R
1/18
Required
Name
Payor Amount Paid
Monetary Amount
It is acceptable to show “0" as the amount paid.
When Loop ID 2010AC is present, this is the amount the Medicaid agency actually paid.
Situational Rule:
Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated
Medicaid agency.
If not required by this implementation guide, do not send.
TR3 Example:
AMT*D*411~
5010X837PA1.ecs
78
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Coordination of Benefits (COB)
Total Non-covered Amount
AMT
Pos: 3000
Max: 1
Detail - Optional
Loop: 2320
Elements: 2
User Option (Usage): Situational
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Code
A8
AMT02
782
Req
M
Type
ID
Min/Max
1/3
Usage
Required
M
R
1/18
Required
Name
Noncovered Charges - Actual
Monetary Amount
Situational Rule:
Required when state Medicaid cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer
identified in Loop ID 2330B. If not required by this implementation guide, do not send.
TR3 Notes:
1. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither
the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
TR3 Example:
AMT*A8*273~
5010X837PA1.ecs
79
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3000
Max: 1
Detail - Optional
Loop: 2320
Elements: 2
Remaining Patient Liability
AMT
User Option (Usage): Situational
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Code
EAF
AMT02
782
Req
M
Type
ID
Min/Max
1/3
Usage
Required
M
R
1/18
Required
Name
Amount Owed
Monetary Amount
Situational Rule:
Required when the Other Payer identified in Loop ID 2330B (of this iteration of Loop ID 2320) has adjudicated this claim and
provided claim level information only.
OR
Required when the Other Payer identified in Loop ID 2330B (of this iteration of Loop ID 2320) has adjudicated this claim and the
provider received a paper remittance advice and the provider does not have the ability to report line item information.
If not required by this implementation guide, do not send.
TR3 Notes:
1. In the opinion of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID
2330B of this iteration of Loop ID 2320.
2. This segment is only used in provider submitted claims; it is not used in Payer-to-Payer Coordination of Benefits (COB).
3. This segment is not used if the line level (Loop ID 2430) Remaining Patient Liability AMT segment is used for this Other Payer.
TR3 Example:
AMT*EAF*75~
5010X837PA1.ecs
80
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Other Insurance Coverage
Information
OI
Pos: 3100
Max: 1
Detail - Optional
Loop: 2320
Elements: 3
User Option (Usage): Required
Element Summary:
Ref
OI03
Id
1073
Element Name
Yes/No Condition or Response Code
Req
O
Type
ID
Min/Max
1/1
Usage
Required
This is a crosswalk from CLM08 when doing COB.
This element answers the question whether or not the insured has authorized the plan to remit payment
directly to the provider.
Code
N
W
Y
OI04
1351
Name
No
Not Applicable
Yes
Patient Signature Source Code
O
ID
1/1
Situational
Situational Rule: Required when a signature was executed on the
patient’s behalf under state or federal law. If not required by this implementation guide, do not send.
This is a crosswalk from CLM10 when doing COB.
Code
P
OI06
1363
Name
Signature generated by provider because the patient was not physically present for
services
Release of Information Code
O
ID
1/1
Required
This is a crosswalk from CLM09 when doing COB.
The Release of Information response is limited to the information carried in this claim.
Code
I
Y
Name
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated
by Federal Statutes
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related
to a Claim
TR3 Notes:
1. All information contained in the OI segment applies only to the payer who is identified in the 2330B loop of this iteration of the
2320 loop.
TR3 Example:
OI***Y*B**Y~
5010X837PA1.ecs
81
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Outpatient Adjudication
Information
MOA
Pos: 3200
Max: 1
Detail - Optional
Loop: 2320
Elements: 9
User Option (Usage): Situational
Element Summary:
Ref
MOA01
Id
954
Element Name
Percentage as Decimal
Req
O
Type
R
Min/Max
1/10
Usage
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
MOA02
782
Monetary Amount
O
R
1/18
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
MOA03
127
Reference Identification
O
AN
1/50
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
ExternalCodeList
Name: 411
Description: Claim Payment Remark Code
MOA04
127
Reference Identification
O
AN
1/50
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
ExternalCodeList
Name: 411
Description: Claim Payment Remark Code
MOA05
127
Reference Identification
O
AN
1/50
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
ExternalCodeList
Name: 411
Description: Claim Payment Remark Code
MOA06
127
Reference Identification
O
AN
1/50
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
ExternalCodeList
Name: 411
Description: Claim Payment Remark Code
MOA07
127
Reference Identification
O
AN
1/50
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
ExternalCodeList
Name: 411
Description: Claim Payment Remark Code
MOA08
782
Monetary Amount
O
R
1/18
Situational
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
MOA09
5010X837PA1.ecs
782
Monetary Amount
O
82
R
1/18
Situational
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Situational Rule: Required when returned in the remittance advice. If not required by this implementation
guide, do not send.
Situational Rule:
Required when outpatient adjudication information is reported in the remittance advice
OR
when it is necessary to report remark codes. If not required by this implementation guide, do not send.
TR3 Example:
MOA***A4~
5010X837PA1.ecs
83
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3250
Max: 1
Detail - Optional
Loop: 2330A
Elements: 8
Other Subscriber Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
IL
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Insured or Subscriber
Entity Type Qualifier
Code
1
2
Req
M
Name
Person
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM104
1036
Name First
O
AN
1/35
Situational
Situational Rule: Required when NM102 = 1 (person) and the person has a first name. If not required by
this implementation guide, do not send.
NM105
1037
Name Middle
O
AN
1/25
Situational
Situational Rule: Required when NM102 = 1 (person) and the middle name or initial of the person is
needed to identify the individual. If not required by this implementation guide, do not send.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Situational Rule: Required when NM102 = 1 (person) and the name suffix of the person is needed to
identify the individual. If not required by this implementation guide, do not send.
NM108
66
Identification Code Qualifier
Code
II
MI
NM109
67
X
ID
1/2
Required
Name
Standard Unique Health Identifier for each Individual in the United States
Member Identification Number
Identification Code
X
AN
2/80
Required
TR3 Notes:
1. If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member
Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other
Subscriber’s Name Loop ID-2330A.
2. If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer
indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is
identified in this Other Subscriber’s Name Loop ID-2330A.
3. See Crosswalking COB Data Elements section for more information on handling COB in the 837.
TR3 Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
5010X837PA1.ecs
84
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3320
Max: 1
Detail - Optional
Loop: 2330A
Elements: 2
Other Subscriber Address
N3
User Option (Usage): Situational
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
Situational Rule:
Required when the information is available. If not required by this implementation guide, do not send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
85
For internal use only
3/3/2011
Health Care Claim : Professional - 837
N4
Other Subscriber City, State, ZIP Pos: 3400Detail - Optional Max: 1
Loop: 2330A
Elements: 5
Code
User Option (Usage): Situational
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Situational Rule:
Required when the information is available. If not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
86
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Other Subscriber Secondary
Identification
REF
Pos: 3550
Max: 1
Detail - Optional
Loop: 2330A
Elements: 2
User Option (Usage): Situational
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Code
SY
REF02
127
Req
M
Type
ID
Min/Max
2/3
Usage
Required
X
AN
1/50
Required
Name
Social Security Number
Reference Identification
Situational Rule:
Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to
identify the entity. If not required by this implementation guide, do not send.
TR3 Example:
REF*SY*123456789~
5010X837PA1.ecs
87
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3250
Max: 1
Detail - Optional
Loop: 2330B
Elements: 5
Other Payer Name
NM1
User Option (Usage): Required
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Code
PR
NM102
1065
Type
ID
Min/Max
2/3
Usage
Required
M
ID
1/1
Required
Name
Payer
Entity Type Qualifier
Code
2
Req
M
Name
Non-Person Entity
NM103
1035
Name Last or Organization Name
X
AN
1/60
Required
NM108
66
Identification Code Qualifier
X
ID
1/2
Required
On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV
must be sent.
Prior to the mandated implementation date and prior to any phase-in period identified by Federal
regulation, PI must be sent. If a phase-in period is designated, PI must be sent unless:
1. Both the sender and receiver agree to use the National Plan ID,
2. The receiver has a National Plan ID, and
3. The sender has the capability to send the National Plan ID.
If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that
would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.
Code
PI
XV
NM109
67
Name
Payor Identification
Centers for Medicare and Medicaid Services PlanID
Identification Code
X
AN
2/80
Required
When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier)
and in Loop ID-2430 (Line Adjudication Information) must match this value.
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services PlanID
TR3 Notes:
1. See Crosswalking COB Data Elements section for more information on handling COB in the 837.
TR3 Example:
NM1*PR*2*ABC INSURANCE CO*****PI*11122333~
5010X837PA1.ecs
88
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3320
Max: 1
Detail - Optional
Loop: 2330B
Elements: 2
Other Payer Address
N3
User Option (Usage): Situational
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
N302
166
Address Information
O
AN
1/55
Situational
Situational Rule: Required when there is a second address line. If not required by this implementation
guide, do not send.
Situational Rule:
Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location
(for example, a clearinghouse). If not required by this implementation guide, do not send.
TR3 Example:
N3*123 MAIN STREET~
5010X837PA1.ecs
89
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Other Payer City, State, ZIP
Code
N4
Pos: 3400
Max: 1
Detail - Optional
Loop: 2330B
Elements: 5
User Option (Usage): Situational
Element Summary:
Ref
N401
Id
19
Element Name
City Name
N402
156
State or Province Code
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 22C
Description: States and Provinces
N403
116
Postal Code
O
ID
3/15
Situational
Situational Rule: Required when the address is in the United States of America, including its territories, or
Canada, or when a postal code exists for the country in N404. If not required by this implementation guide,
do not send.
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Situational Rule: Required when address is outside the United States. If not required by this
implementation guide, do not send.
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Situational Rule: Required when the address is not in the United States of America, including its
territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to
states, provinces, cantons, etc. If not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Situational Rule:
Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location
(for example, a clearinghouse). If not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
5010X837PA1.ecs
90
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Other Payer Claim Control
Number
REF
Pos: 3550
Max: 1
Detail - Optional
Loop: 2330B
Elements: 2
User Option (Usage): Situational
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Code
F8
REF02
127
Req
M
Type
ID
Min/Max
2/3
Usage
Required
X
AN
1/50
Required
Name
Original Reference Number
Reference Identification
Situational Rule:
Required when it is necessary to identify the Other Payer’s Claim Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payer’s Claim Control Number is available. If not required by this implementation guide, do not send.
TR3 Example:
REF*F8*R555588~
5010X837PA1.ecs
91
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3650
Max: 1
Detail - Optional
Loop: 2400
Elements: 1
Service Line Number
LX
User Option (Usage): Required
Element Summary:
Ref
LX01
Id
554
Element Name
Assigned Number
Req
M
Type
N0
Min/Max
1/6
Usage
Required
TR3 Notes:
1. The LX functions as a line counter.
2. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
3. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on
bundling and unbundling.
TR3 Example:
LX*1~
5010X837PA1.ecs
92
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 3700
Max: 1
Detail - Optional
Loop: 2400
Elements: 10
Professional Service
SV1
User Option (Usage): Required
Element Summary:
Ref
SV101
Id
C003
Element Name
Composite Medical Procedure Identifier
SV101-01
235
Product/Service ID Qualifier
Req
M
Type
Comp
Min/Max
Usage
Required
M
ID
2/2
Required
The NDC number is used for reporting prescribed drugs and biologics when required by government
regulation, or as deemed by the provider to enhance claim reporting/adjudication processes. The NDC
number is reported in the LIN segment of Loop ID-2410 only.
Code
ER
HC
IV
WK
SV101-02
234
Name
Jurisdiction Specific Procedure and Supply Codes
Health Care Financing Administration Common Procedural Coding System (HCPCS)
Codes
Home Infusion EDI Coalition (HIEC) Product/Service Code
Advanced Billing Concepts (ABC) Codes
Product/Service ID
M
AN
1/48
Required
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SV101-03
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a modifier clarifies or improves the reporting accuracy of the associated
procedure code. This is the first procedure code modifier. If not required by this implementation guide, do
not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SV101-04
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a second modifier clarifies or improves the reporting accuracy of the
associated procedure code. If not required by this implementation guide, do not send.
5010X837PA1.ecs
93
For internal use only
3/3/2011
Health Care Claim : Professional - 837
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SV101-05
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a third modifier clarifies or improves the reporting accuracy of the
associated procedure code. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SV101-06
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a third modifier clarifies or improves the reporting accuracy of the
associated procedure code. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SV101-07
352
Description
O
AN
1/80
Situational
Situational Rule: Required when, in the judgment of the submitter, the Procedure Code does not
definitively describe the service/product/supply and loop 2410 is not used.
OR
Required when SV101-2 is a non-specific Procedure Code.
Non-specific codes may include in their descriptors terms such as: Not Otherwise Classified (NOC);
Unlisted;
Unspecified; Unclassified; Other; Miscellaneous;
Prescription Drug, Generic; or Prescription Drug, Brand Name.
If not required by this implementation guide, do not send.
SV102
782
Monetary Amount
O
R
1/18
Required
For encounter transmissions, zero (0) may be a valid amount.
5010X837PA1.ecs
94
For internal use only
3/3/2011
Health Care Claim : Professional - 837
This is the total charge amount for this service line. The amount is inclusive of the provider’s base charge
and any applicable tax and/or postage claimed amounts reported within this line’s AMT segments.
Zero “0” is an acceptable value for this element.
SV103
355
Unit or Basis for Measurement Code
Code
MJ
UN
SV104
380
X
ID
2/2
Required
X
R
1/15
Required
Name
Minutes
Unit
Quantity
Note: When a decimal is needed to report units, include it in this element, for example, “15.6".
The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum
number of digits allowed to the right of the decimal is three.
SV105
1331
Facility Code Value
O
AN
1/2
Situational
Situational Rule: Required when value is different than value carried in CLM05-1 in Loop ID-2300. If not
required by this implementation guide, do not send.
See CODE SOURCE 237: Place of Service Codes for Professional Claims
ExternalCodeList
Name: 237
Description: Place of Service Codes for Professional Claims
SV107
C004
Composite Diagnosis Code Pointer
O
Comp
SV107-01
1328
Diagnosis Code Pointer
M
N0
Required
1/2
Required
This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers
indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond
to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim
Loop ID-2300.
SV107-02
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Situational Rule: Required when it is necessary to point to a second diagnosis related to this service line.
Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send.
SV107-03
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Situational Rule: Required when it is necessary to point to a third diagnosis related to this service line.
Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send.
SV107-04
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Situational Rule: Required when it is necessary to point to a fourth diagnosis related to this service line.
Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send.
SV109
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Situational Rule: Required when the service is known to be an emergency by the provider. If not required
by this implementation guide, do not send.
For this implementation, the listed value takes precedence over the semantic note.
Emergency definition: The patient requires immediate medical intervention as a result of severe, life
threatening, or potentially disabling conditions.
Code
Y
SV111
1073
Name
Yes
Yes/No Condition or Response Code
O
ID
1/1
Situational
Situational Rule: Required when Medicaid services are the result of a screening referral. If not required by
this implementation guide, do not send.
For this implementation, the listed value takes precedence over the semantic note.
When this element is used, this service is not the screening service.
Code
5010X837PA1.ecs
Name
95
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Y
SV112
1073
Yes
Yes/No Condition or Response Code
O
ID
1/1
Situational
Situational Rule: Required when applicable for Medicaid claims. If not required by this implementation
guide, do not send.
For this implementation, the listed value takes precedence over the semantic note.
Code
Y
SV115
1327
Name
Yes
Copay Status Code
O
ID
1/1
Situational
Situational Rule: Required when patient is exempt from co-pay. If not required by this implementation
guide, do not send.
Code
0
Name
Copay exempt
TR3 Example:
SV1*HC:99211:25*12.25*UN*1*11**1:2:3**Y~
5010X837PA1.ecs
96
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Durable Medical Equipment
Service
SV5
Pos: 4000
Max: 1
Detail - Optional
Loop: 2400
Elements: 6
User Option (Usage): Situational
Element Summary:
Ref
SV501
Id
C003
Element Name
Composite Medical Procedure Identifier
SV501-01
235
Product/Service ID Qualifier
Code
HC
SV501-02
234
Req
M
Type
Comp
Min/Max
Usage
Required
M
ID
2/2
Required
Name
Health Care Financing Administration Common Procedural Coding System (HCPCS)
Codes
Product/Service ID
M
AN
1/48
Required
This value must be the same as that reported in SV101-2.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
SV502
355
Unit or Basis for Measurement Code
Code
DA
M
ID
2/2
Required
Name
Days
SV503
380
Quantity
M
R
1/15
Required
SV504
782
Monetary Amount
X
R
1/18
Required
SV505
782
Monetary Amount
X
R
1/18
Required
SV506
594
Frequency Code
O
ID
1/1
Required
Code
1
4
6
Name
Weekly
Monthly
Daily
Situational Rule:
Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used
for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation
guide, do not send.
TR3 Example:
SV5*HC:A4631*DA*30*50*5000*4~
5010X837PA1.ecs
97
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Line Supplemental Information
PWK
Pos: 4200
Max: 10
Detail - Optional
Loop: 2400
Elements: 4
User Option (Usage): Situational
Element Summary:
Ref
PWK01
Id
755
Element Name
Report Type Code
Code
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
5010X837PA1.ecs
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Name
Report Justifying Treatment Beyond Utilization Guidelines
Drugs Administered
Treatment Diagnosis
Initial Assessment
Functional Goals
Plan of Treatment
Progress Report
Continued Treatment
Chemical Analysis
Certified Test Report
Justification for Admission
Recovery Plan
Allergies/Sensitivities Document
Autopsy Report
Ambulance Certification
Admission Summary
Prescription
Physician Order
Referral Form
Benchmark Testing Results
Baseline
Blanket Test Results
Chiropractic Justification
Consent Form(s)
Certification
Drug Profile Document
Dental Models
Durable Medical Equipment Prescription
Diagnostic Report
Discharge Monitoring Report
Discharge Summary
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Models
Nursing Notes
Operative Note
Oxygen Content Averaging Report
Orders and Treatments Document
Objective Physical Examination (including vital signs) Document
98
For internal use only
3/3/2011
Health Care Claim : Professional - 837
OX
OZ
P4
P5
PE
PN
PO
PQ
PY
PZ
RB
RR
RT
RX
SG
V5
XP
PWK02
756
Oxygen Therapy Certification
Support Data for Claim
Pathology Report
Patient Medical History Document
Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Renewable Oxygen Content Averaging Report
Symptoms Document
Death Notification
Photographs
Report Transmission Code
O
ID
1/2
Required
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
Code
AA
BM
EL
EM
FT
FX
PWK05
66
Name
Available on Request at Provider Site
By Mail
Electronically Only
E-Mail
File Transfer
By Fax
Identification Code Qualifier
X
ID
1/2
Situational
Situational Rule: Required when PWK02 = “BM”, “EL”, “EM”, “FX” or “FT”. If not required by this
implementation guide, do not send.
Code
AC
PWK06
67
Name
Attachment Control Number
Identification Code
X
AN
2/80
Situational
Situational Rule: Required when PWK02 = “BM”, “EL”, “EM”, “FX” or “FT”. If not required by this
implementation guide, do not send.
PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the
TRN of the electronic attachment.
For the purpose of this implementation, the maximum field length is 50.
Situational Rule:
Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275)
rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the
TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider’s office and is
available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of
“AA” in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send.
TR3 Example:
PWK*OZ*BM***AC*DMN0012~
5010X837PA1.ecs
99
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 4550
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
Date - Service Date
DTP
User Option (Usage): Required
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Code
472
DTP02
1250
Req
M
Type
ID
Min/Max
3/3
Usage
Required
M
ID
2/3
Required
Name
Service
Date Time Period Format Qualifier
RD8 is required only when the “To and From” dates are different. However, at the discretion of the
submitter, RD8 can also be used when the “To and From” dates are the same.
Code
D8
RD8
DTP03
1251
Name
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Date Time Period
M
AN
1/35
Required
TR3 Notes:
1. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply
will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug.
Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is
1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the
entire period during which the drug was supplied, including the last day the drug was used. Example:
20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four
doses of the drug are dispensed and the first dose is used on 1/1/00.
TR3 Example:
DTP*472*RD8*20050314-20050325~
5010X837PA1.ecs
100
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 4700
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
Line Item Control Number
REF
User Option (Usage): Situational
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Code
6R
REF02
127
Req
M
Type
ID
Min/Max
2/3
Usage
Required
X
AN
1/50
Required
Name
Provider Control Number
Reference Identification
The maximum number of characters to be supported for this field is ‘30’. A submitter may submit fewer
characters depending upon their needs. However, the HIPAA maximum requirement to be supported by
any responding system is ‘30’. Characters beyond 30 are not required to be stored nor returned by any
837-receiving system.
Situational Rule:
Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required
by this implementation guide, do not send.
TR3 Notes:
1. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number
in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail
regardless of whether bundling or unbundling has occurred.
2. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the
submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to
automatically post by service line.
TR3 Example:
REF*6R*54321~
5010X837PA1.ecs
101
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 4850
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
Line Note
NTE
User Option (Usage): Situational
Element Summary:
Ref
NTE01
Id
363
Element Name
Note Reference Code
Code
ADD
DCP
NTE02
352
Req
O
Type
ID
Min/Max
3/3
Usage
Required
1/80
Required
Name
Additional Information
Goals, Rehabilitation Potential, or Discharge Plans
Description
M
AN
Situational Rule:
Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported
elsewhere within the claim data set.
If not required by this implementation guide, do not send.
TR3 Notes:
1. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code.
If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will
provide the description.
TR3 Example:
NTE*DCP*PATIENT GOAL TO BE OFF OXYGEN BY END OF MONTH~
5010X837PA1.ecs
102
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Line Adjudication Information
SVD
Pos: 5400
Max: 1
Detail - Optional
Loop: 2430
Elements: 5
User Option (Usage): Situational
Element Summary:
Ref
SVD01
Id
67
Element Name
Identification Code
Req
M
Type
AN
Min/Max
2/80
Usage
Required
This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430
loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier
(Loop ID-2330B, element NM109).
SVD02
782
Monetary Amount
M
R
O
Comp
1/18
Required
Zero “0" is an acceptable value for this element.
SVD03
C003
Composite Medical Procedure Identifier
Required
This element contains the procedure code that was used to pay this service line.
SVD03-01
235
Product/Service ID Qualifier
Code
ER
HC
IV
WK
SVD03-02
234
M
ID
2/2
Required
Name
Jurisdiction Specific Procedure and Supply Codes
Health Care Financing Administration Common Procedural Coding System (HCPCS)
Codes
Home Infusion EDI Coalition (HIEC) Product/Service Code
Advanced Billing Concepts (ABC) Codes
Product/Service ID
M
AN
1/48
Required
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SVD03-03
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
5010X837PA1.ecs
103
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Description: Complimentary, Alternative, or Holistic Procedure Codes
SVD03-04
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a second modifier clarifies/improves the reporting accuracy of the
associated procedure code. If not required this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SVD03-05
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a third modifier clarifies/improves the reporting accuracy of the
associated procedure code. If not required this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SVD03-06
1339
Procedure Modifier
O
AN
2/2
Situational
Situational Rule: Required when a fourth modifier clarifies/improves the reporting accuracy of the
associated procedure code. If not required this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 576
Description: Workers Compensation Specific Procedure and Supply Codes
ExternalCodeList
Name: 843
Description: Complimentary, Alternative, or Holistic Procedure Codes
SVD03-07
352
Description
O
AN
1/80
Situational
Situational Rule: Required when SVC01-7 was returned in the 835 transaction. If not required by this
implementation guide, do not send.
SVD05
380
Quantity
O
R
1/15
Required
This is the number of paid units from the remittance advice. When paid units are not present on the
remittance advice, use the original billed units.
The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum
5010X837PA1.ecs
104
For internal use only
3/3/2011
Health Care Claim : Professional - 837
number of digits allowed to the right of the decimal is three.
SVD06
554
Assigned Number
O
N0
1/6
Situational
Situational Rule: Required when payer bundled this service line. If not required by this implementation
guide, do not send.
Situational Rule:
Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments
and/or adjustments applied to it. If not required by this implementation guide, do not send.
TR3 Notes:
1. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is
used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
TR3 Example:
SVD*43*55*HC:84550**3~
5010X837PA1.ecs
105
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 5450
Max: 5
Detail - Optional
Loop: 2430
Elements: 19
Line Adjustment
CAS
User Option (Usage): Situational
Element Summary:
Ref
CAS01
Id
1033
Element Name
Claim Adjustment Group Code
Code
CO
CR
OA
PI
PR
CAS02
1034
Req
M
Type
ID
Min/Max
1/2
Usage
Required
M
ID
1/5
Required
Name
Contractual Obligations
Correction and Reversals
Other adjustments
Payor Initiated Reductions
Patient Responsibility
Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS03
782
Monetary Amount
M
R
1/18
Required
CAS04
380
Quantity
O
R
1/15
Situational
Situational Rule: Required when the units of service are being adjusted. If not required by this
implementation guide, do not send.
CAS05
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If
not required by this implementation guide, do not send.
See CODE SOURCE 139: Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS06
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS05 is present. If not required by this implementation guide, do not
send.
CAS07
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS05 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS08
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If
not required by this implementation guide, do not send.
See CODE SOURCE 139: Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS09
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS08 is present. If not required by this implementation guide, do not
send.
5010X837PA1.ecs
106
For internal use only
3/3/2011
CAS10
Health Care Claim : Professional - 837
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS08 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS11
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If
not required by this implementation guide, do not send.
See CODE SOURCE 139: Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS12
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS11 is present. If not required by this implementation guide, do not
send.
CAS13
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS11 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS14
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If
not required by this implementation guide, do not send.
See CODE SOURCE 139: Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS15
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS14 is present. If not required by this implementation guide, do not
send.
CAS16
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS14 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
CAS17
1034
Claim Adjustment Reason Code
X
ID
1/5
Situational
Situational Rule: Required when it is necessary to report an additional non-zero adjustment, beyond what
has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If
not required by this implementation guide, do not send.
See CODE SOURCE 139: Claim Adjustment Reason Code
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS18
782
Monetary Amount
X
R
1/18
Situational
Situational Rule: Required when CAS17 is present. If not required by this implementation guide, do not
send.
CAS19
380
Quantity
X
R
1/15
Situational
Situational Rule: Required when CAS17 is present and is related to a units of service adjustment. If not
required by this implementation guide, do not send.
Situational Rule:
Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the
amount originally charged. If not required by this implementation guide, do not send.
TR3 Notes:
5010X837PA1.ecs
107
For internal use only
3/3/2011
Health Care Claim : Professional - 837
1. A single CAS segment contains six repetitions of the “adjustment trio” composed of adjustment reason code, adjustment amount,
and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment
Group Code (CAS01). The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero
adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17CAS19).
TR3 Example:
CAS*PR*1*7.93~
CAS*OA*93*15.06~
5010X837PA1.ecs
108
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Line Check or Remittance Date
DTP
Pos: 5500
Max: 1
Detail - Optional
Loop: 2430
Elements: 3
User Option (Usage): Required
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Code
573
DTP02
1250
DTP03
1251
Type
ID
Min/Max
3/3
Usage
Required
M
ID
2/3
Required
AN
1/35
Required
Name
Date Claim Paid
Date Time Period Format Qualifier
Code
D8
Req
M
Name
Date Expressed in Format CCYYMMDD
Date Time Period
M
TR3 Example:
DTP*573*D8*20040203~
5010X837PA1.ecs
109
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 5505
Max: 1
Detail - Optional
Loop: 2430
Elements: 2
Remaining Patient Liability
AMT
User Option (Usage): Situational
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Code
EAF
AMT02
782
Req
M
Type
ID
Min/Max
1/3
Usage
Required
M
R
1/18
Required
Name
Amount Owed
Monetary Amount
Situational Rule:
Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level
information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
TR3 Notes:
1. In the opinion of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of
this iteration of Loop ID 2430.
2. This segment is only used in provider submitted claims; it is not used in Payer-to-Payer Coordination of Benefits (COB).
3. This segment is not used if the claim level (Loop ID 2320) Remaining Patient Liability AMT segment is used for this Other Payer.
TR3 Example:
AMT*EAF*75~
5010X837PA1.ecs
110
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos: 5550
Max: 1
Detail - Mandatory
Loop: N/A
Elements: 2
Transaction Set Trailer
SE
User Option (Usage): Required
Element Summary:
Ref
SE01
Id
96
Element Name
Number of Included Segments
SE02
329
Transaction Set Control Number
Req
M
Type
N0
Min/Max
1/10
Usage
Required
M
AN
4/9
Required
The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique
within a specific interchange (ISA-IEA), but can repeat in other interchanges.
TR3 Example:
SE*1230*987654~
5010X837PA1.ecs
111
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
Functional Group Trailer
GE
User Option (Usage): Required
Element Summary:
Ref
GE01
Id
97
Element Name
Number of Transaction Sets Included
GE02
28
Group Control Number
Req
M
Type
N0
Min/Max
1/6
Usage
Required
M
N0
1/9
Required
TR3 Example:
GE*1*1~
5010X837PA1.ecs
112
For internal use only
3/3/2011
Health Care Claim : Professional - 837
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
Interchange Control Trailer
IEA
User Option (Usage): Required
Element Summary:
Ref
IEA01
Id
I16
Element Name
Number of Included Functional Groups
IEA02
I12
Interchange Control Number
Req
M
Type
N0
Min/Max
1/5
Usage
Required
M
N0
9/9
Required
TR3 Example:
IEA*1*000000905~
5010X837PA1.ecs
113
For internal use only